| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.72(b) | On 10/29/25, at 9:39 AM, there were twenty irregularly shaped holes and indentations on the interior side of Individual #2's bedroom door. | Screens, windows and doors shall be in good repair. | During licensing inspection, it was found that one of the bedroom doors in Individual#1's bedroom had holes in it. TTSR Head of Maintenance measured and found another door that fit into the existing space and inserted it into the bedroom entry way (Attached photo from 10/29/2025).
A review of regulation 72(b) took place on 10/30/2025 and the topic of discussion centered around the need for all window, screens, and doors will be in good repair. |
10/30/2025
| Implemented |
| 6400.104 | Individual #1's current assessment, completed on 6/27/25, informs that they cannot evacuate within 2.5 minutes without physical assistance and direction every time. Individual #1's Service Plan, last updated 6/25/25, states that Individual #1 is ambulatory, but requires assistance to evacuate a building in the event of a fire. However, the home's Fire Department Notification Letter, dated 1/21/21, neither indicated that any of the home's residing individuals need assistance to evacuate, nor provided the exact location of Individual #1's bedroom. This Fire Department Notification Letter stated, "Please find enclosed a copy of a floor plan." However, no floor plan was attached. In addition, interviews conducted with the agency on 10/29/25 revealed that the home's floor plan referenced in this letter is posted in the home and is not sent to the local fire department. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| (6400.104)- During licensing inspection, it was found that Individual #1's current assessment, completed on 6/27/25, informs that they cannot evacuate within 2.5 minutes without physical assistance and direction every time. Individual #1's Service Plan, last updated 6/25/25, states that Individual #1 is ambulatory, but requires assistance to evacuate a building in the event of a fire. However, the home's Fire Department Notification Letter, dated 1/21/21, neither indicated that any of the home's residing individuals need assistance to evacuate, nor provided the exact location of Individual #1's bedroom. This Fire Department Notification Letter stated, "Please find enclosed a copy of a floor plan." However, no floor plan was attached. In addition, interviews conducted with the agency on 10/29/25 revealed that the home's floor plan referenced in this letter is posted in the home and is not sent to the local fire department.
On 11/14/2025, TTSR Compliance Officer revised the letter to Fire Chief and the revised letter states, "Both Individuals have an unsteady gait and need assistance exiting." Also, Compliance Officer revised the map of the home and both bedrooms are marked with a caption, "Location of Individuals requiring assistance". Both of these letters were sent via mail to the Sligo Fire Hall on 11/14/2025 and both items were put to the attention of the Sligo Fire Chief. Both items will be sent to reviewer. |
11/14/2025
| Implemented |
| 6400.113(a) | Individual #1's has not completed training 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. | 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. | 113(a)- During licensing inspection, it was found that two Individuals did not receive the Annual Fire Safety training within one year of the previous Fire Safety training. One Individual had Fire Safety training on 1/10/2025. There is no record of Individual #1 attending Fire Safety training in 2024. Records could not be found nor offered to licensing inspectors for proof of attendance of Fire Safety for Individual #2 in 2025 and 2024. TTSR has, in the past, scheduled all Fire Safety trainings in the month on January .
As a Corrective Action, a review of regulation 6400.113(a) took place on 11/12/2025 with TTSR Compliance Officer. The topic of discussion was regulation 113(a) and how best to ensure that all DSPs and Individuals receive the Fire Safety within one year of previous training.
TTSR has scheduled the Annual Fire Safety training for December 15th and 16th, 2025 (within the one year allotted timeframe from the last Fire Safety training which was held on January 9th and 10th, 2025). A memo was generated and sent to all locations to include the Administrative building to inform all TTSR Employees and Individuals residing, of the need to attend this mandatory and annual training. For any staff or Individual that can not attend this two day mandatory training, arrangements must be made with TTSR Compliance Officer to schedule a time to receive this mandatory Fire Safety training before the one year timeframe allotted since last Fire Safety training.
To ensure compliance, TTSR Compliance Officer is tasked with maintaining current staff rosters as well as Individual rosters and will review these rosters on a weekly basis until all DSPs and Individuals have received the required and mandatory training within one year of last training.
By signing, TTSR Compliance Officer acknowledges that he has received a retrain on regulation 6400.113(a) and will ensure that he reviews staff and Individual rosters on a weekly basis until all DSPs and Individuals have received this required and mandatory training. |
11/12/2025
| Implemented |
| 6400.141(c)(9) | Individual #1 last had a prostate-specific antigen blood test completed on 10/13/25. However, Individual #1's content of records did not include documentation demonstrating that they had a prostate examination or screening completed in 2024. Therefore, compliance with the annual requirement could not be measured. Individual #1 is 40 years of age or older. | The physical examination shall include: A prostate examination for men 40 years of age or older. | 6400.141(c)(9)- Individual #1 last had a prostate-specific antigen blood test completed on 10/13/25. However, Individual #1's content of records did not include documentation demonstrating that they had a prostate examination or screening completed in 2024. Therefore, compliance with the annual requirement could not be measured. Individual #1 is 40 years of age or older.
On 10/30/2025, Residential Coordinator, who is tasked with making appointments and reviewing all documentation associated with each appointment was retrained on regulation 6400.141(c)(9). Additional section added to the Annual Physical Exam Form which reads, "Prostate/ PSA (age 40 or older" to ensure that medical professionals provide the needed and mandatory prostate exam at each physical on an annual basis (attached page 4). Moreover, Residential Coordinator has developed a list of all individuals aged 40 or older and provided this list to all PCP for each individual to ensure that they receive this screening at each annual physical in the future. Residential Coordinator will be responsible for reviewing each physical received and making sure that any Individual over the age of 40 received a prostate screening. |
10/30/2025
| Implemented |
| 6400.142(g) | Individual #1's most recent written dental hygiene plan was completed on 10/22/24. This exceeds the annual requirement. | A dental hygiene plan shall be rewritten at least annually. | During licensing inspection, it was found that after review of health records, the "Dental Care Contact" form was geared more toward individuals that have teeth and not those who do not have teeth. Doctors in the past were completing the form by simply writing, "N/A" for how many times the individual should be brushing his teeth and how many times the individual should be flossing. This form did not identify for those without teeth, how many times a day the individual should be using mouthwash/ swab gums. Also, the plan needs to be re-written annually and the last documented dental hygiene plan was dated for 10/22/2024.
TTSR Residential Coordinator made additions to the attached Dental Care Contact form to add, "If no teeth, how many times a day should they (individual) use mouthwash/ swab gums?". This form will be signed and dated by the licensed dentist annually during each visit/ examination. Also, this question was added to the Individuals' Dental Hygiene Plan which will be completed/ updated annually by Residential Coordinator.
A review of regulation 142(g) took place on 10/30/2025. Residential Coordinator will be tasked with making sure that upon receipt of any Dental Care Contact, that she will review for completeness and any changes made to dental plan will be forwarded to appropriate TTSR Program Specialist. This will alert program Specialists that any plans that require updating receive the specific changes made to ensure that all staff are made aware of the changes and can implement those changes into the Individual's daily care. |
10/30/2025
| Implemented |
| 6400.143(a) | Individual #1's date-of-birth is 6/14/67. The agency provided physician documentation showing Individual #1 had a prostate-specific antigen blood test that was cancelled on 9/5/24. Agency interviews conducted on 10/29/25 revealed that Individual #1's prostate-specific antigen blood test was cancelled on 9/5/24, due to refusal behaviors. However, Individual #1's content of records included neither documentation of Individual #1's refusal of the prostate-specific antigen blood test that had been cancelled on 9/5/24, nor continued attempts to train them regarding the need for health care. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | On 11/3/2025, TTSR Residential Coordinator received a retrain on regulation 6400.143(a). After review, Residential Coordinator revised the existing "Refusal Of Medical Appointment Document" to reflect the need for explanation of why the Individual was refusing the medical appointment as well as a section on how the Individual was provided with follow up counseling or training on the importance of attending all medical appointments (Attached). Residential Coordinator will be responsible for ensuring that any Individual that refuses a medical appointment will receive this counseling/ training and will document the results of this counseling/ training on the refusal document. After DSPs have completed their portion of the Refusal document, TTSR Residential Coordinator will review for completeness and compliance. |
11/03/2025
| Implemented |
| 6400.32(r) | On 10/29/25, at 9:35 AM, Individual #2's bedroom had two access doors: the main entry door to Individual #2's was equipped with a locking mechanism requiring a key to lock and unlock the door from the outside, while the other access door, which opened into a walk-in closet that led directly into Individual #2's bedroom, was not equipped with a locking mechanism. The Department requested documentation of Individual #2's bedroom door lock preference, but the agency did not possess such records. In addition, Individual #2 was not home during the inspection for interview regarding their bedroom door lock preference. | An individual has the right to lock the individual's bedroom door. | 32(r)- During licensing inspection of residential home it was found that Individual #2 had two access doors leading to their bedroom. One is the bedroom door and the other is a door that contains a walk in closet. Both were not equipped with a locking mechanism. At the time of the inspection, Individual #2 was not available to be interviewed for preference of locks on the door or not.
On 11/3/2025, TTSR Program Specialist met with Individual #2 and a review of regulation 6400.32(r) took place. The topic of discussion was the Individual's rights in general and whether or not to have locks on all doors leading to the bedroom or not to have locks leading to the bedroom. It was explained that it was their choice and nobody else's. Individual#2 was asked directly whether or not they wanted locks on both doors leading to the bedroom. Though non-verbal, the individual signaled to Program Specialist that they did not want locks on their door by shaking their head right to left repeatedly. TTSR will honor their wishes not to place accessible locks on the doors and had Individual#2 sign a document stating that they preferred not to have locks on the doors (Attached signature page).
By signing attached, TTSR Program Specialist acknowledges that they reviewed regulation 6400.32(r) on 11/3/2025 and will ensure that s/he is able to provide documentation for all of their caseload, any person that wishes to either have or not have locks on doors leading to bedrooms.
Individuals will be asked yearly whether or not they wish to have locks on all doors leading to bedroom. |
11/03/2025
| Implemented |
| 6400.46(d) | Direct Support Worker #1 completed a two-year certification training in first aid, Heimlich techniques, and cardio-pulmonary resuscitation on 2/11/20, and then again on 11/23/23. This exceeds the 2-year certification period. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | During licensing inspection, it was learned that DSP#1 did not complete First Aid/ CPR training the required and expected timeframe allowed. This DSP was trained on First Aid / CPR on 2/11/2020 and then again on 11/23/2023. This exceeds the two year re-certification timeframe allowed.
A review of regulation 6400.46 (d) took place with the Human Resource department for TTSR on 11/10/2025. The topic of discussion was regulation 46 and the need for all Program Specialists and DSPs to be retrained in First Aid/ CPR, Heimlich within a two year window from the previous re-certification. Newly promoted HR Assistant will be tasked with creating a spreadsheet with all current DSPs, and Administrative staff and will monitor and track all trainings completed and will create an alert system to where all DSPs and Administrative staff are alerted one month prior to the scheduled trainings to ensure that all trainings are completed within the allotted timeframe as identified under regulation 6400. 46(d).
Compliance will be assured through bi-weekly reviews of upcoming trainings and alerts on the spreadsheet and notification will be made to any DSP and/ or Administrative staff are aware of and will complete all required trainings as needed and within timeframes allotted.
By signing attached document, TTSR HR Department acknowledges that they have been retrained on regulation 46(d) and will ensure that all DSPs and Administrative staff are re-trained in First Aid/ CPR/ Heimlich within two years of previous training. |
11/10/2025
| Implemented |
| 6400.163(a) | At 10:14 AM on 10/29/25, ten tablets of Individual #1's, prescribed Standard Farms CBD THC, were stored in a locked, plastic medication container equipped with a timer and day tracker functionality for administration. Agency interviews revealed that this medication had been taken out of its original labeled bottle, which was stored at the provider agency's main office. | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | 6400.163(a)- During licensing inspection on 10/29/25, ten tablets of Individual #1's, prescribed Standard Farms CBD THC, were stored in a locked, plastic medication container equipped with a timer and day tracker functionality for administration. Agency interviews revealed that this medication had been taken out of its original labeled bottle, which was stored at the provider agency's main office.
TTSR Residential Coordinator delivered the CBD THC tablets to the residence of the home. Once the final 10 tablets were administered to Individual#1, the locked medication container was removed from the home and brought to the TTSR Administrative Building. TTSR Residential Coordinator talked to staff at the site on 10/29/2025 and reviewed regulation 6400.163 (a) that staff will be responsible to ensure that all Medication Administration policies and procedures are followed and to ensure that all CBD THC pills will remain in their original container and the time/ locked medication container will no longer be used. |
10/29/2025
| Implemented |
| 6400.165(f) | Individual #1 is prescribed medication to treat symptoms of a diagnosed psychiatric illness. However, Individual #1's content of records did not include a written protocol to address their social, emotional, and environmental needs relative to symptoms of the psychiatric illness. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness. TTSR Program Specialist spoke to Behavioral Specialist for TTSR and a copy of the Social Emotional Environmental was provided to Program Specialist on 11/4/2025 (dated 11/3/2025). Program Specialist will maintain a copy of this plan and a copy was sent to the site where Individual #1 lives for review by staff. Copy of plan attached. |
11/04/2025
| Implemented |
| 6400.166(a)(5) | On 10/29/25, the medication strength was not documented on Individual #1's October 2025 Medication Administration Record for the prescribed, Standard Farms CBD THC, and read as follows: "Standard Farms CBD THC---Take 2 tablets by mouth 4 x daily for mood." Physician orders for Individual #1's prescribed, Standard Farms CBD THC, were not kept at the home. In addition, these orders were requested by the Department from the agency but not provided. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | On 10/29/2025, TTSR Residential Coordinator received the medication book for Individual #1 and wrote in the strength of the THC tablets (5 mg.) onto the MAR. TTSR Residential Coordinator also contacted the pharmacy that creates the MARS for each Individual and asked that the medication as well as instructions on how often it is to be administered, how many tablets for each administration, times of each administration, route of administration, and reason for medication on the MAR. Attached is a copy of Individual #1's MAR which shows the strength written in by Residential Coordinator for the month October 2025. |
10/29/2025
| Implemented |