| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.77(b) | The first aid kit was missing scissors and tweezers. | 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. | The Program Administrator put the scissors into the First Aid Kit, July 8, 2022. Staff reported removing the scissors because they didn't understand they needed to be in the kit. Staff was trained on the contents of the First Aid Kit. |
07/08/2022
| Implemented |
| 6400.141(c)(3) | Individual 1's physical occurred 6/27/22 (but admitted on 1/11/22); the following items were missing/unanswered on the physical form.
- Immunizations
- Vision/Hearing
- Prostate Exam
- 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 6/23/21 which was before the admission. Genesis had a copy but experienced trouble when scanning for your review. Operations Director purchased a brand new scanner/printer, July 7, 2022 at 12:30pm, to enable scanning, but was not able to get acclimated to the new system in a sufficient time. The receipt showing the purchase of the printer is attached. |
01/11/2022
| Implemented |
| 6400.142(a) | No Dental Exam or Dental Plan on file for individual 1. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | This individual refused to go to any dentist appointment we scheduled his first appt. on January 14, 2022. He has dentures and reports his plan is to go to the dentist when he "loses more weight". The Program Specialist provided a training to this individual on care and dental hygiene, and the importance of visiting the dentist. The Program Specialist also had this individual sign a refusal to attend any dentist appointments until he determines he has lost enough weight. |
08/25/2022
| Implemented |
| 6400.217 | There was no signed consent for release of information on file for 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 has met with all individuals and requested their signature on an updated Consent to Release Medical information form between July 18, 2022 and August 24, 2022. |
08/24/2022
| Implemented |
| 6400.165(f) | There was no behavior support plan on file for individual 1 | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness. | This individual after several sessions and attempts has refused to work with the Behaviorist at Genesis. The Clinician was not able to gather enough information to update his plan. This individual did come with a BSP dated 2020 which was the last time he agreed to work with a Clinician. Genesis and the individual's team have been working to find a behaviorist that meets this individuals requirements, but have not been successful. |
01/11/2022
| Implemented |
| 6400.166(b) | Individual 1's MAR for Atorvastatin 20mg tab was not initialed for administration for the 7/6 dose (the medication was not in the blister pack for that date) | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | On July 11, 2022, staff did correct the missed initials on the MAR. The medication was not missed as the initials and dates were on the blister pack. . |
07/11/2022
| Implemented |
| 6400.181(f) | There was no documentation showing that the annual assessment dated 4/4/22 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. | A checkbox is added to the Annual Assessment that the Program Specialist will check and date to indicate the assessment was sent to the team and when. Due to the nature of this document no changes could be made to the signed version. The Annual Assessment was emailed 8/30/22. |
08/30/2022
| 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 Face sheet was updated to record the religious affiliation of this person. |
07/11/2022
| Implemented |