Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00147194 Renewal 12/13/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.151(c)(2)Direct Service Worker #1 had a Tuberculin skin test completed on 2/3/16 then again 3/8/18. The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. During licensing inspection, it was learned that Staff#1 did not have a TB Test performed and read within 2 years of previous physical examination and TB/ Mantoux test After looking at our records, it was learned that Staff #1 had last received a TB/ Mantoux test on February 3rd of 2016. Current records show that this staff did not receive the next TB/ Mantoux test for 2018 until February 28th of 2018. During a meeting held on 12/19/2018, TTSR CEO met with members of the Human Resource Department and a review of Pa. Code Chapter 6400.151(c)(2) took place. The regulation states, ¿Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician¿s assistant or certified nurse practitioner.¿TTSR Human Resource Department states that when monitoring all staff for needed physicals and TB tests, that they had thought that Staff#1 was not due for a physical until the end of February as their records had indicated. When learned of the actual date that the TB test was due after licensing inspection, the records were changed to the appropriate date to ensure that Staff #1 receives the TB test within 2 years of the date of last test.In the future, all records for staff physical due dates will be reviewed by TTSR Human Resource Coordinator and their monitoring tool will be updated to ensure that all staff working for TTSR have received their physicals and TB tests with results within 2 years of previous physical and TB test. By signing attached signature page, all parties present at time of this review acknowledge that they reviewed Pa. Code Chapter 6400.151(c)(2) and they understand the regulation and will adhere to ensuring that all staff receive TB tests within 2 years of the previous TB test. [Immediately and at least quarterly for 1 year, the CEO or designee shall audit the aforementioned tracking system to ensure all staff persons' Tuberculin skin testing records are up to date and completed timely. (DPOC by AES,HSLS on 12/28/18)] 12/19/2018 Implemented
6400.167(b)Clindamycin 1.2% Benz 5% apply once daily prescribed for Individual #1 was initialed as administer on 12/14/18 at 8:00AM; however, on 12/14/18 at approximately 11:30 AM the medication was not available in the home. Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant.At time of licensing inspection, Clindamycin 1.2% Benz 5% apply once daily prescribed for Individual #1 was initialed as administer on 12/14/18 at 8:00AM; however, on 12/14/18 at approximately 11:30 AM the medication was not available in the home.After the closing interview conducted by State Licensing Agents, TTSR Nurse travelled to the site to look for the missing medication. The Clindamycin 1.2% Benz 5% was found in a cluttered drawer of prescribed medications and lotions (some that are listed on the MAR and some lotions that are not medicated but maintained in the drawer). TTSR Nurse compared the MAR to those medications and lotions and maintained ONLY the listed medications on MAR which will be kept double locked. The other non-prescribed lotions and over the counter medications were moved and will be maintained in a separate drawer of the filing cabinet still double locked. TTSR Nurse will do random and routine monthly checks of the medication drawer for all TTSR individuals to ensure that medications listed on the MAR are present and easy for any TTSR Medication Administration Certified staff to find and administer.By signing the attached signature page, all parties present acknowledge that they have reviewed Pa. Code Chapter 6400.167(b) and will follow the above mentioned protocol for ensuring that all medications are present at the site at all times and can be found easily by all administrators of medication. [Documentation of the aforementioned audits shall be kept. (DPOC by AES, HSLS on 12/28/18)] 12/14/2018 Implemented
SIN-00087541 Renewal 12/08/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.85(b)The wooden gate leading to the three feet and 6 inches high above ground swimming pool was not latched and the padlock on the aforementioned gate was unlocked. An aboveground swimming pool that is under 4 feet in height shall be made inaccessible to individuals when the pool is not in use.6400.85(b)- Attached is a picture of the gate that leads to the 3 foot 6 inch swimming pool located adjacent to the Glory Apartment 2 site. As pictured, staff have secured the lock as well as the latch to the entrance door to the pool. [Documentation of the aforementioned monthly monitoring of each community home by the TTSR administration will be maintained and review will by the CEO or designee at least quarterly for completion and accuracy. (AS 1/20/16)] House Supervisor, Amanda Riggle was called in to TTSR Administrative Office on 12/28/2015. A meeting was held to discuss regulation 6400.85 (b) in which ¿an above ground pool that is under 4 feet in height shall be made inaccessible to individuals when the pool is not in use.¿ By signing the attached document, Amanda acknowledges that the pool is under the 4 foot mark and must be locked when not in use. Amanda will be entrusted to make sure on a regular basis (daily basis during warm weather climates) that the lock to the pool is locked and the latch secured closed. TTSR administration will conduct routine site checks of all TTSR homes and will oversee that the lock and latch are secure when inspecting this site. 12/28/2015 Implemented
6400.112(c)The written fire drill record for the fire drill conducted on 12/10/14 did not include the amount of time it took for evacuation.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. 6400.112(c)- A review of the fire drill document took place with Glory Apartment 2 House Supervisor on 12/28/2015. At this meeting/ training, TTSR Assistant Director reviewed the Fire Drill document and detailed all areas that need to be performed and documented at the time of each and every fire drill conducted at this site on a monthly basis. Areas that need to be documented on the form each month include but are not limited to date, time, amount of time it took to evacuate, the exit route used, problems encountered, and whether the fire alarm or smoke detector was operative. House supervisor for Glory Apartment acknowledges that she will be in charge of reviewing all fire drills before submission to the TTSR administrative office and will follow up with staff (who performed the drill) if any of the above mentioned information is missing from the fire drill document. Once turned into TTSR administrative offices, TTSR secretary will again review the document for completeness and will follow up with appropriate staff if document is incomplete. 12/28/2015 Implemented
SIN-00043547 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
SIN-00238689 Renewal 01/30/2024 Compliant - Finalized
SIN-00202189 Renewal 03/22/2022 Compliant - Finalized
SIN-00166533 Renewal 11/13/2019 Compliant - Finalized