Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00219563 Renewal 02/22/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106The annual furnace cleaning and inspection that was documented on 9/5/22 was not completed by a professional furnace cleaning company.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. TTSR is currently in the process of seeking HVAC Certification for furnace inspection and cleaning for the TTSR Maintenance Department (who has completed the furnace inspection in the past for TTSR). If for some reason, the TTSR Maintenance Department is unable to receive certification for furnace inspection and cleaning, TTSR will contact a local professional heating company who will clean and inspect all furnaces in all 6400 residential homes agency-wide at least annually and within 365 days of last furnace inspection/ cleaning 02/28/2023 Implemented
6400.15(b)The agency used a Department's licensing inspection instrument modified in June 2018. The current inspection summary instrument for the community homes for individuals with intellectual disability or autism was promulgated in February 2020.(b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance.Per recommendations from licensing inspectors, TTSR was asked to download the Regulatory Compliance Guide for Pa. Code Chapter 6400 (February 14, 2023 Edition). On Page 22 of the RCG, TTSR found the link under Code 6400.15(b) which provides the updated Inspection tool for 6400 homes and includes all elements of the Department¿s instrument. Copies of this document have been downloaded and printed for future use and until a more updated version of the Inspection tool becomes available. Attached is a copy of the ¿55 Pa. Code Chapter 6400- Community Homes for Individuals with an Intellectual Disability or Autism¿ that will be used for future self assessments 02/23/2023 Implemented
SIN-00147193 Renewal 12/13/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.81(j)The bedroom belonging to Individual #1 did not have a door at the entrance. A bedroom shall have doors at all entrances for privacy.At time of annual licensing inspection, there was no door on the entrance to the bedroom of Individual #1, rather a drape was used for privacy. While on site, it was explained that Individual #1 prefers to have the drape in lieu of an actual door and it has been this way since the individual arrived at TTSR. Although there is no door and this is the preference of Individual#1, there is nothing noted in Individual #1¿s Annual Assessment nor his ISP. On 12/27/2018, Individual #1 arrived at office of the Programming Department to meet with his Program Specialist. Program Specialist again asked Individual #1 if he wanted a bedroom door or if he wanted to keep the privacy drape. Individual #1 again stated that he did not want a bedroom door and wanted the privacy drape to remain. Program Specialist had Individual #1 sign a document proclaiming that he did not want a bedroom door and preferred the privacy drape (attached). Also attached to this document is an email addressed from TTSR Program Specialist to Individual #1¿s Supports Coordinator requesting that information be added to Individual #1¿s ISP and that Individual #1 prefers not to have a bedroom door and also prefers a privacy drape. The third attachment is a signature page that acknowledges that the Program Specialist for TTSR has reviewed Pa. Code Chapter 6400.81(j) and will ensure that if the Individual prefers not to have a bedroom door on his bedroom entrance and prefers a privacy drape, that this information will be added to the Individual¿s ISP and Annual Assessments moving forward. Program Specialist also acknowledges and will be tasked with asking the Individual on a Quarterly basis what his preferences are as it pertains to wanting or not wanting a bedroom door for his bedroom for privacy. [Individual #1's ISP was updated 1/2/19 to include Individual #1's preference of a privacy curtain on his bedroom doorway. At least quarterly, in addition to inquiring about the preference of a curtain over a door with Individual #1, the program specialist shall counsel/work/meet with Individual #1 regarding having a door on his/her bedroom to ensure privacy. Documentation shall be kept. (DPOC by AES,HSLS on 1/11/19)] 12/27/2018 Implemented
SIN-00071331 Renewal 11/05/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The fire drill records from October, 2013 to October, 2014 do not indicate problems encountered.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. On 11/6/2014, TTSR Secretary (Denise Babcock) met with Assistant Director, Matthew Gladin to discuss an area of non-compliance found during licensing inspection. The topic of discussion was the need for change on TTSR¿s ¿Fire System Check/ Fire Drill Report¿. Additions were made to the attached form which allows the staff responsible for conducting the fire drill to document ¿Problems encountered during the fire drill¿. If on the report, staff specify that there were problems encountered during the fire drill, staff are to document in detail what the problem was and how they will attempt to remedy the problem during future drills. Denise Babcock will be responsible for ensuring that on each fire drill received on a monthly basis, that the staff responsible for conducting the fire drills is successfully completing this section of the report to ensure follow up by appropriate TTSR Administrator. Changes were made to the Fire drill form on 11/4/2014 and was trained to Denise Babcock on 11/6/2014. Denise will talk to each house supervisor for each site to ensure that all are aware of these changes made to the form and to ensure that appropriate follow up occurs in the event that problems occurred during any fire drill. At a supervisor meeting held on 11/20/2014, all house supervisors were given the new form for fire drills and were given an explanation of the changes made to the fire drill form and how to properly ensure that the fire drill form should be completed in its entirety (signature page attached) 11/06/2014 Implemented
SIN-00202188 Renewal 03/22/2022 Compliant - Finalized
SIN-00087540 Renewal 12/08/2015 Compliant - Finalized