| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(2) | Individual #1 made a purchase on 4/14/24 at Dollar General. The expense record indicates the purchase was for $32.06, however the corresponding receipt is only for $31. This led to the expense record to not be up to date and a discrepancy of $1.06 for April 2024. | (2) Disbursements made to or for the individual.
| The $1.06 will be refunded to the individual by C-NTA for the record error. |
06/01/2024
| Implemented |
| 6400.64(f) | At the time of the inspection on 5/1/24, there was a bag of trash sitting on the ground next to the carport as well as a box of old pots/pans. | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | The bag of garbage and box of pots and pans were immediately taken from the home. A retraining was held with the staff to make sure this regulation is followed moving forward. |
05/17/2024
| Implemented |
| 6400.67(a) | At the time of the inspection on 5/1/24, it was observed that individual #1's chest of drawers was missing the right dresser drawer handle on the 3rd drawer from the bottom. | Floors, walls, ceilings and other surfaces shall be in good repair. | Our maintenance department purchased all new handles for the dresser and replaced them on 5/2/2024. A re-training was also completed with all staff working in the home to educate them on the importance of reporting any broken or worn-out furniture. Training was completed on 5/13/2024 with Program Director. |
05/17/2024
| Implemented |
| 6400.77(b) | At the time of the inspection on 5/1/24, there was no antiseptic or thermometer in the first aid kit. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | This was immediately corrected on 5/1/2024. Re-training was held for all House Managers and Maintenance on 5/2/2024 explaining the importance of this regulation. Program Director also reviewed C-NTA's First Aid checklist to ensure they know how to properly complete. |
05/17/2024
| Implemented |
| 6400.141(a) | Individual #1's annual physical was completed on 5/9/22 and not again until 7/25/23, outside of the annual timeframe. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Physical was complete, but late. Program Director knew upon reviewing of files and sited on self assessment, but due it being inaccuratecly completed we were still cited on the late physical. |
05/17/2024
| Implemented |
| 6400.141(c)(11) | The recommended bloodwork/lab space on the annual physical completed 7/25/23 for Individual #1 was left 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. | Medical Specialist called the individuals PCP to ensure no bloodwork was needed at the current time. A training was also held by the Residential Director, to ensure the medical specialist understands the regulations moving forward. |
05/17/2024
| Implemented |
| 6400.141(c)(14) | The medical info pertinent to diagnosis and treatment in case of emergency on the 7/25/23 annual physical for Individual #1 was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | On 5/9/24, the Medical Specialist contacted the primary care provider to discuss adding the information pertinent information to diagnose or treat in the event of an emergency. The doctor completed the updated form with all required information. |
05/23/2024
| Implemented |
| 6400.142(a) | The last dental appointment for individual #1 was on 6/13/22. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | A dentist appointment was made for this individual for 6/20/24 |
06/20/2024
| Implemented |
| 6400.142(g) | The dental hygiene plan for individual #1 is not dated. It is unclear if this has been rewritten annually due to no date being on the document. | A dental hygiene plan shall be rewritten at least annually. | The dental hygiene plan for the above individual was reviewed and re-signed and dated by the Program Specialist on 5/1/2024 |
05/23/2024
| Implemented |
| 6400.181(d) | The annual assessment dated 4/19/24 for Individual #1 was not signed or dated by the program specialist. | The program specialist shall sign and date the assessment. | Retraining was completed with the Program Specialist on 5/1/2024 to ensure they know regulations. The above assessment was reviewed and signed. |
05/23/2024
| Implemented |
| 6400.181(e)(1) | The annual assessment dated 4/19/24 does not include information regarding individual #1's preferences. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | On 5/1/2024, the Program Specialist met with the Director to review above assessment to add preferences. |
05/23/2024
| Implemented |
| 6400.181(e)(10) | (Repeat from 6/20/23) The assessment dated, 4/19/24 for Individual #1 does not include or address a lifetime medical history. | The assessment must include the following information: A lifetime medical history. | On 5/1/2024, the Program Specialist met with the Director to review above assessment to add the lifetime medical history. |
05/23/2024
| Implemented |
| 6400.181(e)(11) | (Repeat from 6/20/23) The assessment dated, 4/19/24 for Individual #1 does not include or address if/when the individual had a psychological or if this is applicable. | The assessment must include the following information: Psychological evaluations, if applicable. | The Program Specialist worked with Supports Coordinator to get psychological information on individual 1. |
05/23/2024
| Implemented |
| 6400.34(a) | Individual #1 was last informed of their individual rights on 4/22/22. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | Individual reviewed their rights on 5/3/2024 with the Program Specialist. |
05/23/2024
| Implemented |
| 6400.181(f) | The 4/19/24 annual assessment was sent to individual #1 and the SC but no other team members who attended the ISP meeting. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | Above assessment was sent to the missing team member on 5/1/2024. |
05/23/2024
| Implemented |