| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | There was no self-assessment fully completed 3-6 months before the certificate expiration or 6-9 months after the license expiration. | 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 |
| 6400.106 | The 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 |
| 6400.141(b) | Individual #1's most recent annual physical completed on 03/10/23 was not signed and dated by a medical professional. | The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. | CNTA staff were retrained on the importance of properly completed medical forms. A team meeting was also held with the individual's family recommending that a CNTA staff accompany the individual to medical appointments to help ensure forms are adequately complete. |
08/07/2023
| Implemented |
| 6400.141(c)(6) | There is record of a negative TB test completed 03/05/21 for Individual #1, and none since. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | A team meeting was held with the individual's family notifying them of our vaccination policy. It was recommended a CNTA staff attend medical appointments with the individual. |
08/07/2023
| Implemented |
| 6400.141(c)(14) | Individual #1's most recent annual physical completed on 03/10/23 does not include a review of the "Medical 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. | Retraining for house managers and program specialist on guidelines for physical completion. |
08/07/2023
| Implemented |
| 6400.165(g) | (Repeat from Inspection held on 6/28/22) There is a record of a quarterly psychiatric exam completed 10/31/22 for Individual #1 and not again until 04/18/23. | 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. | House Manager, Program Specialist retained on scheduling guidelines for psych exams. |
08/06/2023
| Implemented |