Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00269736 Renewal 07/08/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.24The 1970 Controlled Substances Act requires accurate counts be kept for controlled medications. The count for the controlled substance, Clonazepam, for individual 1 had 25 tablets when there were only 24 tablets, and it was discovered that on 07/04/25 the staff member administering the medication failed to update the on-hand count when the medication was administered. The count was corrected during the inspection.The home shall comply with applicable Federal and State statutes and regulations and local ordinances.Count was corrected immediately during the inspection Staff member responsible received supervision / training input from program supervisors to ensure their knowledge was sufficient related to the importance of updating counts at the time of medication administration. 07/08/2025 Implemented
6400.34(a)Individual 1 had their individual rights presented to them on 01/04/2025, however no previous rights were on file to determine annual compliance.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.Individual 1 DID have their individual rights presented to them in 2024 but a copy of these were not in the binder and available to the inspection team on the day of the inspection. The 2024 copy had been incorrectly archived out of the binder - it has subsequently been replaced. 07/09/2025 Implemented
6400.166(a)(4)PRN Loperamide HCL 2 mg and Acetaminophen 160 for individual 1 were in with the medications but were not on the MAR. The provider contacted the pharmacy and an updated MAR with the medications was provided during the inspection.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication.Violation was rectified immediately on day of inspection 07/08/2025 Implemented
SIN-00228361 Renewal 07/05/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)Drills from 4/5/23, 3/7/23, 2/9/23, 1/5/23, and 12/6/22 do not indicate whether smoke detectors were operative during the drill. Individuals were verbally prompted to leave during these drills.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. The fire drill form has been updated to include the question of Is the smoke detector operable. The Residential Lead staff have been trained on the importance of an operable smoke detector and that checking it is a part of the process. 07/12/2023 Implemented
6400.52(c)(1)There were no person-centered practices, community integration, individual choice and supporting individuals to develop/maintain relationships training found in record for staff member#1.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.This staff person will complete the Person Centered training. 09/15/2023 Implemented
6400.169(a)There was no annual medication training practicum provided or course requirements for initial medication training for staff member#2.A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration).Genesis uses the Medication Administration approved Observation Checklist to complete all initial and annual practicums. This form was used as required to show the staff person's Pass or Fail in the Medication Administer process. However, the information was not copied onto the Summary and Requalification form. We did complete the annual practicum which was provided. 07/07/2023 Implemented
SIN-00207663 Renewal 07/07/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC 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 - AllergiesThe 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
6400.217There was no signed consent for release of information on file for the individual 1Written 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 teamThe 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 1Each 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
SIN-00248434 Renewal 07/09/2024 Compliant - Finalized
SIN-00190314 Renewal 07/08/2021 Compliant - Finalized