Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00219564 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-00071332 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
6400.186(b)Individual #1 did not sign the three month reviews for the following dates: 12-30-13, 3-21-14 and 9-23-14. The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. On 11/25/2014, TTSR Assistant Director Matthew Gladin met with all TTSR Program Specialists who are in charge of attending all TTSR consumers¿ 3 month reviews of the ISP as well as . The topic of this meeting/ training was to discuss the need for Program Specialists to ensure the following: 1) Individuals will sign and date the ISP Review signature page upon review of the ISP. 2) Program Specialist will sign and date the ISP Review signature page upon review of the ISP. 3) Program Specialists will sign and date the most recent assessment for all individuals. By signing attached signature page, all Program Specialists acknowledge that they received the training on the above mentioned topics and attest that they understand that these 3 steps must be done for all ISP reviews as well as for assessments prior to completion. As oversight, all of TTSR Administration, including Program Specialists will meet on a monthly basis to review any updates to any individual¿s ISP that was reviewed during the prior 30 day timeframe to ensure that all Administrative staff are made aware of important changes and to ensure that the signature pages contain the signatures of both the program Specialist as well as the individual. All assessments will brought to this meeting (if done during the prior month timeframe) to ensure that the assessment contains necessary signatures and dates. 11/25/2014 Implemented
SIN-00043546 Renewal 10/16/2012 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)On 10/16/12, the agency self-assessment did not include the date the assessment was completed. None of the agency's self-assessments included a date. (Partially implemented-adequate progress 4/11/2013 CEM)(a) The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency's certificate of compliance, to measure and record compliance with this chapter. Since Tammy Nelson, CEO, is the person responsible for the completion of each house assessment, she and the Program Manager as well as Compliance Officer for TTSR met on 3/20/2013 to discuss the protocol for completion of assessments. Attached is a copy of the signature sheet as well as the curriculum of topics discussed during this training meeting. In summary, the training involved the completion of the self-inspections as well as a review of the timelines and expectations of the CEO for TTSR in ensuring that the self-assessments for each home are completed thoroughly (INCLUDING ACTUAL DATES WRITTEN ON SCORESHEETS WHICH SHOW THE DATE OF INSPECTION)and in a timely manner (3 to 6 months prior to the expiration date of the agency¿s certificate of compliance). 03/11/2013 Implemented
6400.202(d)On 10/16/12, a review of the agency's incident management record revealed that Individual #1 had been placed in multiple manual restraints which exceeded 30 minutes within a 2-hour period. *On 12/25/11, Individual #1 was restrained 5 times between 7:00pm and 8:40pm totalling 45 minutes. *On 5/9/12, Individual #1 was restrained 3 times between 6:40pm and 8:05pm totalling 35 minutes. *On 5/11/12, Individual #1 was restrained 3 times between 8:03pm and 9:41pm totalling 32 minutes. *On 8/16/12, Individual #1 was restrained 3 times between 4:00pm and 5:45pm totalling 45 minutes. (Partially implemented-adequate progress 4/11/2013 CEM)(d) An individual shall be released from the manual restraint within the time specified in the restrictive procedure plan not to exceed 30 minutes within a 2-hour period. 202(d) During a review of 6400 regulations with all house supervisors (sign-in sheet attached as well as a curriculum of what was taught), Compliance Officer for TTSR talked in depth about item 202(d) of the regulations which references violations pertaining to utilization of restraints exceeding 30 minutes in a 2 hour timeframe. TTSR Program Manager spoke and reviewed TTSR¿s Policy and Procedure 7-2-1 which pertains to the agency¿s Restrictive Procedure policies (attached). Program Manager will be responsible for analysis of data pertaining to restraints and will provide feedback to all staff upon receipt of the debriefing documentation. Compliance Officer will oversee the monitoring of incidents in HCSIS. Staff will be provided with de-escalation and positive approach trainings at a date to be determined. Staff are trained to utilize physical interventions when an individual is escalated and displaying behaviors that are a danger to themselves or others. It cannot be assured that staff will not utilize restraints over the 30 minute timeframe in the future, however, by offering these trainings to staff, it is our hopes that staff will adhere to the restrictive procedure policy and will do everything in their power to not only avoid restraints, but also be mindful that they are not to exceed 30 minutes in a 2 hour timeframe. In these trainings, staff will be retrained on healthy and safe alternatives to restraint. These trainings will be made in the near future to include all staff that work at this site. 03/11/2013 Implemented
SIN-00183922 Renewal 02/25/2021 Compliant - Finalized
SIN-00126901 Renewal 12/28/2017 Compliant - Finalized