Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00225878 Renewal 06/20/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)There was no self-assessment fully completed 3-6 months prior to the certificate expiration or 6-9 months after the last inspection.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. All C-NTA staff responsible for the self assessments will be trained on the proper time frames for completion of self assessments. 08/07/2023 Implemented
6400.106The furnace was cleaned on 10/20/21 and not again until 1/9/23, outside of the annual timeframe.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. The Director will develop a schedule with the furnace company to ensure timely cleanings following all state guidelines. 08/07/2023 Implemented
6400.112(g)The fire drill conducted on 4/21/23 did not document the time the fire drill took place. Fire drills shall be held on different days of the week and at different times of the day and night. All Residential staff will be retrained on the proper completion of the agency's fire drill form. 08/07/2023 Implemented
SIN-00154457 Renewal 06/06/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.73(a)The railing in the attic stops short at the top two steps. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. The railing was extended by the agency contractor. Pictures have been provided to show the completion. 06/20/2019 Implemented
6400.103The emergency evacuation procedure did not include the individual's responsibilities during an emergency evacuation.There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location. The evacuation procedure was updated and provided to the staff and individuals. The residential program director will be responsible for updated these plans as needed. 06/21/2019 Implemented
6400.104The fire department notification letter was not dated. It is unclear when the letter was sent to the fire department.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. A new fire department letter was sent with an updated date of June 10, 2019. A new template was created in order to avoid future violations 06/10/2019 Implemented
SIN-00135347 Renewal 06/14/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The hand railing and steps had peeling paint on the side egress of the home.Floors, walls, ceilings and other surfaces shall be in good repair. Maintenance contractor painted the steps at the individuals' home. Management will complete a weekly / monthly spot check to ensure that all maintenance issues are resolved in a timely manner. 08/31/2018 Implemented
6400.141(c)(14)Individual #1's physical dated 2/27/18 did not indicate information pertinent to diagnosis and treatment in case of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Program Specialist will ensure that each section of an individuals physical is completed. 08/31/2018 Implemented
6400.181(e)(12)Individual #1's assessment dated 10/12/17 did not include recommendations for training.The assessment must include the following information: Recommendations for specific areas of training, programming and services. Program Director will review assessment to ensure that the recommendations for training for each individual is completed. 08/31/2018 Implemented
6400.181(e)(13)(i)Individual #1's assessment dated 10/12/17 did not include current health status.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health. Program Director will review assessment to ensure that individuals' assessment includes current health status'. 08/31/2018 Implemented
6400.183(7)(iii)Individual #1's ISP dated 1/11/18 did not include potential to advance in vocational programming.The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following:Assessment of the individual's potential to advance in the following: Vocational programming. Program Specialist will inform SC to update ISP in order to include the individuals' potential to advance in vocational programming. 08/31/2018 Implemented
6400.183(7)(iv)Individual #1's ISP dated 1/11/18 did not include the potential to advance in Competitive community-integrated employment.The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: Assessment of the individual's potential to advance in the following: Competitive community-integrated employment. Program Specialist will inform SC to update ISP in order to include the individuals' potential to advance in Competitive Community Integrated Employment. 08/31/2018 Implemented
6400.186(c)(2)Individual #1's ISP reviews dated 12/11/17, 3/11/18 di not report on community integration or behavioral plan. The ISP reviews dated 12/11/17, 3/11/18, and 6/11/18 did not include dental plan review. The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. Program Director updated monthly / quarterly review form in order to ensure that all aspects of the individual's needs are addressed. 08/31/2018 Implemented
6400.213(1)(i)Individual #1's record did not include the religious affiliation.Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph. The field "Religious Affiliation" was added to the Residential Assessment in addition to it being in the Admission Packet in order to ensure that the field is consistently filled out. 08/31/2018 Implemented
6400.213(11)Individual #1's record is not consistent in recording diagnosis. The physical dated 2/27/18 identifies 4 diagnosis. The assessment and ISP identify 9. Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. Program Director / Program Specialist will update the SC's in order for them to update the ISPs to what the residential provider has on file. Program Director / Program Specialist, in addition to updating the SC's, will update physical form and other forms with the individuals' diagnoses to ensure consistency. If there is a change, then the Program Director / Program Specialist will update the forms and the SC's. 08/31/2018 Implemented
SIN-00116104 Initial review 06/20/2017 Compliant - Finalized