Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00197875 Renewal 04/06/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(a)Members Mark antibacterial soap was in the soap dispensers in both bathrooms which is a poisonous material. Listed as contact poison control.Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.Ganister Station will order Refresh Azure Foam from Allegheny Supply Company. According to the MSDS sheet under Most important symptoms and effects, both acute, and delayed under ingestion: it states no specific symptoms known. There is also no recommendations under notes for the doctor. 04/22/2022 Implemented
2380.181(e)(7)Indivdiual # 1's 11/19/21 assessment does not indicate his ability to sense heat sources.The assessment must include the following information: The individual¿s knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated.Program Specialist, Tristan McIntosh completed an addendum on April 6, 2022 and added the following to Randolph's assessment: "Ability to sense and move away quickly from heat sources which exceed 120 degrees F and are not insulated (i.e. oven or stove): Due to Randy's diagnoses of being blind and deaf, his ability to sense heat sources is unable to be assessed. This addendum was mailed to the team on April 6, 2022 with these updates. 04/22/2022 Implemented
SIN-00183916 Renewal 02/16/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(5)The current TB information was not included on the 09/16/20 physical examination for Individual # 1. The space was left blank.The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positvie, an initial chest X-ray with results noted.(ATTACHMENT 1) Ganister Station provides a letter to each parent, residential provider, and/or guardian regarding the individual's physical. This letter was updated with the following information "According to Chapter 2380.111 (c)(5), Ganister Station is required to have the current TB results on each current physical. Please make sure the physician completes ALL sections on the physical and medical history forms we have provided." (ATTACHMENT 2) Yearly Physical and Consent Forms Document- Once the annual physical form and consent forms are returned to Ganister Station, the clerical staff and Program Specialist will be responsible for double checking the physical to ensure that all sections of physical were completed correctly (Please note that in the event a clerical staff is not available, the Program Specialist can designate a 2nd staff). The Program Specialist and Clerical and/or 2nd staff will then initial when they completed looking over the physical form. (ATTACHMENT 3) Email to all program specialist and clerical with new process 03/10/2021 Implemented
SIN-00145650 Renewal 12/12/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(7)The Health Maintenance section on Individual #1 , 5/15/18 physical exam was left blank.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals.The physical for individual #1 was up-dated to include an assessment of health maintenance needs and the need for blood work at recommended intervals. The secretary will initially screen all incoming physicals and forward them to the program specialist for a final review to assure all requirements are met. 01/02/2019 Implemented
2380.181(e)(10)Individual #2 , 3/8/18 assessment included a LMH from May of 2016. Updated medical information wasn't included.The assessment must include the following information: A lifetime medical history.The assessment for Individual #2 was up-dated to include an up-dated lifetime medical history. The program specialist will be responsible to assure all individuals have current and up-to-date lifetime medical histories attachments to their assessments. 01/02/2019 Implemented
2380.186(c)(1)Individual #2 , 11/6/18, 8/2/18, 5/8/18, 2/8/18 ISP Reviews did not include progress and participation towards ISP outcome of Exploring.The ISP review must include the following: A review of the monthly documentation of an individual¿s participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the facility licensed under this chapter.The ISP review was amended to include progress and participation toward the ISP outcome of Exploring (Attachment A). The program specialist will ensure future reviews include all regulatory areas relative to progress and participation. The reviews will be submitted to the immediate supervisor of the program specialist for review/approval. 01/02/2019 Implemented
SIN-00118870 Renewal 10/06/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.173(9)Individual #1's epilepsy protocol states to give diastat after 5 minutes, not to be given more than once a day. ISP indicates ativan is to be given for seizure activity, and if not effective after 10 minutes, give diastat. ISP also indicates diastat is to be repeated in 30 minutes if original dose is not effective. Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under §  2380.186.The program specialist contacted Geisinger Health Systems to secure their written instruction and clarification for administration of Diastat Acudial (Attachment I). The program forwarded track changes to the supports coordinator for inclusion into the ISP (Attachments J1 through and including J 4). Staff have been trained in the diastat protocol (Attachment K). The program specialist will be responsible to provide oversight to all individual ISP's to prevent future content discrepancies. 11/06/2017 Implemented
2380.181(e)(3)(i)Individual #1's assessment dated 2/21/2017 did not include functional skills. The assessment must include the following information: The individual¿s current level of performance and progress in the following areas:  Acquisition of functional skills.Individualm#1's assessment has been amended by the program specialist to include a comprehensive assessment of functional skills, level of performance, and progress. All assessments for individuals receiving services has been reviewed to assure regulatory requirements. The program specialist has been trained in the regulatory requirements in order to avoid future noncompliance (Attachment E). 11/06/2017 Implemented
2380.181(e)(12)Individual #1's assessment dated 2/21/17 and Individual #2's assessment dated 10/7/16 did not include recommendations for specific areas of training, vocational programming and competitive community-integrated employment.The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment.Individual's #1 and #2 assessments have been amended by the program specialist to include more comprehensive information to address specific areas of training, vocational programming, and competitive community-integrated employment. Track changes have been submitted to each individuals supports coordinator for inclusion into the ISP. All individual assessments of those receiving supports have been reviewed and amended to assure compliance. The program specialist has received training in comprehensive completion of individual assessments, as it is defined in the job description as her responsibility (Attachment E). 11/06/2017 Implemented
2380.183(5)Individual #1 is prescribed medication for mood disorder. Record did not include a protocol to address the social, emotional and environmental needs of the individual.The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness.The program specialist is responsible for, and has written, a social and environmental needs plan for the individual. (Attachment B 1, B 2). The program specialist provided the supports coordinator with the protocol and requested that the protocol be included in the ISP. (Attachment C). Staff have been trained on the plan. (Attachment D). A review of all individual files was completed, and three additional individuals were also in need of protocols. The program specialist received training on the requirements for regulation 2380.183(5) to prevent future noncompliance. (Attachment E). 11/07/2017 Implemented
2380.183(7)(i)Individual #1's ISP and Individual #2's ISP did not include an assessment of the individual's potential to advance in the following: Vocational programming.The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual's potential to advance in the following: Vocational programming.The iSP's for individual #1 and individual #2 were amended by the program specialist to include a comprehensive review of their respective potential and needed supports to advance in vocational programming. (Attachments F 1 through and including F 9, and Attachments G 1 through and including G 10). The program specialist forwarded the amended assessment to the individuals' SC's for inclusion to the ISP.(Attachments C and H). A review of all individuals served was completed to assure regulation compliance. The program received training is assessment requirements, which included the need to address each individuals potential to advance in vocational programming. (Attachment E). 11/06/2017 Implemented
2380.183(7)(ii)Individual #1's ISP and Individual #2's ISP did not include an assessment of the individual's potential to advance in the following:  Community involvement.The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual's potential to advance in the following:  Community involvement.The ISP for individual #1 and individual #2 were amended to assure a more comprehensive review of their potential to advance in the area of community involvement. Documentation also includes correspondence to their respective supports coordinators. A review of all individuals in program attendance was completed. The program specialist was trained in regulatory requirements specific to individuals potential to advance with community involvement (Attachment E). 11/06/2017 Implemented
2380.183(7)(iii)Individual #1's ISP and Individual #2's ISP did not include an assessment of the individual's potential to advance in the following:  Competitive community-integrated employment.The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual's potential to advance in the following:  Competitive community-integrated employment.The assessments were amended by the program specialist to include additional information to adequately address the potential of individuals #1 and individual #2 to advance in competitive community-integrated employment. The program specialist provided the individuals SC's with the amended assessments for inclusion to the ISP. The program specialist received training in the regulatory requirements in order to prevent future occurrences. (Attachment E). Additionally, all individuals assessments were reviewed for compliance. 11/06/2017 Implemented
2380.185(b)Individual #1's ISP indicates ativan is to be given for seizures. No ativan is present at the program. The ISP shall be implemented as written.Ativan is present at program, and a Medication Administration Record has been completed (Attachment A). The activity director, who is trained in medication administration, will be responsible to assure records for administration will be at program for future months. 11/07/2017 Implemented
SIN-00099952 Renewal 08/19/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.59(c)The 01/04/16 coliform water test was completed late. The previous water test was completed on 09/03/15.A facility that is not connected to a public water system shall have a coliform water test by a Department of Environmental Resources certified laboratory stating that the water is safe for drinking purposes at least every 3 months. Written certification of the water test shall be kept.The coliform test was completed 01/04/2016, 03/29/2016, and 06/29/2016. A sample was collected 09/16/2016. (Attachments K 1 through 11). A schedule of tests to be completed through September of 2017 was developed and available for review (Attachment L 1).It is the responsibility of maintenance staff to assure future compliance and have water tested in a timely fashion. The CEO will review the schedule on a quarterly basis. 09/19/2016 Implemented
2380.67(a)The dryer lint trap contained approximately a softball sized amount of lint. Furniture and equipment shall be nonhazardous, clean and sturdy.The lint from the dryer was removed at the time of licensing. Attachment J 1 provides documentation of the form that has been implemented to assure each time the dryer is used, the lint is removed. It is each staff's responsibility to empty the lint from the dryer after every use. 09/19/2016 Implemented
2380.89(h)The 06/14/16 fire drill log did not indicate which smoke detector was set off.A fire alarm shall be set off during each fire drill.All fire drills will include documentation of the specific smoke detector that was set off. The activity director shall be responsible for accurate documentation. Attachments I 1 -2 document the alarm tested during drills held in July and August, 2016. 09/19/2016 Implemented
2380.111(b)Individual #1's 11/10/15 physical dxam was not signed by the physician.The physical examination documentation shall be signed and dated by a licensed physician, certified nurse practitioner or certified physician's assistant.An e-mail has been sent to the support coordinator to request the physician to sign it. Documentation shall be secured and forwarded. 10/15/2016 Implemented
2380.111(c)(7)Individual #2's 6/20/16 physical exam did not include recommended intervals for blood work. This section was blank. Individual #3's 6/6/16 physical exam did not include health maintence needs. This section was left blank. The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals.The physician for individual #2 was contacted, via telephone, by the program specialist. The verbal response, which indicated the recommendation for regular blood work to be completed at three month intervals, was entered, initialed, and dated by the program specialist(Attachment G 1) All individual physicals ere reviewed to assure each regulatory requirement was met. As it is the responsibility of clerical staff to review initial and annual physicals for regulation compliance, training was provided to avoid future compliance (Attachment H 1). 09/19/2016 Implemented
2380.173(1)(iv)REPEATED VIOLATION- 5/6/15 Individual #2's record did not include religious affiliation. Individual #1's record did not include religious affiliation. Each individual¿s record must include the following information: Personal information including: Religious affiliation.The record for individual #2 was up-dated by clerical staff to include religious affiliation (Attachment E 1). A review was completed by clerical staff to assure all individual files addressed religious affiliation(s). It is the responsibility of clerical staff to assure this regulation is met. Documentation of training is Attachment E 2. 09/19/2016 Implemented
2380.173(9)REPEATED VIOLATION- 5/6/15 Individual #3's 6/6/16 physical exam indicated an allergy to bee stings. Individual #3's Individual Support Plan (ISP) and 5/10/16 assessment did not indicae bee stings as an allergy. Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under §  2380.186.Documentation was obtained from the primary care physician 08/30/2016 to document Individual #3 does not have an allergic reaction to bee stings. (Attachment F 1) 09/19/2016 Implemented
2380.181(e)(11)Individual #1's 4/1/16 assessment did not include a review of the most recent psychological evaluation completed within the year.The assessment must include the following information: Psychological evaluations, if applicable.Individual #1 did not have a psychological evaluation completed within the year. Attachments D 1-2 document e-mail exchange between the Program specialist and supports coordinator to support this statement. 09/19/2016 Implemented
2380.185(b)Individual #1's Individual Suppor tPlan (ISP) indicated sharps should be locked. Ten kitchen knives were stored in an unlocked drawer to the right of the stove . The ISP shall be implemented as written.All kitchen knives were locked to assure the safety of Individual #1 at the time of licensing. The assessment for Individual #1 was up-dated to include documentation that she can use knives safely when she is cooking and is not at risk for knives to be stored in an unlocked area and with other utensils that are used. A copy of the assessment was sent to all identified team members and was also reviewed with the individual. (Attachments B 1-2-3-4-5-6-7-8). Additionally, tracking changes were forwarded to the SC to request the ISP be up-dated. (Attachment C 1). The program specialist if responsible for both initial and up-dated assessments and required up-dates to the ISP. The program specialist is also responsible to assure the ISP is implemented as written. 09/19/2016 Implemented
2380.186(c)(2)REPEATED VIOLATION-5/6/15 Individual #1's 6/28/16 Individual Support Plan (ISP) review did not include a review of Individual #1's social, emotional, environmental needs plan. The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.Individual #1 does not have a emotional, environmental needs plan. She does have behavioral supports through Skills of Central Pennsylvania. Attachment A, 1-2-3 is a copy of the quarterly review (3/01/2016 through 05/31/2016) which includes a review of the plan. The program specialist is responsible for the review. 09/19/2016 Implemented
SIN-00078315 Renewal 05/06/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.173(1)(ii)Race was missing from Individual #3's record. Eye color was missing from Individual #2.Each individual's record must include the following information: Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks.The Program Specialist has corrected the record for individual #2 to include eye color and #3 for race. Attachment H (Ind #2 Admission Record) I (Ind. #3 Admission Record). To Assure Compliance: Upon initial admission the Program Secretary will construct the record and the Program Specialist will review it to assure regulation compliance. The Program Supervisor has provided training on the process. Attachment K - Training Record 07/02/2015 Implemented
2380.173(1)(iv)Religious affiliation was missing from Individual #2's record.Each individual¿s record must include the following information: Personal information including: Religious affiliation.The Program Specialist has corrected the record for individual #2 to include Religious affiliation. Attachment H (Ind #2 Admission Record) To Assure Compliance: Upon initial admission the Program Secretary will construct the record and the Program Specialist will review it to assure regulation compliance. The Program Supervisor has trained all staff in the process. Attachment K Training Record 07/02/2015 Implemented
2380.173(9)Individual #3's Individual Support Plan (ISP) stated that they were on a low sodium diet. Individual #3's physical had them on a reduced carbohydrate diet and their medication administration record had them on a 1400 diabetic diet.Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under §  2380.186.The Residential Medical Coordinator accompanied Individual # 3 for her annual physical where they obtained the most current dietary guideline for Ind #3. Attachment J (Updated Physical for #3). The Medical Coordinator provided the Support Coordinator with the current physical. The Program Specialist included the information in the new assessment and provided the assessment to the team. Future Occurrence: The Program Executive Secretary will review all physical to assure they are complete then the Program Specialist will review it to assure there are no discrepancies. The Program Supervisor has trained responsible staff. Attachment K (Training Record) 07/06/2015 Implemented
2380.181(e)(12)The assessments for Individuals #1 and #3 did not contain recommendations for specific areas of training, vocational programming and competitive community-integrated employment.The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment.Correction: Who: The Program Specialist What: Assessments have been amended to include specific areas of training, vocational programming and competitive community-integrated employment and provided to the individuals Teams. Attachment F-6 (#1 Assessment page 6) and G-6 (#3 Assessment page 6). Future Occurrences. The assessment format has been updated to include and will provide documentation of individual's potential and recommendations for specific areas of training,vocational programming and competitive community integrated employment. It will be provided to team members at least 30 days prior to ISP meeting date. The Program Specialist will review every 3 months this section of the ISP. 07/08/2015 Implemented
2380.181(e)(13)(iv)The assessment for Individual #3 did not include progress and current level in socialization.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Socialization.The Program Specialist has corrected the record for individual #2 to include eye color and #3 for race. Attachment H (Ind #2 Admission Info) I (Ind. #3 Admission Info). To Assure Compliance: Upon initial admission the Program Secretary will construct the record and the Program Specialist will review it to assure regulation compliance. The Program Supervisor has provided training of the process to responsible staff. Attachment K - Training Record 07/08/2015 Implemented
2380.181(e)(13)(vi)The assessments for Individuals #1 and #3 did not include their progress and current level in community-integration.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Community-integration.Correction: Who: The Program Specialist What: Individual #1 & #3¿s assessments has been amended to include their progress and current level in community-integration and was provided to the Teams. Attachment F-6 (#1 Assessment) G -8 (#3 Assessment). Future Occurrences. The assessment format has been updated to include and will provide documentation of individual's progress and current level and will be provided to team members at least 30 days prior to ISP meeting date. The Program Specialist will review every 3 months this section of the ISP. 07/08/2015 Implemented
2380.183(7)(i)The Individual Support Plans (ISPs) for Individuals #1 and #3 did not include an assessment of their potential to advance in vocational programming.The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following: Vocational programming.Correction: Responsible: The Program Specialist What: Assessments have been amended to include Vocational Programming and has been provided to the team. Attachment F-6 (#1 Assessment page 6) and G-4 (#3 Assessment page 4). Future Occurrences: The Program Specialist has updated the assessment. The format has been updated to include their potential to advance in vocational programming and will provide documentation of individual's potential. It will be provided to team members at least 30 days prior to ISP meeting date. The Program Specialist will be review every 3 months this section of the ISP. 07/08/2015 Implemented
2380.183(7)(ii)The Individual Support Plan (ISP) for Individual #1 did not include an assessment of their potential to advance in community involvement.The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following:  Community involvement.Correction: Person Responsible: Program Specialist What: The Assessment has been amended to include Community Involvement. Attachment F -7 (#1 Assessment page 7) and it has been provided to the team. Future Occurrences. The assessment format has been updated to include Community Involvement and will provide documentation of individual's potential and will be provided to team members at least 30 days prior to ISP meeting date. The Program Specialist will review every 3 months this section of the ISP. 07/08/2010 Implemented
2380.183(7)(iii)The Individual Support Plans (ISPs) for Individuals #1 and #3 did not include an assessment of their potential to advance in competitive community-integrated employment.The ISP, including annual updates and revisions under §  2380.186 (relating to ISP review and revision), must include the following: Assessment of the individual¿s potential to advance in the following:  Competitive community-integrated employment.Correction: Responsible: The Program Specialist What: Individual #1 and #3 Assessments have been amended to include Competitive Community Integrated employment. Attachment F-4 (#1 Assessment page 4) and G-4 (#3 Assessment page 4) and provided to the team. Future Occurrences. The assessment format has been updated to include competitive employment and will provide documentation of individual's potential and will be provided to team members at least 30 days prior to ISP meeting date.The Program Specialist will review this section of the ISP every 3 months. 07/08/2015 Implemented
2380.186(c)(2)The Individual Support Plan (ISP) reviews for Individual #3 did not review their 60 minutes of unsupervised time or their Social, Emotional and Environmental plan. The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.Program Specialist will include a review of Ind # 3's use of unsupervised time as well as the SEE plan in the scheduled quarterly to be completed. The Program Specialist notified the Support Coordinator requesting an ISP update for identified issues. Attachment A: ISP 3 month review B: Notice to SC The Program Specialist Supervisor has trained the Program Specialist to assure that all components of the ISP are reviewed. Attachment C: Training Log 07/09/2015 Implemented
2380.186(e)The program specialist for Individual #1 did not notify their supports coordinator of the option to decline the Individual Support Plan (ISP) review documentation. The program specialist for Individual #2 did not notify their mother of the option to decline the ISP review documentation. The program specialist shall notify the plan team members of the option to decline the ISP review documentation.The Program Specialist has notified the respective Individual's teams of the option to decline ISP reviews . Attachments D & E: Copy of Letters. The Program Specialist will continue to include the option to decline in all future contacts. 07/08/2015 Implemented
SIN-00223591 Renewal 05/01/2023 Compliant - Finalized
SIN-00164785 Renewal 01/21/2020 Compliant - Finalized
SIN-00079200 Change in Location Capacity 05/21/2015 Compliant - Finalized
SIN-00048629 Renewal 05/08/2013 Compliant - Finalized