| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(c) | REPEAT-6/20/23 inspection-The following homes self-assessments did not contain a written summary of corrections- Hollsopple 4/1/24 & 3/11/24, Carnegie- 4/1/24, Phillips 4/1/24 & 2/29/24, Kinzey-4/1/24 & 2/7/24. | A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year.
| C-NTA's compliance department and Residential Director reviewed the RCG for a better understanding of how the self-assessment needs to be completed. Licensors on sight also explained this to Director in detail at time of inspection. |
05/23/2024
| Implemented |
| 6400.64(a) | During the annual inspection home walk-through on 5/1/24 the shower in the downstairs bathroom contains what appeared to be black/pink mold around the bottom of the shower stall. There was also a black mold in the sink in this same bathroom. | Clean and sanitary conditions shall be maintained in the home. | On 5/1/24 after the inspection Residential Program Director reached out to the staff working, re-trained on proper cleanliness and asked them to scrub the bathroom which was completed later that evening. |
05/23/2024
| Implemented |
| 6400.67(a) | During the annual inspection on 5/1/24 the ceiling in the shower of the downstairs bathroom, the paint was peeling off of the ceiling in an area approx. 12" x 12". | Floors, walls, ceilings and other surfaces shall be in good repair. | Immediately following the inspection on 5/1/24 C-NTA maintenance crew painted the ceiling of the downstairs bathroom. |
05/23/2024
| Implemented |
| 6400.82(f) | During the inspection on 5/1/24 the downstairs bathroom did not have a trash receptacle, individual clean paper towel, or a clean cloth towel. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | Immediately following the inspection on 5/1/24 C-NTA maintenance put a garbage can in the bathroom and installed a paper towel holder with paper towels. |
05/23/2024
| Implemented |
| 6400.112(b) | REPEAT 6/20/23- 6400.112(b) -The fire drill conducted on 7/12/23 did not list the person(s) conducting the fire drill. There was no way to identify if the fire drill was conducted during normal staffing conditions. | Fire drills shall be held during normal staffing conditions and not when additional staff persons are present. | Retraining with the Street Direct Support Staff took place on 5/9/24 to educate them on the proper way to complete the monthly fire drills and the documentation. |
05/23/2024
| Implemented |
| 6400.141(c)(14) | REPEAT 6/20/23-6400.141(c)14 -Individual #1's annual physical exam completed on 3/7/24 did not contain medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | C-NTA Medical Coordinator resent a completed physical form to the PCP that had the missing information. The PCP reviewed and signed the form. |
05/23/2024
| Implemented |
| 6400.181(e)(10) | REPEAT 6/20/23-Individual #1's annual assessment 2/17/24 does not contain the lifetime medical history. There was a medical history summary in the record, but it was dated 4/2/24. It was not completed at the time of the annual assessment. | The assessment must include the following information: A lifetime medical history. | Immediately following the inspection, the completed Medical History Summaries were stapled directly to the Assessments. |
05/23/2024
| Implemented |
| 6400.165(g) | REPEAT 6/20/23- Individual #1 was seen on 8/2/23, 8/30/23,12/20/23, for a medication review. The medication listed for review Lurasidone HCL did not indicate the reason why the medication was prescribed. This was left blank on the form. 10/4/23 Psych review did not contain what medications were prescribed for Individual #1. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | The Residential Coordinator contacted the individuals Dr to make the appropriate changes to the medical consult form and the doctor made the required changes. |
05/23/2024
| Implemented |
| 6400.181(f) | Individual #1's annual assessment was signed and dated by the PS on 2/29/24. There is no date on the cover sheet of the assessment as to when the annual assessment was sent to the Team members. This section on the cover sheet is left blank. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | Immediately following the inspection, the Program Specialist re-sent assessment to the family and properly documented it. |
05/23/2024
| Implemented |