| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | On 1/31/24, at 11:49 AM, the miniature refrigerator in Individual #1's bedroom had food particles and brown sticky substances throughout the shelves and the inside door. | Clean and sanitary conditions shall be maintained in the home. | During licensing inspection, the personal hotel sized refrigerator belonging to Individual #1 was deemed to have been unsanitary and potential risk to Individual #1s health. Upon completion of the inspection of the house, staff talked to Individual#1 and he stated that the refrigerator was not operable, hence why he felt he did not have to clean it. When asked if he wanted to keep the refrigerator in his room, Individual#1 stated that he no longer wanted to have this or any other refrigerator in his bedroom and was content with using the house refrigerator located in the kitchen of the home. When asked what he wanted to do with his inoperable refrigerator, IndividuAl#1 stated that he wanted to ¿throw it away¿. Staff threw away the refrigerator on 1/31/2024 per Individual #1¿s wishes.
A retrain took place on 2/6/2024 in which site supervisor as well as Individual#1 received a training on regulation 64(a) and a discussion took place about the importance of clean and sanitary conditions in the home at all times. Also on the sign off sheet for training is a signature for Individual #1 stating that he acknowledges that his wishes were to ¿throw away¿ the inoperable refrigerator and that he does not wish to possess a personal refrigerator at this time. |
02/06/2024
| Implemented |
| 6400.72(a) | On 1/31/24, the two windows located in the staff office of the home did not have a screen. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | At time of licensing inspection, the screens in the staff room windows were found to not be place d in the windows. Although the screens were on site in the staff room, they were not positioned in the windows. TTSR Head of Maintenance inserted the screens into the windows on 1/31/2024. Attached to POC is a photo of the screens in the windows and the photo was taken on 2/6/2024.
Compliance will be assessed through routine monthly inspections by site staff, site supervisor, as well as TTSR Administrative staff (unannounced site inspections) and TTSR will continue to ensure that this window remains coupled with suitable screens at all times.
At retrain on regulation 72(a) took place on 2/6/2024. During this retrain, staff as well as appropriate members of the TTSR Administrative staff reviewed regulation and acknowledge that compliance will be assured and that all windows shall be securely screened when windows or doors are open. |
02/06/2024
| Implemented |
| 6400.72(b) | On 1 /31/24 the two windows in Individual #2's bedroom have been screwed shut. | Screens, windows and doors shall be in good repair. | During licensing inspection of the home, the windows in Individual#2¿s bedroom were screwed shut. The reason for these windows being inoperable was due to recent unsafe and dangerous behaviors exhibited by Individual#2 to include elopement, stealing neighborhood property, entering without consent into neighbor¿s homes and property, and several incidents of police interventions. In the Individual¿s ISP, it does not read that Individual#2 can have his windows screwed shut for safety reasons. For this reason, TTSR Head of Maintenance unscrewed the windows and the windows can now be opened by individual#2. Attached to POC is a photo taken on 2/6/2024 that shows that both windows are unscrewed and able to be opened.
Until such time as plans can be changed to allow for this safety precaution, TTSR will ensure through routine (monthly) site inspections by direct care staff, site supervisor, as well as TTSR Administration occur and that the windows are able to be opened at all times to meet compliance with regulation 72(b).
A retrain on regulation 72(b) took place with site supervisor, TTSR Administration as well as Head of Maintenance on 2/6/2024 to review regulation 72(b) and ensure that windows are always able to be opened and are not screwed shut prohibiting exit. |
02/06/2024
| Implemented |
| 6400.73(a) | On 1/31/24 there was not well-secured handrail for the three exterior steps located outside the front entrance of the home. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | During licensing inspection, it was determined that because the front door steps has at least three steps that the stairway requires that a railing be placed on the side for safety reasons. On 2/6/2024, TTSR Head of Maintenance placed a railing on the stairway leading to the front door. Attached to POC is a photo taken 2/6/2024 which shows the new railing on the stairway.
To ensure compliance year round, routine site inspections by TTSR Administration as well as staff, site supervisor, and Maintenance department, TTSR will ensure that the railing remains intact and has no movement when utilized to ensure the safety of anyone that uses the railing to enter or exit the home through the front door.
On 2/6/2024, all parties received a retrain on regulation 73(a). All parties acknowledge the need for a railing in the event that the step count exceeds 2 stairs. |
02/06/2024
| Implemented |
| 6400.81(k)(3) | On 1/31/24, at 12:14 PM, there were no linens on Individual #1's mattress in his bedroom. | In bedrooms, each individual shall have the following: Bedding, including pillow, linens and blankets appropriate for the season. | On 2/1/2024, TTSR CEO provided Individual#1 with bed sheets when it was discovered during licensing inspection that the bed sheets that he had did not fit his bed. CEO had purchased and provided Individual #1 with twin fitting sheets to fit his twin bed mattress on 2/1/2024. During a meeting/ retrain with Site Supervisor held on 2/2/2024, a review of regulation 81(k)(3) took place and Site Supervisor acknowledges that he will perform routine (weekly/ monthly) house checks and will relay to TTSR CEO any needs for the individuals/ house to ensure that their needs/ wants are met. TTSR Administrative staff will also conduct random and routine house inspections throughout the year to see that all are met in the home.
Attached is a photo of the bed sheets on the bed in Individual#1¿s bedroom on 2/1/2024. |
02/02/2024
| Implemented |
| 6400.81(k)(6) | On 1/31/24 there was no mirror in Individual #1's bedroom. | In bedrooms, each individual shall have the following: A mirror. | On 2/2/2024, a mirror was placed on Individual #1¿s wall. House supervisor will be tasked with making sure that a mirror remains on the walls of the individual who resides at this site to remain in compliance with regulation 6400.81(k)(6). During a meeting with house supervisor held on 2/2/2024, a review of regulation 6400.81(k)(6) took place and site supervisor acknowledges (by signing the attached meeting signature page) that he will ensure that there is a mirror in the bedroom at all times through routine bedroom inspections. TTSR Administrative staff will conduct random and routine house inspections throughout the year to see that all are met in the home. In the event that an individual wishes to not have a mirror in their bedroom, TTSR will apply for a waiver to request that a mirror not be placed in the bedroom. Until such time as a waiver is obtained, the mirror will remain in the individual¿s bedroom to ensure regulation compliance.
Attached is a photo of a mirror that was placed in Individual#1¿s bedroom on 2/2/2024. |
02/02/2024
| Implemented |
| 6400.82(d) | On 1/31/24, at 12:22 PM, the door in the bathroom of the basement of the home is a swing door with no doorknob or latch and does not securely close to ensure privacy while in use. | Privacy shall be provided for toilets, showers and bathtubs by partitions or doors. Curtains are acceptable dividers if the bathroom is used only by one sex or only by individuals 9 years of age or younger. | During licensing inspection, the basement bathroom door did not lock for privacy 82(d). On 2/8/2024, TTSR Head of Maintenance purchased a brand new door and door handle that locks and installed both in the bathroom and replacing the door that did not lock. Attached to POC is a photo of the door with lock (taken on 2/8/2024). |
02/08/2024
| Implemented |
| 6400.82(e) | On 1/31/24 there was not a nonslip surface or mat in the shower located in the basement of the home. | Bathtubs and showers shall have a nonslip surface or mat. | During licensing inspection, it was found that the basement shower did not have a non-skid/ non-slip surface inside the shower. On 1/31/2024, TTSR Site Supervisor purchased a non-skid pad and placed it in the shower to meet compliance standards as identified under regulation 82 (e) . As an extra precaution, a bath mat was also purchased and placed at the foot of the entry to the shower. |
02/06/2024
| Implemented |
| 6400.163(a) | On 1/31/24, at 11:49 AM, a bottle of Allergy Relief Eye Drops without the original labeled container was on top of the dresser in Individual #1's bedroom. | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | During licensing inspection, it was found that Individual #1 had purchased (personal funds) eye drops to be used any time that his eyes felt dry or ¿scratchy¿ (allergies). The bottle was found in his bedroom and not locked in the double locked medication cabinet located in the staff room. The bottle was immediately placed in the locked medication cabinet in the staff room and then the room was secured and locked by staff ensuring compliance (1/31/2024).
A training/ discussion took place on 2/7/2024 in which Individual #1 and Site Supervisor were retrained on regulations 163(a)- medication not being in original container and regulation 163(d)- medication not locked appropriately double locked in staff office. During this retrain, both recipients were retrained on the need for locking medications and ensuring that all medication remain in their original container regardless of whether or not the medication is an over- the-counter medication or prescribed. Both parties also were retrained on the importance of adding the eye drops to the MAR for effective record keeping. Attached is a signature page acknowledging that both received a retrain on the above mentioned regulations and they agree to adhere to the regulations to ensure compliance moving forward.
Compliance will be assessed through routine monthly inspections by site staff, site supervisor, as well as TTSR Administrative staff (unannounced site inspections) and TTSR will continue to ensure that all medications are kept in their original containers at all times and that all medications will be locked securely behind double locks in order to achieve compliance. |
02/07/2024
| Implemented |
| 6400.163(d) | On 1/31/24, at 11:49 AM, a bottle of Allergy Relief Eye Drops were on the dresser in Individual #1's bedroom. Individual #1 does not self-administer medications. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | During licensing inspection, it was found that Individual #1 had purchased (personal funds) eye drops to be used any time that his eyes felt dry or ¿scratchy¿ (allergies). The bottle was found in his bedroom and not locked in the double locked medication cabinet located in the staff room. The bottle was immediately placed in the locked medication cabinet in the staff room and then the room was secured and locked by staff ensuring compliance (1/31/2024).
A training/ discussion took place on 2/7/2024 in which Individual #1 and Site Supervisor were retrained on regulations 163(a)- medication not being in original container and regulation 163(d)- medication not locked appropriately double locked in staff office. During this retrain, both recipients were retrained on the need for locking medications and ensuring that all medication remain in their original container regardless of whether or not the medication is an over- the-counter medication or prescribed. Both parties also were retrained on the importance of adding the eye drops to the MAR for effective record keeping. Attached is a signature page acknowledging that both received a retrain on the above mentioned regulations and they agree to adhere to the regulations to ensure compliance moving forward. |
02/07/2024
| Implemented |