Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00219567 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
6400.182(c)The annual assessment for Individual #1, completed on 7/26/22, states that Individual #1 can evacuate independently in two and a half minutes; however, requires verbal prompting to hurry. Individual #1's Individual plan, last updated 2/23/23, in the Fire Safety section reads "[Individual #1] needs physical assistance with evacuating due to her balance if there is a fire and during fire drills."The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.On 2/23/2023, Program Specialist for TTSR e-mailed the Supports Coordinator for Individual #1. In the email, Program Specialist requested that the ISP be changed for [Individual #1] in the Fire Safety Section of the document. Supports Coordinator changed the ISP to reflect what is in the Assessment for [Individual #1]. The changes read, "[Individaul #1] can independently evacuate in the case of fire with minimal verbal prompts to hurry up. There are working smoke detectors in her home. [Individual #1] is able to call 911 in case of emergency. She knows her address and is working on her phone number. [Individaul #1] had fire safety training on 1/5/2023 with TTSR. She completes a monthly fire drill and is able to evacuate within 2 1/2 minutes and completes a night time fire drill 2 times per year" In the attached set of emails between PS and SC, you can see that the SC states that although the changes were made, that TTSR will not be able to see the changes for "several weeks" but when the Plan is updated and accessible to TTSR, TTSR will communicate with staff at the site of the changes so that they are aware whether it be by team meeting or a TTSR memo to the home for review. 02/23/2023 Implemented
SIN-00202195 Renewal 03/22/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.113(a)Individual #1, date of admission 6/23/21, received training in general fire safety 6/24/21. 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
SIN-00106770 Renewal 01/06/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.81(k)(5)Individual #1's bedroom does not have a closet or wardrobe. In bedrooms, each individual shall have the following: Closet or wardrobe space with clothing racks and shelves accessible to the individual. On 1/18/2017, TTSR maintenance department visited the site and asked Individual #1 what he wanted as far as clothing racks for his bedroom. Individual states that he wanted a bar going across the walls of the small closet space in the corner of his bedroom so as to hang shirts to go along with his dressers which hold his t shirts and bottoms. On 1/18/2017, TTSR maintenance department installed a bar in Individual¿s closet space so as to hang shirts. House supervisor will be tasked with making sure that the bar remains in the closet area to hang clothes so as to remain in compliance with regulation 6400.81(k)(5). During a meeting with house supervisor held on 1/18/2017, a review of regulation 6400.81(k)(5) took place and acknowledges (by signing the attached meeting signature page) that he will ensure that Individual #1 has access to a closet space to hang clothing at all times through routine house inspections. TTSR Administrative staff will conduct random and routine house inspections throughout the year to see that all 6400 regulations are met in the home. Attached is a photo taken on 1/18/2017 which shows Individual¿s clothes hanging in closet area. [Immediately and at least quarterly, a designates staff person shall check all community homes to ensure all individuals' bedroom have a closet or wardrobe space with clothing racks and shelves accessible to the individual. (AS 2/7/17)] 01/18/2017 Implemented
6400.112(d)The fire drill held on 2-27-16 at 4:10 PM had an evacuation time of 2 minutes and 45 seconds. There is not a extended evacuation time specified in writing by a fire safety expert. Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. After review of the Fire Log for this site, TTSR Administration did see that there was a fire drill conducted on 2/27/2016 at 4:10PM which did state that one individual refused to leave his bedroom and participate in the fire drill. After review, it was learned that the House supervisor did call TTSR Administrative Secretary to report that Individual #1 did initially refuse to leave his home after a few minutes had passed since the start of the fire drill but did leave successfully after 2 minutes and 45 seconds. When informed, TTSR Secretary did tell House Supervisor that she was to ensure that another fire drill was to take place and that Individual #1 was to be retrained on the importance of participating in fire drills. After review, TTSR has learned that another fire drill took place on 3/7/2016 to ensure that Individual #1 participated and was again trained on the importance of participating in fire drills through the process of review of general Fire Safety talking points reviewed with all consumers during every fire drill (fire safety, evacuation procedures, responsibilities, meeting place, and smoking safety for those who smoke). During the fire drill which took place on 3/7/2016, it was learned that Individual#1 participated in and properly evacuated the site in 2 minutes and 30 seconds. It was also learned that this refusal to participate in fire drills was an isolated instance and all other fire drills were participated in throughout the year and all individuals residing at this site were successfully able to evacuate within 2 minutes and 30 seconds (average was close to 2 minutes and 30 seconds) throughout the year. There were no changes made to the structure of this home nor is there a ¿fire safe room¿ in the home. Attached is a ¿Fire System Check/ Fire Drill Report¿ which shows results of fire drill which was performed with Individual#1 who refused the fire drill on 3/7/2016. 01/26/2017 Implemented
SIN-00054355 Renewal 01/07/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The home's license expired on January 6, 2014. The self- inspection was completed on 4/17/13 and 4/22/13 which is more than 6 months prior to the license expiration date. Repeat Violation 10/16/12, et al.(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. On 1/30/2014, Training Toward Self Reliance, Inc. CEO as well as the Assistant Director for TTSR met at approx. 10:00AM to discuss the findings of the Licensing Inspection that was held on January 7th, 2014 through January 9th, 2014. One of the areas of non-compliance for all TTSR sites reads, ¿The home's license expired on January 6, 2014. The self- inspection was completed on 4/30/13 which is more than 6 months prior to the license expiration date.¿ During this meeting between the CEO and Assistant Director, it was agreed upon that after review of the regulations associated with this area of non-compliance that the Assistant Director as well as the CEO will be solely responsible for not only the inspection of all TTSR sites agency-wide, but also will ensure that the Licensing Score sheets are completed in the time frame designated by PA Code Chapter 6400.15 (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.) To ensure that the assessments are completed in the time allotted, TTSR CEO as well as Assistant Director will complete the above mentioned tasks during the months of September and October 2014 (which is within the 3 to 6 month timeframe allotted for completion of this task as our License will be set to expire in January of 2015). TTSR CEO will maintain these Score sheets for submission during the next State Licensing Inspection in 2015. Attached in binder is a signed document which shows that the meeting took place on 1/30/2014. 01/30/2014 Implemented
SIN-00043550 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
6400.62(a)On 10/17/12, power steering fluid, spray cleaner with bleach, and interior paint were found unlocked in the basement area of the home. All individuals in the home are not able to safely use and recognize poisons. (Fully implemented 4/11/2013 CEM)(a) Poisonous materials shall be kept locked or made inaccessible to individuals. Items were locked on scene during the inspection. On 10/18/2012, the items in question were found to be locked in a secure cabinet. On 3/12/2013, trained inspectors who conduct house inspections on a monthly basis using the House Monthly Monitoring Tool inspected this site (see attached monitoring tool). Attached to the Monitoring tool is a sign off sheet for those TTSR administrators who were trained on 3/11/2013 (curriculum attached). Attached is also a sign in sheet and curriculum for a 6400 Regulations/ restrictive procedure policy training which was held on 3/14/2013 which was held for all house supervisors. House supervisors will be responsible for implementing and monitoring of all policies and procedures pertaining to regulations associated with meeting the compliance set forth by 6400 regulations. TTSR administration will serve as oversight as the monthly inspectors to ensure that compliance standards are maintained. 03/11/2013 Implemented
6400.65On 10/17/12, the bathroom in Individual #1's bedroom did not have any form of ventilation. (Fully implemented 4/11/2013 CEM)Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. On 10/18/2012, a ventilation fan was installed in the bathroom (see attched). On 3/12/2013, trained inspectors who conduct house inspections on a monthly basis using the House Monthly Monitoring Tool inspected this site (see attached monitoring tool). Attached to the Monitoring tool is a sign off sheet for those TTSR administrators who were trained on 3/11/2013 (curriculum attached). Attached is also a sign in sheet and curriculum for a 6400 Regulations/ restrictive procedure policy training which was held on 3/14/2013 which was held for all house supervisors. House supervisors will be responsible for implementing and monitoring of all policies and procedures pertaining to regulations associated with meeting the compliance set forth by 6400 regulations. TTSR administration will serve as oversight as the monthly inspectors to ensure that compliance standards are maintained. 03/11/2013 Implemented
SIN-00259129 Renewal 01/22/2025 Compliant - Finalized
SIN-00166536 Renewal 11/13/2019 Compliant - Finalized