| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(d) | The fire drill during sleeping hours dated April 15, 2022, took 3 minutes and 21 seconds to evacuate. There was no subsequent follow up drill in that month. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | Due to the nature of this document it cannot be altered. However, going forward the drills were conducted timely and successfully. |
07/08/2022
| Implemented |
| 6400.141(c)(3) | Individual 1's June 2022 physical did not include the following information.
- Immunizations
- Vision/Hearing
- TB Test
- GYN/Mammogram
- Info on communicable disease
- Information pertinent to emergency
- Physical Limitations
- Allergies | 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. | The physical was completed on June 24, 2022 however staff took the incorrect form to the appointment. The correct form was faxed to the doctor's office for completion. The doctor has faxed the correct form back to Genesis, August 25, 2022. |
08/25/2022
| Implemented |
| 6400.217 | There was no signed consent for release of information on file for the individual 1 | Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.
| The Program Specialist worked with all Genesis individuals to complete a current Consent to Release Medical Information form. |
08/25/2022
| Implemented |
| 6400.181(f) | There was no documentation showing that the annual assessment dated 9/16/21 for individual 1 was sent to 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. | The Annual Assessment was emailed to the SC 8/30/22. Due to the nature of the document it cannot be altered. |
09/18/2021
| Implemented |
| 6400.213(1)(i) | There was no documentation showing the religious affiliation on file for individual 1 | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | The religious affiliation has been added to the Face Sheet. July 11, 2022. |
07/11/2022
| Implemented |