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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.81(k)(5) | Individual #1's bedroom does not have 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 1/25/2017, TTSR maintenance department visited the site of Individual #1. TTSR maintenance department installed a bar/ clothes rack in Individual¿s bedroom so as to hang shirts and pants if desired. House supervisor will be tasked with making sure that the bar/ rack remains in the bedroom and is accessible to the consumer so as to hang clothes and remain in compliance with regulation 6400.81(k)(5). During a meeting with house supervisor, Ryan Truitt held on 1/25/2017, a review of regulation 6400.81(k)(5) took place and Ryan acknowledges (by signing the attached meeting signature page) that he will ensure that Individual #1 has access to a rack or bar to hang clothing at all times through routine bedroom 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 1/25/2017 which shows Individual¿s clothes hanging in bedroom.[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)] |
01/25/2017
| Implemented |
| 6400.81(k)(6) | Individual #1's bedroom does not have a mirror. | In bedrooms, each individual shall have the following: A mirror. | On 1/9/2017, 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, Ryan Truitt held on 1/9/2017, a review of regulation 6400.81(k)(6) took place and Ryan 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 6400 regulations 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. Attached is a photo of mirror in bedroom of Individual #1.[Immediately and at least quarterly, a designated staff person shall check all individuals' bedrooms to ensure each individual has a mirror as required. House supervisor shall educate all staff persons working in community homes that each individual shall have a mirror in their bedroom and to monitor thoughout the course of their duties. (AS 2/7/17) |
01/09/2017
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | 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. 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 |
| 6400.81(k)(2) | Individual # 1 had a queen size mattress on the floor of his/her bedroom with no box spring and no foundation. | (2) A clean, comfortable mattress and solid foundation.
| On 2/6/2014,TTSR Trainer/ Maintenance Department Worker, John Michael purchased a new box spring from Fallers Furniture in Clarion, PA. This box spring was assembled and placed under the mattress of Individual #1 who resides at 22 Theiss Road in Knox, PA (see attached photo).
All furnishings to include, but not be limited to couches, mattresses, box springs, dressers, etc. will be inspected on a bi-monthly basis by TTSR Administrative staff to ensure that all sites meet the requirements set forth in 6400 regulations. Any needed repairs will be done on an as needed basis by TTSR Maintenance department so that all TTSR homes remain in compliance.
By signing below, John Michael acknowledges that he conducted the above mentioned tasks to ensure that the bed box spring was purchased, assembled, and installed to the bedroom located at 22 Theiss Road in Knox, PA. and that this box spring meets the licensing regulations (see attached signature page).
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02/06/2014
| Implemented |
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