Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00283187 Unannounced Monitoring 02/09/2026 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.65At the time of the inspection on 2/10/26, the basement bathroom was not ventilated by mechanical ventilation and did not have a window.Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. To correct this issue, a mechanical ventilation fan was installed in the basement bathroom on 2/12/2026, ensuring the bathroom is now properly ventilated and compliant with the regulation. 02/12/2026 Implemented
6400.66At the time of the inspection on 2/10/26, the front porch light bulb was inoperable.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. To correct this issue, the light bulb was immediately replaced on 2/10/2026 to ensure the porch area is properly illuminated and meets the requirement that rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and avoid accidents. Staff were re-trained of the importance of maintaining proper lighting throughout the home and exterior areas to ensure the safety of individuals and staff. 02/10/2026 Implemented
6400.71At the time of the inspection on 2/10/26, the emergency numbers were not listed by the telephone in the living room.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. The telephone numbers for the nearest hospital, police department, fire department, ambulance service, and poison control center were immediately posted by the telephone in the living room to ensure they are readily accessible in the event of an emergency on 2/10/2026. Staff were retrained of the requirement that emergency telephone numbers must be posted by each telephone with an outside line within the home. 02/10/2026 Implemented
6400.77(b)At the time of the inspection on 2/10/26, a thermometer was not available 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. On 2/10/206 a thermometer was immediately added to the first aid kit to ensure the kit contains all required items in accordance with regulatory requirements. Staff were reetrained on the requirement that the first aid kit must contain antiseptic, adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, and scissors, and that these supplies must be maintained and readily available. 02/10/2026 Implemented
6400.141(c)(3)Individual #1's date of admission was 1/7/26 and the Tetanus/Diphtheria immunization was not administered prior to their admission, as the last time the individual was administered the immunization was 2003.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. C-NTA's Medical Specialist contacted the individual's primary care provider to review the individual's immunization status and arrange for administration of the recommended immunization in accordance with CDC guidelines. Documentation of the individual's immunization status and any updates will be maintained in the individual's medical record. House Managers and Program Specialist were re-trained of the requirement to review immunization records during the admission process to ensure individuals are current with recommended vaccinations. 02/19/2026 Implemented
6400.141(c)(14)(repeat violation from the 4/28/25 inspection) For Individual #1, the 12/22/25 physical form does not identify if there is any 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's Medical Specialist contacted the individual's primary care provider to obtain clarification and ensure that the required medical information was documented. The physical examination form was updated to include the necessary information regarding diagnoses and treatment considerations relevant to emergency care. House Managers, Program Specialists and Medical Specialist were re-trained to review completed physical examination forms upon receipt to ensure all required sections are completed by the physician, including the section identifying medical information pertinent to diagnosis and treatment in case of an emergency 02/20/2026 Implemented
6400.151(b)Staff #5's 12/17/25 physical form was not signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. On 2/12/2026 Human Resource Coodinator contacted Workplace Health to notify them of the error. Worksplace Health immediately sent documentation that included a signature from the provider to verify the physical was complete. Human Resource Coodinator and HR Director were re-trained to review all physical examination forms upon receipt to ensure they are fully completed, signed, and dated by the appropriate licensed medical professional before being filed. 02/12/2026 Implemented
6400.46(b)Staff #6 had fire safety training on 8/6/24 and not again until 8/7/25 which is outside the required annual timeframe.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).C-NTA's Training Coodinator was re-trained by the Residential Director of the regulatory requirement that Program Specialists and Direct Support Professionals must complete fire safety training annually by a fire safety expert. 02/16/2026 Implemented
6400.165(g)(repeat violation from the 4/28/25 inspection and 8/11/25 unannounced inspection) Individual #1's psychiatric medication review on 2/5/26 did not include documentation of the psychotropic medications and their necessary dosages or the reason of prescribing the psychotropic medications.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 Medical Specialist contacted the prescribing physician to obtain complete documentation for the psychotropic medication review, including the reason for prescribing the medication, the need for continued use, and the necessary dosage. Updated documentation was obtained and placed in the individual's medical record. 02/16/2026 Implemented
6400.169(a)Staff #2's original medication training was 3/13/19 and this staff person did not complete their medication training in 2025 until 3/16/25, which was not completed prior to the original certification date of March 13th.A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration).Medication Administration Trainers were re-trained requirement that medication administration certification and renewal training must be completed prior to the expiration date which includes the original certification date. 02/16/2026 Implemented