Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00273632 Unannounced Monitoring 08/11/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(c)Individual #1's personal funds were used to purchase laundry detergent, laundry softener, and dryer sheets for the home on the following dates: · 7/11/25 -- Walmart - $24.26 · 7/26/25 -- Walmart - $26.54Individual funds and property shall be used for the individual's benefit. Individual #1 has been reimbursed for both purchases. Staff have been retrained that personal funds may only be used for the individual's personal expenses, not household supplies. House managers will ensure household items are purchased with agency funds. 09/01/2025 Implemented
6400.141(c)(4)Individual #1's date of admission was 12/26/24. A 9/26/24 physical was used for admission to the home. There is not a complete hearing screening on file for Individual #1.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. A hearing screening has been scheduled and will be placed in Individual #1's record upon completion. Admission records for all other individuals have been reviewed to ensure compliance. Program Specialist and Medical Specialist have been retrained on 55 Pa. Code 6400.141 (c)(4) requirements. 10/15/2025 Implemented
6400.141(c)(7)Individual #1's date of admission was 12/26/24. A 9/26/24 physical was used for admission to the home. There is not a completed gynecological examination on file for Individual #1.The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. Individual #1's gynecological examination was completed on 9/10/25, the earliest available date due to new patient scheduling requirements. Documentation of this appointment and results have been placed in their record. 09/10/2025 Implemented
6400.141(c)(13)Individual #1's date of admission was 12/26/24. A 9/26/24 physical was used for admission for the home. To date, there has not been an updated physical completed. This physical indicates that Individual #1 is only allergic to Diflucan, however, Individual #1's Individual Support Plan indicates that the individual is also allergic to the following medications or the medications or contraindicated: Geodon, Cortisone shot, Ritalin, Depakote, Zoloft, Phenobarbital, and Depakote and Lamictal cannot be utilized together.The physical examination shall include: Allergies or contraindicated medications.The provider contacted Individual #1's primary care physician to obtain an updated, complete medical record of all allergies and medication contraindications. Once received, the information will be shared with the Supports Coordinator to ensure the Individual Support Plan is updated accurately. 10/15/2025 Implemented
6400.165(f)Individual #1 is prescribed medication to treat the symptoms of a diagnosed psychiatric illness. There is not a written protocol to address the social, emotional, and environmental needs of the individual related to the symptoms of 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.A written protocol addressing Individual #1's social, emotional, and environmental needs in relation to their psychiatric diagnosis will be developed in collaboration with her Supports Coordinator, treatment team, and direct support staff. This protocol will include strategies for managing symptoms, supporting emotional regulation, and ensuring a safe and supportive environment. 10/15/2025 Implemented
6400.165(g)Individual #1 is prescribed medication to treat the symptoms of a diagnosed psychiatric illness. This individual has only had quarterly medication reviews on 1/7/25 and 7/7/25.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.Individual #1's next quarterly medication review has been scheduled and will be completed as required. Staff have been retrained on the requirement to conduct timely quarterly medication reviews for all individuals prescribed psychiatric medications. 09/12/2025 Implemented
6400.186Individual #1 was admitted to the home on 12/26/24. At this time, the individual had a behavior support plan (BSP) in place for day programming, which ended in February 2025. Individual #1 exhibited many of the same behaviors in the home that the day programming BSP addressed, including telling falsehoods, exaggerating or "making up" pain, however, Croyle-Nielsen Therapeutic Association has not implemented a BSP for use within the residential setting.The home shall implement the individual plan, including revisions.A residential Behavior Support Plan for Individual #1 will be developed in collaboration with her Supports Coordinator, treatment team, and residential staff. The BSP will address behaviors exhibited in the home and include proactive strategies, interventions, and supports specific to the residential environment. The Behavior Support Specialist will train all staff working with the individual. 10/15/2025 Implemented
SIN-00263908 Renewal 04/28/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(d)(1)Individual #1 does not have a current and up-to-date financial record. On 4/10/25, $31.53 was spent according to the receipt. It was documented as $32.03.The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. The individual's financial records have been immediately reviewed and updated to reflect all current balances and transactions. Direct Support Staff at the house were re-trained on this regulation as well. C-NTA is moving all financial modules digitally to Therap. 05/02/2025 Implemented
6400.141(c)(4)Individual #1's physical completed on 02/25/25 indicated the hearing screening was attached. It was not attached.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. Individuals #1's results from their hearing and vision screening were obtained on May 2, 2025, and added to the file. Program Specialist and Medical Specialist were re-trained on this regulation with focus on the importance for Dr's to complete the form in its entirety. 05/02/2025 Implemented
6400.141(c)(13)Individual #1's physical completed on 02/25/25 documented the following allergies, bee venom, bee sting kit, Penicillins, Phenytoin, Sulfa-Antibiotics, Barbiturates, Progesterone, Valproic Acid, Diphenhydramine, Cyclobenzaprine, and Estrogens. These allergies do not match the allergies listed in the ISP or on the individual's demographic sheet.The physical examination shall include: Allergies or contraindicated medications.All known allergies listed on the 02/25/25 physical exam were reviewed and verified with the individual's physician and pharmacy on 5/5/2025. The individual's ISP, demographic sheet, MAR, and medication administration records were updated to reflect the accurate and complete list of allergies. All updated documents were signed and dated by the Program Specialist and reviewed with the team. 05/05/2025 Implemented
6400.141(c)(14)(Repeat from April 2024 Inspection) Individual #1's physical completed on 02/25/25 does not document the medical information pertinent to treat or diagnose in the event of an emergency. This section is blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. On 5/5/2025, the individual's physician was contacted to complete the missing emergency medical information section on the 02/25/25 physical form. The updated physical with the completed section has been obtained and placed in the individual's record. 05/05/2025 Implemented
6400.144At the time of the inspection, the Bacitracin was not available in the home for Individual #1, despite being on the MAR.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. Bacitracin was obtained and made available in the home for Individual #1 on 5/2/2025. Staff were immediately notified and administration resumed per the MAR. Retraining on regulation 6400.144 was also completed with the House Manager on 5/1/2025. 05/02/2025 Implemented
6400.32(c)Individual #1 is allergic to penicillin. They were prescribed amoxicillin for ten days starting 10/19/24 and 01/21/25.An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment.The physician's clarification notes from January 2025 permitting amoxicillin despite a penicillin allergy were obtained and stored with the medical information. On 5/12/2025 the Program Specialist added the information to the assessment and requested to the SC it be added to the ISP. 05/12/2025 Implemented
6400.34(a)(Repeat from April 2024 Inspection) Individual #1's rights were reviewed and signed on 01/01/24 and not again until 01/20/25, outside of the annual timeframe.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.Program Specialist was retrained on 5/9/2025 on the regulatory requirement to review and explain rights upon admission and annually thereafter, without lapse. The training included acceptable timeframes (no more than 365 days between reviews) and how to track due dates for each individual. 05/09/2025 Implemented
6400.165(c)(Repeat from April 2024 Inspection) On 10/19/24, Individual #1 was prescribed amoxicillin to be given twice a day for seven days. It was documented that the first dose was administered in the evening of 10/19/24. The last dose was to be given at 8am on 10/26/24. On 10/26/24 at 3:03pm HAB documented that the 8pm dose of the medication was given on time, that the individual was out of program. Individual #1 was prescribed amoxicillin twice a day for ten days on 1/21/25. They took their first dose in the evening of 1/21/25. It was documented that they were administered the drug twice a day for the next ten days. This was an additional dose.A prescription medication shall be administered as prescribed.On 5/1/2025 the Medical Specialist contacted the Pharmacy who confirmed that no additional doses were administered according to the total number of pills delivered. The MAR entries for 10/26/24 and the final date of the 1/21/25 prescription course were reviewed and annotated to reflect that these were documentation errors. A retraining on proper medication documentation for all DSP's took place on 5/5/2025 during a Residential team meeting. 05/01/2025 Implemented
6400.165(g)(Repeat from April 2024 Inspection) The quarterly psychiatric medication reviews do not include a full list of psych meds the individual takes, their dosages, or the reason for taking them.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 physician was contacted, and a revised psychiatric medication review for Individual #1 was obtained on 5/12/2025. The updated review includes a full list of all prescribed psychiatric medications, dosages, and the reason for each medication, as well as justification for continuation and dosage levels. The revised review has been filed in the individual's record. Retraining for the House Managers was completed on 5/6/2025 on the expectation of not leaving a medical appointment without having all needed information completed accurately. 05/12/2025 Implemented
6400.167(a)(3)Individual #1 is to receive one tablet of Senna 8.6 a day. It was documented that Individual #1 received two doses of this medication on 06/20/24 and 06/21/24.Medication errors include the following: Administration of the wrong dose of medication.On 5/1/2025 the Medical Specialist contacted the Pharmacy who confirmed that no additional doses were administered according to the total number of pills delivered. These were documentation errors. 05/01/2025 Implemented
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