Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00249943 Unannounced Monitoring 06/24/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(12)Individual #1's 2/5/24 physical examination indicated that Individual #1 had no physical limitations, however, this individual required a wheelchair due to spinal cord issues.The physical examination shall include: Physical limitations of the individual. The Residential Medical Coordinator returned the individuals physical to his Primary Care Physician to properly complete the physical limitations section of this physical to reflect their needs. 08/22/2024 Implemented
6400.141(c)(14)The medical information pertinent to diagnosis and treatment in case of an emergency section of Individual #1's 2/5/24 physical examination states, "call 911 in event of an emergency."The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. The Residential Medical Coordinator returned the individuals physical to his Primary Care Physician to properly complete medical information pertinent to diagnosis and treatment. The appropriate changes to reflect the individual's needs was completed. 08/22/2024 Implemented
6400.52(c)(6)Individual #1 has an Individual Support Plan (ISP), physical therapy protocol, and a bowel protocol that staff must be trained on before they work with the individual. There were a total of 26 staff who worked with Individual #1 from 3/1/24 -- 6/3/24. · Staff persons #4, 5, 14, 24, and 25 were only trained in Individual #1's ISP. · Staff persons #8, 9, 13, and 16 were only trained in Individual #1's physical therapy and bowel protocol. · Staff persons #17 and 19 received no training in Individual #1's plans and protocols.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual.Individual #1 has passed away therefore staff listed above will no longer be working with them and would not need re-trained on this plan for future care. The Residential Director did however meet with all management and direct support staff to re-train them on the regulations regarding training prior to working with an individual. Re-training on the ISP and protocols for the other individual living in that home occurred for all staff working in that home as well. 08/05/2024 Implemented
6400.165(c)Individual #1 has a PRN prescription for Lactulose. The instructions indicate that this medication is to be given every 6 hours as needed for no bowel movement in 3 days. Additionally, the instructions on Individual #1's Medication Administration Record indicate this medication was not to be given overnight. On the following dates, this medication was given less than 6 hours apart or during the overnight hours: · 3/15/24 -- given at 3:03am and again at 8:06am · 3/18/24 -- given at 5:17pm, 10:15pm and 4:05am on 3/19/24 · 4/13/24 -- given at 2:40pm and 8:18pm · 4/23/24 -- given at 3:02pm and 8:31pmA prescription medication shall be administered as prescribed.Residential Program Medication Administration Trainer re-trained all staff at the home on the proper procedures for medication administration. 08/21/2024 Implemented
6400.181(f)Individual #1's 8/25/23 assessment was only provided to the individual, not the rest of the individual's team.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.Residential Program Director sent a copy of the annual assessment to all team members. 08/23/2024 Implemented
SIN-00240372 Unannounced Monitoring 01/26/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(3)Individual #1 has not had a TDAP immunization since 5/24/10. This immunization is due every 10 years.The 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. Individual #1's TDAP immunization was completed on 3/5/24. 03/05/2024 Implemented
6400.52(c)(6)Individual #1 has an Individual Support Plan (ISP), Behavior Support Plan (BSP), and an AFO Brace that requires staff training. Additionally, Individual #1 has diabetes that requires blood glucose monitoring by staff, requiring diabetes training. There were a total of 23 staff persons that worked in Individual #1's home from 10/1/23 to 1/31/24. None of these staff were fully trained in Individual #1's plans and protocols. · Only staff persons #2, 5, 7, 9, 11, 18, 21, and 22 are trained in Individual #1's ISP and BSP. · Staff persons #6, 10, 12,and 23 are not trained in Individual #1's OAF brace. · Staff persons #6, 8, 10, and 16 are not trained in diabetes and completed blood glucose testing. Individual #1 also had a Dexcom glucose monitor from 10/12/23 -- 11/28/23. Only staff persons #1 and 5 were properly trained in the use of this device.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual.Staff persons #1, 3, 4, 6, 8, 10, 12, 13, 14, 15, 16, 17, 19, 20, 23 will be trained in person by the Program Specialist on Individual #1's ISP on 3/29/24. Staff persons #1, 3, 4, 6, 8, 10, 12, 13, 14, 15, 16, 17, 19, 20, 23 will be trained in person by the Behavior Support Director on Individual #1's BSP on 3/29/24. Staff persons #6, 10, 12, and 23 are not trained in Individual #1's OAF brace. Staff member #6 is no longer employed at C-NTA. Staff member #10 was trained on 10-9-23. Staff member #12 was trained on 6/5/23. Staff member #23 was trained on 6/5/23. Staff persons #3, 6, 8, 9, 10, 12, 14, 15, 16, 19, 21, and 22 are not trained in diabetes. Staff member #3 Is not currently med trained nor diabetic trained, but never signed off that they passed medications or completed any diabetic duties. They are currently only working in double staff houses so they do not have to pass medications. We are continuing to provide them emotional support to complete these trainings. If they are unable to complete the proper training, they will only be scheduled in a double staff house. The Residential Program Director met with Staff #3 on 3/14/24 to remind them of these regulations and expectations. · Staff member #6 is no longer employed with C-NTA. · Staff member #8 is not currently diabetic trained, but never signed off on any diabetic duties. While working with Individual #1 they were the second support staff and didn't need to be trained. They will be scheduled to complete Diabetic training in May of 2024. · Staff member #9 was not diabetic trained, but never signed off on any diabetic duties. While working with Individual #1, they were the second support staff and didn't need to be trained. They completed diabetic training on 3/14/24 but has not received the certificate of completion from yet. · Staff member #10 did sign off and complete diabetic duties without proper diabetic training. They completed this training on 3/14/24. We have not received his certificate of completion yet. · Staff member #12 Is not currently med trained nor diabetic trained, but never signed off that they passed medications or completed any diabetic duties. They are currently only working in double staff houses so they do not have to pass medications. We are continuing to provide them emotional support to complete these trainings. If they are unable to complete the proper training, they will only be scheduled in a double staff house. The Residential Program Director met with them on 3/14/24 to remind her of these regulations and expectations. · Staff member #14 did sign off and complete diabetic duties without proper diabetic training. They are scheduled to complete their training on 4/18/24. · Staff member #15's diabetic training expired but did not sign off or complete diabetic duties. They are scheduled to re-train in May of 2024. · Staff member #16 was not diabetic trained, but never signed off or completed any diabetic duties. While working with Individual #1 they were the second support staff and didn't need to be trained. They completed diabetic training on 3/14/24 but has not received the certificate of completion yet. · Staff member #19 was not diabetic trained, but never signed off or completed any diabetic duties. While working with Individual #1 they were the second support staff and didn't need to be trained. They completed diabetic training on 3/14/24 but has not received the certificate of completion yet. · Staff member #21 was not diabetic trained, but never signed off or completed any diabetic duties. They are no longer employed by C-NTA. · Staff member #22 was not diabetic trained, but never signed off or completed any diabetic duties. While working with Individual #1 they were the second support staff and didn't need to be trained. They completed diabetic training on 3/14/24 but has not received the certificate of completion yet. 03/29/2024 Implemented
SIN-00225890 Renewal 06/20/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(c)The self-assessment completed on 1/31/23 identified the following violations: 70, 71, 82e, 82f, and 171. There was no written summary of corrections provided.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. Staff at C-NTA will be trained to follow regulations pertaining to proper completion of self assessments. 08/07/2023 Implemented
SIN-00207409 Renewal 06/28/2022 Compliant - Finalized