Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00219568 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
SIN-00106773 Renewal 01/06/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)The written fire drill record for the fire drill held on 10-16-16 did not indicate the time. 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 review of the fire drill document took place with New Bethlehem 2 House Supervisor as well as TTSR secretary tasked with reviewing all fire drill documentation after submission to the office on 1/26/2017. At this meeting/ training, TTSR CEO and 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 New Bethlehem 2 site acknowledges that he 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. Attached is a signature page to show that the meeting between Secretary, house supervisor, TTSR CEO, and TTSR Assistant Director took place on 1/26/2017. [Within 30 days of receipt of the plan of correction, aforementioned trainings and procedures shall be implemented at all community homes to ensure a written fire drill record is 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. Documentation of trainings shall be kept. (AS 2/7/17)] 01/26/2017 Implemented
6400.112(d)Individual #1 had an evacuation time of 6 minutes for the fire drill held on 10-14-16 at 12:00 AM. There is not an extended evacuation time 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 10/14/2016 at 12:00AM which did state that one individual refused to get out of bed 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 refuse to leave his bedroom after a few minutes had passed since the start of the fire drill but did leave successfully after 6 minutes. When informed, TTSR Secretary did tell House Supervisor that he was to ensure that another fire drill was to take place within 48 hours 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 10/16/2016 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 10/16/2016, it was learned that Individual#1 participated in and properly evacuated the site within 2 minutes and 3 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) 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 10/14/2016. 01/26/2017 Implemented
SIN-00087546 Renewal 12/09/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(f)The initial assessment completed on 7/21/15 for Individual #1 was not sent to the entire team.(f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). 6400.181(f)- On Monday, 12/28/2015, TTSR CEO met with all TTSR Program Specialists who are in charge of attending all TTSR consumers¿ 3 month reviews of the ISP. The topic of this meeting/ training was to discuss the need for Program Specialists to ensure the following: 1)The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. 2)The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). By signing the attached signature page, all Program Specialists acknowledge that they received the training on the above mentioned topics on 12/28/2015 and attest that they understand that these steps must be done for all ISP reviews. TTSR Compliance Officer Joshua Altman will be tasked with oversight on this matter to ensure that all ISP documentation is submitted to the SCs and plan team members within 30 calendar days after the ISP review meeting and that all assessments are sent to SCs and plan team members within 30 calendar days prior to an ISP meeting.[Program Specialist and/or compliance officer will review all ISPs and invitations letters and other documents to ensure the entire plan team for all individuals are being sent the assessment. Documentation of correspondence to plan team members will be kept and a 25% sample will be reviewed by the CEO or designee at least quarterly for 1 year to ensure all plan team members are being sent the assessments as required. (AS 1/20/16)] 12/28/2015 Implemented
6400.186(d)The 3 month ISP review completed on 8/10/15 for the review period of 5/2/15 through 8/2/15 for Individual #1 was not sent to the entire team.The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. 6400.186(d)- On Monday, 12/28/2015, TTSR CEO met with all TTSR Program Specialists who are in charge of attending all TTSR consumers¿ 3 month reviews of the ISP. The topic of this meeting/ training was to discuss the need for Program Specialists to ensure the following: 1) The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting. 2) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). By signing the attached signature page, all Program Specialists acknowledge that they received the training on the above mentioned topics on 12/28/2015 and attest that they understand that these steps must be done for all ISP reviews. TTSR Compliance Officer will be tasked with oversight on this matter to ensure that all ISP documentation is submitted to the SCs and plan team members within 30 calendar days after the ISP review meeting and that all assessments are sent to SCs and plan team members within 30 calendar days prior to an ISP meeting.[Program Specialist and/or compliance officer will review all ISPs and invitations letters and other documents to ensure the entire plan team for all individuals are being sent the ISP reviews as required. Documentation of correspondence to plan team members will be kept and a 25% sample will be reviewed by the CEO or designee at least quarterly for 1 year to ensure all plan team members are being sent the ISP reviews as required. (AS 1/20/16)] 12/28/2015 Implemented
SIN-00259131 Renewal 01/22/2025 Compliant - Finalized
SIN-00183925 Renewal 02/25/2021 Compliant - Finalized