| 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 prior to the certificate expiration or 6-9 months after the last annual 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 |
| 6400.22(d)(1) | (Repeat from Inspection held on 6/28/22) Individual #1 is not financially independent. They need assistance balancing their money to assure that the transactions are correct each month. Individual #1 has a savings account and receives Snap Benefits. There was no financial record for either the Snap Benefits or the Savings Account for Individual #1. | 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. | C-NTA will make corrections to their Residential funds procedures to secure proper records and to create all of the necessary financial logs. |
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(c)(3) | (Repeat from Inspection held on 6/28/22) Individual #1's most recent annual physical completed on 1/19/23 indicated that Individual #1 last had their TDAP on 9/10/10. Individual #1 is overdue for their TDAP immunizations. | 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. | Staff will be retrained on required vaccines to follow all guidelines. |
08/07/2023
| Implemented |
| 6400.141(c)(10) | Individual #1's most recent physical completed on 1/19/23 indicates that Individual #1 is not free from communicable diseases. There were no precautions identified as required on the physical. | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | Staff will be trained on asking question and proper communication at Dr appointments to ensure all information documented is accurate. |
08/07/2023
| Implemented |
| 6400.144 | Individual #1 has a PRN for Geri-Lanta Liquid on their MAR. At the time of the inspection, this PRN was not available in the home. | 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.
| Medication administration trainer, House Managers, Residential Coordinators, and Program Specialist will be re-trained on checking medications daily for accuracy. |
08/06/2023
| Implemented |
| 6400.181(e)(4) | Individual #1's current assessment completed on 1/13/23 does not identify their need for supervision in the community. That portion of the assessment is discussing an individual by the name of "Adam" and what that individual's needs are. | The assessment must include the following information: The individual's need for supervision.
| Program Specialists have been re-trained on proper completion of assessments. |
08/07/2023
| Implemented |
| 6400.181(e)(9) | Individual #1's current assessment completed on 1/13/23 does not identify their disability. That portion of the assessment is discussing an individual by the name of "Adam" and what that individual's disability is. | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | Retrain Program Specialists on proper completion of the assessments according to guidelines. |
08/07/2023
| Implemented |
| 6400.181(e)(10) | Individual #1's current assessment completed on 1/13/23 does not include a lifetime medical history. | The assessment must include the following information: A lifetime medical history. | Retraining to all staff that lifetime medical history is needed. Lifetime Medical history will be completed for Individual #1 and added to their assessment. |
08/07/2023
| Implemented |
| 6400.181(e)(11) | Individual #1's current assessment completed on 1/13/23 does not indicate whether Individual #1 had a psychological. | The assessment must include the following information: Psychological evaluations, if applicable. | All C-NTA staff responsible for the self-assessments will be trained on the proper time frames for completion of self-assessments. Individual #1's assessment will be updated to reflect whether or not they had a psychological evaluation. |
08/07/2023
| Implemented |
| 6400.213(1)(i) | Individual #1's demographic information does not include their next of kin. | Each individual's record must include the following information: Next of Kin. | Training was provided to Program Specialist to document next of kin in all individual's demographic information. Individual #1's demographic information was updated to reflect their next of kin. |
08/07/2023
| Implemented |