Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00202199 Renewal 03/22/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.113(a)Individual #1, date of admission 5/13/16, received fire safety training 1/10/22. The agency did not provide fire safety training to Individual #1 in 2021, therefore compliance could not be measured. 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
6400.166(a)(11)Individual #1's March 2022 medication administration record did not include the diagnosis or purpose for each medication.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.A review of 55PA Code Chapter 6400.166(a)(11)took place with TTSR Administrator and Residential Coordinator who met with TTSR Assistant Director and TTSR Compliance Officer. This meeting took place on 3/31/2022 and the review consisted of the following: ¿ Violation found during licensing inspection in which the MARS for identified individuals did not contain the diagnosis or purpose of medications prescribed by a physician on the MAR for staff knowledge. ¿ Need for all MARS agency-wide to include the diagnosis and purpose for all medications prescribed by a physician to include pro re nata medications Compliance will be measured during routine monthly reviews and checks of all MARS received from the pharmacy to ensure that all MARS have all required information including the diagnosis and purpose for all medications prescribed by a physician to include pro re nata medications. TTSR Residential Coordinator states that the pharmacy responsible for the creation of all MARS was informed of the need to reflect diagnosis and purpose of all prescribed medications on the MARS on 3/29/2022. On 3/30/2022, TTSR also received the MARS for April 2022 but Residential Coordinator has hand written all diagnosis and purposes on the MARS (hand written) and this will ensure that all staff are aware of the purpose of each medication for the month until the pharmacy makes the needed additions starting in May of 2022. Attached is a copy of the MAR for individual #1 which shows that the MAR which will be used to track medications administered shows the diagnosis or purpose of each medication for the individual for the month of April 2022. Also attached is the sign off sheet that shows that the Residential Coordinator was retrained on 55PA Code Chapter 6400.166(a)(11) and that the pharmacy who creates the MARS for individuals at TTSR will show diagnosis and purpose of all medications for every TTSR individual. 03/29/2022 Implemented
SIN-00147199 Renewal 12/13/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency completed a self-assessment for the home on 10/10/18.The agencies certificate of compliance has an expiration date of 1/6/19.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. TTSR Administrative staff met on 12/18/2018 to discuss the violation and review actions to be taken to prevent the violation from occurring in the future. Those present at the time of this meeting were TTSR CEO, TTSR Assistant Director, and TTSR Compliance Officer. Current procedures for completion were discussed and it was learned that Assistant Director (who was responsible for ensuring completion of the self-assessments for this current licensing inspection) did in fact start the process within the 3 to 6 month timeframe but did not finish them within the timeframe permitted. TTSR checked their Licensing Certificate of Compliance for 2019 (effective 1/6/2019 through 1/6/2020) and will ensure that all self- assessments for all sites are completed within the 3 to 6 month timeframe ( 7/6/2019 to 10/6/2019). TTSR Compliance Officer will receive and review all self-assessments upon completion to ensure that they were completed within the 3 to 6 month timeframe from the expiration of the license. Attached is a signature page showing those in attendance at this meeting participated in the development of the corrective action for this violation. 12/18/2018 Implemented
6400.21(a)Direct Service Worker #1 date of hire 12/7/18 had a PA criminal background check completed on 11/24/15.An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire. During licensing inspection, it was learned that Staff#1 did not have a Criminal History Background check submitted with results within 15 days of hire. After looking at our records, it was learned that this staff had left the agency and chose to end employment with TTSR. Records show that this staff chose to return to work 4 months later. It was thought that the Criminal Background check would still be valid at that time but did not realize that this is a violation of Pa Code Chapter 6400. 21(a). On 12/19/2018, TTSR CEO met with members of the Human Resource department and a review took place of Pa. Code Chapter 6400. 21(a) which states that ¿An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employees of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person¿s date of hire.¿ Since this was found, TTSR did in fact submit a request for Criminal History for Staff#1 on 12/13/2018 and results showed, ¿No Record¿ (attached is a copy of this Criminal History Check results dated 12/13/2018). In the future, TTSR CEO will continue to submit ¿Authorization to Run Criminal History Checks¿ as authorized by the applicant. The TTSR CEO will ensure that the Criminal History Background Check is submitted within 5 days after applicant¿s date of hire. From there, Human Resource Department will receive back the Record Check details and prepare this document to be placed in the new hire¿s personnel file while ensuring that the date of the Check is within the allotted timeframe for compliance. 12/19/2018 Implemented
6400.112(e)The only fire drill held during sleeping hours between 12/13/17 and 11/13/18 was conducted on 10/19/18 at 12:00AM.A fire drill shall be held during sleeping hours at least every 6 months. On 12/18/2018, TTSR Administrators met to discuss areas of non-compliance found during annual licensing inspection. Results showed that during the reviewed time period for inspection that the site (Morris Street Site located at 1408 Morris Street in Sligo, PA) failed to perform an overnight/ sleeping fire drill at least every 6 months (6400.112(e).) TTSR Secretary, acknowledge that she will, on a monthly basis, be responsible for the review of all fire drills submitted to the TTSR Administrative Office to ensure that staff who conducted the fire drill are properly and completely filling all necessary sections of the fire drill report to include: - Date of fire drill - Time of fire drill (unannounced) to include overnight/ sleeping drill at least every 6 months - Amount of time it took to evacuate - Exit route used - Problems encountered during fire drill - Whether the fire alarm or smoke detector was operative. New to the process will be after receipt and review by TTSR Secretary, all fire drills will be forwarded to TTSR Compliance Officer for a second review to ensure that all sites are completing necessary steps for a proper fire drill and also documenting needed information on appropriate TTSR Fire Drill forms. House Supervisor for the Morris Street site, acknowledges that she will adhere to 55 PA Code Chapter 6400.112(e) and ensure that she, as well as her staff, perform and document at least one overnight/ sleeping fire drill at least every six months. By signing the attached document, all parties present at this meeting to discuss violation found for 55 PA Code Chapter 6400.112(e) agree that they will follow the identified protocol listed above to ensure compliance for this site in the future. 12/18/2018 Implemented
6400.141(c)(3)Individual #1 date of admission 4/16/18 had a Tetanus/Diphtheria completed 12/20/07 and then again 4/25/18The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. On 12/18/2018, TTSR CEO met with TTSR Residential Coordinator, as well as TTSR Registered Nurse who is involved in the referral, review, and transition process for all newly admitted consumers to TTSR¿s program. A discussion/ training was had on 6400.141(c)(3) and the need for any individual to have a physical examination within 12 months prior to admission and annually thereafter and that the new admission has had immunizations (for individuals 18 years of age or older as recommended by the United States Public Health Service Centers for Disease Control). During this review period for licensing, the Residential Coordinator states that when a new admission arrived at TTSR, she would ensure that the individual has a completed physical with all necessary information printed on the document along with authorized signatures. Because of the medical background and familiarity with medical documentation and reviewing physicals, as of 12/18/2018, this responsibility will solely be with the TTSR Registered Nurse (Department Head) who will oversee this process by checking all newly admitted consumers¿ physicals before admission to TTSR is authorized. By signing attached document, all parties present at this meeting acknowledge their roles to ensure that future physicals received contain needed information for compliance. 12/18/2018 Implemented
SIN-00126905 Renewal 12/28/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(11)The physical examination completed on 7/21/17, for Individual #1, did not include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. This section was blank.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. On 1/18/2018, a meeting/ training was held with TTSR nurse, and a discussion and review of the consumers¿ physicals was had. It was discussed that at time of annual licensing inspection, Individual#1, residing at the Sligo House, had a physical done that did not include an assessment of the individual¿s health maintenance needs, medication regimen, and need for blood work at recommended intervals. Rob Buzard (TTSR Nurse), who was hired after the date specified on the physical, acknowledges the importance of ensuring that this information is present on all physicals going forward and will be tasked with review of all incoming physicals as of the date of this corrective action for all TTSR consumers to ensure that an assessment of the individual¿s health maintenance needs, medication regimen, and need for blood work at recommended intervals is present on all physicals received. By signing attached document, Nurse will take responsibility for review of all physicals and acknowledges that he is had been trained on Chapter 6400.141 ( C )(11) on 1/18/2018. [Immediately, the CEO shall develop and implement a policy and procedures that all individuals' current physical examinations included all required information to include a process to obtain the missing information from the medical professional completing the physical examination. Immediately, the CEO shall educate staff persons responsible for reviewing Individuals' physical examination of information required to be included in individuals' physical examinations as per 6400.141(c)(1)-(15) and the process for obtaining the missing information and that required areas can not be left blank. Immediately and upon completion, the designated person shall review all individuals' current physical examinations and obtain missing information (including Individual #1).Documentation of trainings shall be kept. Documentation of reviews shall be kept. (AS 1/26/18)] 01/18/2018 Implemented
6400.181(e)(12)The assessment completed on 8/28/17, for Individual #1, did not include recommendations for specific areas of training, programming and services. This section was blank.The assessment must include the following information: Recommendations for specific areas of training, programming and services. On 1/19/2018, a meeting/ review of 55 PA Code Chapter 6400.181(12) took place. During annual licensing inspection it was learned that there was an instance in which Program Specialist failed to ensure completeness of the annual assessment for the individual. The violation was as follows: - 55 PA Code Chapter 6400.181(12)- The assessment completed on 8/28/17, for Individual #1, did not include recommendations for specific areas of training, programming and services. This section was blank. During the 1/19/2018 review with Program Specialist who oversees the caseload of the individual who¿s assessment was reviewed, Tom accepted responsibility for leaving the recommendations for specific areas of training, programming and services section blank stating that at time of assessment this section did not pertain to the individual and no changes were thought to be recommended at that time. By signing attached document, Tom acknowledges that he has been retrained on 55 PA Code Chapter 6400.181(12). Tom will review all assessments for completeness and if there are any sections of the assessments that do not pertain to the consumer at that time, Tom will ensure that something is written in that section rather than leaving the section blank (Example- ¿No recommendations at this time¿). TTSR Compliance Officer will be tasked with review of all assessments to ensure completeness as of this date of review. [Within 30 days of receipt of the plan of correction, the CEO or designated management staff person shall educate the program specialist(s) what assessments must include as per 6400.181(c)(1)-(14). Documentation of trainings shall be kept. Immediately, the program specialist shall review all individuals' current assessments to ensure all required information is included. Documentation of reviews shall be kept. At least quarterly for 1 year, a designated staff person shall audit a 25% sample of assessments to ensure all required information is include. Documentation of audits shall be kept. (AS 1/26/18)] 01/19/2018 Implemented
SIN-00259132 Renewal 01/22/2025 Compliant - Finalized