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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.213(1)(i) | Individual #1's record did not include identifying marks. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. (ii) The race, height, weight, color of hair, color of eyes and identifying marks. | On 2/2/2024, TTSR Compliance Officer met with TTSR Residential Coordinator as well as Program Specialists who oversee the caseloads for Individual #1 and all of TTSR¿s consumers, and a discussion/ training was had on the need for any identifying marks/ characteristics for newly admitted individuals into TTSR¿s care to be noted on the individual¿s Identification Sheet. The Program Specialists stated that when a new admission comes to TTSR, that he/ she will ensure that this question is asked of the individual (if not already identified on the TTSR Admission packet prior to admission) and will mark any physical identifying marks down on their admission packet. If any identifying marks or characteristics are found during the initial intake process interview, the Program Specialist will convey this information (as well as other pertinent information required on the individual¿s Identification Sheet) to the TTSR Residential Coordinator who is in charge of completing the Identification Sheet to be maintained on the TTSR server as well as in the Individual¿s documentation books.
Attached is a copy of individual #1¿s Personal Identification Sheet which shows that the individual was asked by TTSR Program Specialist, if he had any identifying marks and the individual stated that he did not (2/2/2024). Program Specialist also relayed to Residential Coordinator that no identifying marks were found at initial intake interview. For this reason, TTSR has marked on Individual #1¿s Identification Sheet ¿None¿ for Identifying Characteristics/ Marks. Also attached is a signature page which shows that TTSR Compliance met with all parties involved to review regulation 213(1)(ii) and agree to follow mentioned procedures when initial intake of any new consumer takes place. |
02/02/2024
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(c) | The fire drill conducted 1/21/22 did not include the 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. | A retrain was held on 4/1/2022 for all supervisors who had areas of non-compliance during the licensing inspection as it pertains to fire drills and PA Code Chapter 6400.112(c). A full retrain of all areas of need for each fire drill (to include 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, review of the revised fire drill process as well as a review of the revised fire drill checklist ) was conducted in which these identified supervisors were retaught all regulations regarding fire safety. Attached is a copy of the sign off sheet which indicates that this retrain took place and that all site supervisors acknowledge that they are aware and will be responsible for initial review of all fire drills before submission to the Administrative office for second review. If areas of the fire drill are found during initial review, supervisor will ensure that feedback is given to the staff and another fire drill will be conducted during that shift with those same staff until the fire drill and all documentation is completed as needed and is compliant with Pa 55 Code standards. |
04/01/2022
| Implemented |
| 6400.113(a) | Individual #1had fire safety training 1/10/20 and then again 1/10/22 | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | TTSR was unable to conduct its annual fire safety training for all staff and individuals within the agency during January of 2021. The reason for not being able to offer this training was due to the COVID-19 pandemic and state and local regulations prohibiting gathering s of people over a certain number as well as the uncertainty and severity of the virus and pandemic itself. Also during this time when TTSR normally has its annual fire safety training for all staff and individuals, Clarion County was experiencing high numbers of confirmed COVID cases throughout the area. It was deemed necessary to cancel the scheduled trainings in order to keep both the individuals and staff safe from the virus and pandemic. At the time the decision was made to cancel the annual fire safety training, TTSR was unaware that there were oversight approved videos that could be watched in lieu of a formal face to face training as TTSR is accustomed to doing. TTSR was successfully able to complete and offer the annual fire safety which took place on January 10th and 11th , 2022 and we, as an agency, are compliant until January of 2023. In the event that TTSR is unable to, in the future, conduct mandatory trainings in order to compliance in whatever area is needed, TTSR is looking to purchase Fire Safety videos that are ODP approved and meet the requirements for for compliance as it relates to 55 PA Code Chapter 6400.113(a). TTSR has already purchased fire safety videos called ¿Fire Safety Training, Training For Anyone Including Individuals With Developmental Disabilities And For Persons Providing Them Services¿. These videos are distributed by Program Development Associates (www.Disability Training.com) and will be maintained at each site and will be used in the event that TTSR can not conduct our Annual Fire Safety Training face to face and in large numbers. TTSR is also looking into a company named Reliant to research what offerings they have in the event that we can not offer Fire Safety training in-person and need to seek approved fire safety trainings on-line for both staff and individuals. Lastly, TTSR is looking into videos called, ¿Get Out Alive¿ which we were told were ODp approved videos that meet requirements for fire safety training for both individuals and staff. |
04/01/2022
| Implemented |
| 6400.166(a)(11) | Individual #1's March 2022 medication administration record did not include the diagnosis or purpose for each medication. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | A review of 55PA Code Chapter 6400.166(a)(11)took place with TTSR Administrator and Residential Coordinator who met with TTSR Assistant Director and TTSR Compliance Officer. This meeting took place on 3/31/2022 and the review consisted of the following:
¿ Violation found during licensing inspection in which the MARS for identified individuals did not contain the diagnosis or purpose of medications prescribed by a physician on the MAR for staff knowledge.
¿ Need for all MARS agency-wide to include the diagnosis and purpose for all medications prescribed by a physician to include pro re nata medications
Compliance will be measured during routine monthly reviews and checks of all MARS received from the pharmacy to ensure that all MARS have all required information including the diagnosis and purpose for all medications prescribed by a physician to include pro re nata medications. TTSR Residential Coordinator states that the pharmacy responsible for the creation of all MARS was informed of the need to reflect diagnosis and purpose of all prescribed medications on the MARS on 3/29/2022. On 3/30/2022, TTSR also received the MARS for April 2022 but Residential Coordinator has hand written all diagnosis and purposes on the MARS (hand written) and this will ensure that all staff are aware of the purpose of each medication for the month until the pharmacy makes the needed additions starting in May of 2022. Attached is a copy of the MAR for individual #1 which shows that the MAR which will be used to track medications administered shows the diagnosis or purpose of each medication for the individual for the month of April 2022. Also attached is the sign off sheet that shows that the Residential Coordinator was retrained on 55PA Code Chapter 6400.166(a)(11) and that the pharmacy who creates the MARS for individuals at TTSR will show diagnosis and purpose of all medications for every TTSR individual. |
03/29/2022
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC 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 |
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