Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00237227 Renewal 01/09/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(b)There was a spray bottle with clear liquid which was not in its original labelled container.Poisonous materials shall be stored in their original, labeled containers.Attachment #1 shows all spray bottles with clear liquids were removed from the cleaning closet. All poisonous materials are stored in their original containers. Attachment #2 and #3 picture the cleaning closet and showing that all materials are in their original containers. 01/15/2024 Implemented
2380.87(b)The kitchen does not have a strobe light for individuals who are deaf.If one or more individuals or staff persons are not able to hear the fire alarm system, the fire alarm system shall be equipped so that each person who is not able to hear the alarm shall be alerted in the event of a fire.Administrative Assistant, called MEI Systems on January 9th 2024. A strobe light was installed in the kitchen on January 11th, 2024. Please see Attachment 4 shows the completion from the work order and attachment 5 and 6 show the strobe light that was installed in the kitchen. 01/11/2024 Implemented
2380.91(a)Individual #1 attends day program on Mondays and Wednesdays. Individual #1's initial admission was on Wednesday, 8/9/2023 but fire safety training was not conducted until the following day of attendance, which was Monday, 8/14/2023. Fire safety training needs to be conducted on the individual's first day of attendance in order to satisfy this regulation.An individual shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general firesafety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, and smoking safety procedures if individuals smoke at the facility.Initial Fire Safety Training will be completed on the individual's first day of attendance at Ganister Station. The Initial Fire Safety Training will be completed by the Program Specialist/Supervisor or the Clerical Staff. 01/16/2024 Implemented
2380.181(a)Individual #1 did not have an assessment completed within 60 days of admission. The assessment that was completed was an "OLTL Assessment", however this specific assessment does not meet all the regulatory components required by regulation 181e1-14.Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter.In order to meet both OLTL and ODP regulations, Ganister Station combined both assessments. Individual #1 has a completed assessment that meets OLTL and ODP regulations. This is known and as the Dual Assessment. Please see attachment #8 for full assessment. 01/12/2024 Implemented
2380.183(a)(3)Individual #1's ISP plan meeting held on 10/12/2023 did not have a Direct Service Worker's input or attendance at the meeting.The individual plan shall be developed by an interdisciplinary team, including the following: The individual's direct care staff persons.Ganister Station will complete a meeting signature sheet for every team meeting. The team meeting will be kept in the individual's personal file. At the bottom of the signature page, it states that the individual's direct service worker must be present for the individual support plan. Please see attachment #9. 01/25/2024 Implemented
2380.183(a)(4)Individual #1's ISP plan meeting held on 10/12/2023 did not have a Program Specialist in attendance at the meeting.The individual plan shall be developed by an interdisciplinary team, including the following: The program specialist.Ganister Station will complete a meeting signature sheet for every team meeting. The team meeting will be kept in the individual's personal file. At the bottom of the signature page, it states that the Program Specialist must be present during an ISP meeting. Please see attachment #10. 01/25/2024 Implemented
2380.183(b)Individual #1's ISP plan meeting held on 10/12/2023 did not have at least 3 members of the individual plan team present.At least three members of the individual plan team, in addition to the individual and persons designated by the individual, shall be present at a meeting at which the individual plan is developed or revised.During further investigation, it was founded that there was more than three members of the individual plan team present for the meeting that was held on 10/12/2023. Please see attachment #12. 01/25/2024 Implemented
SIN-00197874 Renewal 01/04/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(a)XTRA Laundry Detergent, Equate Sunscreen Sport and Banana Boat Sunscreen were located in the laundry room not locked. Poisonous Substances must be kept locked.Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.Laundry door will have a lock placed on it. 01/05/2022 Implemented
2380.111(c)(4)Individual #2's Physical exam dated 07/22/21 does not include a vision and hearing screening. It states, "not completed".The physical examination shall include: Vision and hearing screening, as recommended by the physician.Ganister Station reached out to Individual's #2 residential provider for clarification on the hearing and screening. 01/24/2022 Implemented
2380.185(1)Individual #1's 12/08/20 and 12/03/21 assessments state that individual #1 recognizes poisonous materials. The ISP dated 06/23/21 states it is not clear if individual #1 identifies danger signs or warning labels re: Poisonous materials.The individual plan, including revisions, must include the following: The individual's strengths, functional abilities and service needs.Update Assessment to be consistent with individual #1's ISP. 01/06/2022 Implemented
SIN-00159325 Renewal 10/09/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.87(b)The first aid room, which has a door that closes, does not have a strobe light. The program has an individual's attending daily that have hearing impairmentsIf one or more individuals or staff persons are not able to hear the fire alarm system, the fire alarm system shall be equipped so that each person who is not able to hear the alarm shall be alerted in the event of a fire.(SECRETARY) CALLED MORROCCO ELECTRIC ON OCTOBER 9, 2019 TO ORDER THE STROBE LIGHT. A BILL DATED ON OCTOBER 28TH, 2019 STATES THAT A NEW STROBE LIGHT WAS INSTALLED AND HAS A BUILT IN 10 YEAR WARRANTY BACK UP (ATTACHEMENT C1). A PICTURE WAS TAKEN ON OCTOBER 28TH, 2019 (AFTER THE INSTALLATION) TO SHOW THAT THE INSTALLATION WAS COMPLETED (ATTACHMENT C2). 10/28/2019 Implemented
2380.176(a)The sensory room, there is a tall filing cabinet in the front on the room near a desk that was unlocked containing individual's personal information. This information was arriving and departing schedules of the individuals that attend the program.Individual records shall be kept locked when they are unattended.ALL INDIVIDUAL'S PERSONAL INFORMATION WAS REMOVED FROM THE UNLOCKED FILING CABINET (ATTACHMENT B1) AND MOVED TO A LOCKED DRAWER (ATTACHMENT B2). ALL PERSONAL INFORMATION WILL BE KEPT IN A LOCKED DRAWER AT ALL TIMES. 10/09/2019 Implemented
2380.181(e)(5)Assessment 5/4/19 states Individual # 2 is able to self-administer medications. She does not, however, take any medications while at day program. It also states she continues to self-medicate but is monitored by her mother to ensure mediations are taken properly. Individual # 2's current ISP last updated 9/26/19, of the medication, medication supplement section, it states after each of her prescribed medications that she is not self-medicating. Under the section Adaptive/Self Help, it states Individual # 2's mother monitors her to ensure her meds are taken appropriately. Individual # 2's mother reported that Individual # 2 knows when it is time take her meds. There is no evidence that Individual # 2 has been assessed by Ganister Station in the three following areas, how much medication to be taken, able to recognize and distinguish the medication, and when to take the medication.The assessment must include the following information: The individual¿s ability to self-administer medications.TAMMY MARTIN (LPN) COMPLETED A MEDICATION SELF-ADMINISTRATION ASSESSMENT ON INDIVIDUAL #2 (ATTACHEMENT A1). IT WAS THEN DETERMINED THAT INDIVIDUAL #2 IS ABLE TO SELF-MEDICATE AFTER COMPLETION OF THE ASSESSMENT. TIMOTHY REYNOLDS (PROGRAM SPECIALIST) EMAILED INDIVIDUAL #2'S SUPPORT COORDINATOR (LAUREN ECKLUND) TO UPDATE HER INDIVIDUAL SUPPORT PLAN SO THAT IT CAN REFLECT THE SELF-ADMINISTRATION ASSESSMENT (ATTACHEMENT A2). THE FOLLOWING AREAS NEEDED UPDATED: UNDER MEDICATION INFORMATION; THE INDIVIDUAL SUPPORT PLAN STATES THAT INDIVIDUAL #2 IS UNABLE TO SELF-MEDICATE. THIS NEEDS CHANGED TO "YES, SHE IS ABLE TO SELF-MEDICATE." A LETTER DATED OCTOBER 11, 2019 WAS SENT TO INDIVIDUAL #2'S TEAM INDICATING THAT A SELF-ADMINISTRATION ASSESSMENT WAS COMPLETED AND THE RESULTS OF THE ASSESSMENT (ATTACHEMENT A3). THE MEDICATION SELF-ADMINISTRATION ASSESSMENT CHECK LIST WILL BE COMPLETED FOR EACH INDIVIDUAL DURING THE TIME OF THE INITIAL OR ANNUAL ASSESSMENT. THE MEDICATION SELF-ADMINISTRATION ASSESSMENT CHECKLIST WILL BE COMPLETED BY THE PROGRAM SPECIALIST AND ONCE COMPLETED, IT WILL BE ATTACHED TO THE ASSESSMENT. 10/23/2019 Implemented
SIN-00139071 Renewal 08/30/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(a)4 bottles of Banana Boat Sun Screen unlocked in laundry room. Label stated contact poison control if ingested.Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.All poisonous substances will be locked as per regulatory requirements. A shelf in the utility closet has been designated as the storage area for sunscreen. The sunscreen noted in the unlocked laundry room has been relocated to this designated area. Staff were trained on the guidelines of 2380.53(a) 09/21/2018 Implemented
2380.84A fire safety inspection occurred on 03/31/17 and not again until 07/25/18.The facility shall have an annual onsite fire safety inspection by a fire safety expert. Documentation of the date, source and results of the fire safety inspection shall be kept.A new fire expert has been secured for future inspections. The program specialist will be responsible to contact the fire expert no less than one month in advance of the current expiration date to assure regulatory requirements. It should be noted the program specialist present at the time of licensing, and responsible for compliance, has resigned her position. Training for the new program specialist will include components necessary for meeting licensing requirements. 09/21/2018 Implemented
2380.173(9)Individual #1's physical dated 1/22/18 includes diagnosis of Vitamin Deficiency, Migraines, GERD, Inflammation of Lips, Allergic Rhinitis and Nasal Dryness. Assessment dated 9/9/17 does not include aforementioned diagnosis. Assessment includes diagnosis of Dry Eyes which is not included in the physical.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 up-dated all diagnoses on the physical, medical history summary, and also provided notification to the individual supports coordinator to assure accuracy. In order to prevent future content discrepancies, the program specialist will review all relative documents and provide notification to other team members. It should be noted the program specialist assigned to this individual has resigned her position. The new program specialist will receive training to assure future regulation compliance. 09/21/2018 Implemented
SIN-00116742 Renewal 06/30/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(1)Individual #2's physcial dated 6/12/17 did not inlcude a medical history. The physical examination shall include: A review of previous medical history.The individuals physician was contacted by clerical staff and an amended physical form was completed to include a medical history for the individual. In order to prevent future occurrences, a physical for individual referrals will requested and reviewed by the program specialist supervisor in order to assure compliance. The first day of attendance will not be scheduled until the review has been completed and all components of the physical form have been satisfied. 07/13/2017 Implemented
2380.111(c)(9)Individual #2's physcial dated 6/12/17 did not inlcude a allergies. The physical examination shall include: Allergies or contraindicated medication.The individual's physician was contacted by clerical staff and made the needed revision to the physical, which includes an allergy also listed as a contraindicated medication. .To prevent future occurrences, all physicals will be reviewed to assure all components of the physical have been satisfied. This review will include both annual physicals as well as those received prior the an individual's first day of program. 07/13/2017 Implemented
2380.183(5)Individual #2's ISP did not inlcude a SEEN plan. 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.A SEEN plan has been written by the program specialist supervisor and submitted to the individual's supports coordinator for inclusion in the ISP. In order to prevent future concerns of this nature, all ISP's will be reviewed prior to the first date of attendance for all individuals. Necessary revision(s) to the ISP will be submitted, in writing, to the individual's respective supports coordinator. 08/11/2017 Implemented
2380.183(7)(i)Individual #2's ISP did not include an assessment of the 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.A written request has been submitted by the Chief Executive Officer to the individual's supports coordinator in request of a revision to the ISP. The request serves as notification of the need to address the individuals potential to advance in the community. A date for the individual's 60 day outcome meeting has been scheduled for August 10, 2017, at Somerset Ganister Station, beginning at 10:00 AM. In order to prevent future occurrences, the program specialist supervisor will be responsible to review ISP's prior to an individuals first day of attendance to assure regulatory compliance. In the event the ISP is in need of revision, written notification will be made, and a 60 day outcome meeting will be scheduled with invitations sent to all team members. 08/10/2017 Implemented
2380.183(7)(iii)Individual #2's ISP did not include an assessment of the 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.A written request was made by the Chief Executive Officer to the individual's supports coordinator in request of a revision to the ISP. The requested revision included the identified need to address potential for advancement in competitive community integrated employment. An invitation to all team members has been sent to attend the 60 day outcome meeting scheduled August 10, 2017 at Somerset Ganister Station, beginning at 10: am. 08/10/2017 Implemented
SIN-00095117 Renewal 07/14/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(8)Individual #1's physical dated 6/10/16 did not have physical limitations.The physical examination shall include: Physical limitations of the individual.The physical for individual #1 has been submitted to Somerset Family Practice to have the required field completed. A letter was sent July 28, 2016 to provide notification to caregivers, and/or those who accompany individuals receiving supports at Ganister Station to their annual physical explaining the need that all fields within the physical must be completed. The assistant activity director/secretary will review all incoming physicals to assure all fields are completed. Additionally a review of all individual physicals was completed. 08/23/2016 Implemented
2380.111(c)(10)Individual #1's phsycial dated 6/10/16 and individaul #4's physcial dated 3/10/16 did not include information pertinent to diagnosis and treatment in case of an emergency. The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.The physical for individual #1 has been re-submitted to Somerset Family Practice to have information pertinent to diagnosis and treatment in case of an emergency completed. A letter to caregivers was sent outlining the need for all fields within the physical to be completed. The assistant activity director/secretary will review all incoming physicals to assure compliance with regulation. 08/23/2016 Implemented
SIN-00086990 Unannounced Monitoring 11/10/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.13The facility's certificate of compliance states the total number of persons which may be cared for at one time may not exceed 29 or the maximum capacity permitted by the certificate of occupancy, whichever is smaller". On 10/30/2015 the facility cared for a total of 33 individuals. The maximum capacity specified on the certificate of compliance may not be exceeded.Staff ratios will be maintained at all times during program hours. Any activity incorporating staff, the full roster of participants, and volunteers will be scheduled at a location separate from the Ganister Station building at 129 Brantwood Road, Somerset PA 15501. The Program Specialist will be responsible to assure the location where the activity is scheduled has a valid occupancy permit for the number of persons in attendance. The holiday party, scheduled December 23, 2015, will be held in the Church Activity Hall, Faith Lutheran Church, Route 31 East, Somerset, PA 15501.See attachement #1. Implemented
2380.14(a)The facility did not have a occupant load number on their most current certificate of occupancy issued 5/27/2009. It states, occupant load TBD. A facility shall have a valid firesafety occupancy permit listing the appropriate type of occupancy from the Department of Labor and Industry, the Department of Public Safety of the city of Pittsburgh, the Department of Licensing and Inspection of the city of Philadelphia or the Department of Community Development of the city of Scranton.Staff ratios will be maintained at all times during program hours. Any activity incorporating staff, the full roster of participants, and volunteers will be scheduled at a location separate from the Ganister Station building at 129 Brantwood Road, Somerset PA 15501. The Program Specialist will be responsible to assure the location where the activity is scheduled has a valid occupancy permit for the number of persons in attendance. The holiday party, scheduled December 23, 2015, will be held in the Church Activity Hall, Faith Lutheran Church, Route 31 East, Somerset, PA 15501.See attachement #1. Implemented
2380.51Individual #1 is deaf. The facility does not have strobe lights in the bathrooms. A facility serving one or more individuals with a physical disability, blindness, a visual impairment, deafness or a hearing impairment shall have accommodations to ensure the safety and reasonable accessibility for entrance to, movement within and exit from the facility based upon each individual's needs.Stobe lights were installed in the facility bathrooms in the facilty. See attachment #2. Implemented
SIN-00078314 Renewal 05/06/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(a)There was no fire drill conducted in the month of January 2015. An unannounced fire drill shall be held at least once a month.) A schedule of fire drills has been written and it will be maintained by the Program Specialist to assure a drill is completed monthly. The drills will be unannounced to other program staff, and participants. Attachment C: Schedule 05/01/2015 Implemented
2380.111(b)Individual #2 annual physical was not dated by a licensed physician, certified nurse practitioner or certified physician's assistant. The physical examination documentation shall be signed and dated by a licensed physician, certified nurse practitioner or certified physician's assistant.The secretary will screen all completed physicals upon receipt to assure documentation is signed and dated by a licensed physician, certified nurse practitioner, or certified physicians assistant. The completed physical will subsequently be reviewed by the Program Specialist. In the event that any required documentation does not meet regulatory requirements, it will be the responsibility of the Program Specialist to follow-up and correct. Attachment B: Completed Physical 05/08/2015 Implemented
2380.186(c)(2)Individual #2's ISP reviews- 2/19/15, 11/12/15, 8/2/14 and 5/5/14 did not review the SEEN plan in its entirely that is in the ISP. The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter.The Program Specialist will include a comprehensive review of all SEEN plans as part of each individuals quarterly, as well as a review of each section of the ISP. Attachment A: Quarterly Review 05/05/2015 Implemented
SIN-00063539 Renewal 05/13/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.173(9)The ISP for Individual #2 indicated two different dates of birth. The physical for Individual #2 states she should follow a diet of no concentrated sweets. The ISP and assessment for Individual #2 states she is to follow an 1800 calorie, low cholesterol, low sodium diet and to avoid high salt and sugar, no concentrated sweets. Each individual¿s record must include the following information: Content discrepancies in the ISP, the annual update or revision under §  2380.186.Discrepancy between ISP and Admission was corrected. Attachment A. Individual #2's physician was contacted by the Program Specialist and added to the physical. All documents have the same information. Attachment B ,C. The Program specialist will review Admission and Physical information at the Annual Review meeting. 05/16/2014 Implemented
2380.183(5)The ISP's for Individual #1, #2, and #3, did not include the SEEN plans. 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 contacted the Support Coordinator for each of the individual 2 by email on by phone and requested that the SEE plans were added to the ISP's. Review of the SEE plans was added to the Annual Review Process to assure completion in the future by the Program Specialist. Attachment: D, E. 05/16/2014 Implemented
SIN-00049173 Renewal 05/07/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.87(b)The fire alarm system is not equipped with strobe lights to alert two individuals attending the program who are deaf.(b)  If one or more individuals or staff persons are not able to hear the fire alarm system, the fire alarm system shall be equipped so that each person who is not able to hear the alarm shall be alerted in the event of a fire.Strobe lights will be installed. Attachment A: Contract for Installation [Partially Implemented] 05/24/2013 Implemented
2380.181(e)(13)(ii)The assessment for Individual #2 does not include progress in the area of motor and communication skills.(e)  The assessment must include the following information: (13)  The individual's progress over the last 365 calendar days and current level in the following areas: (ii)   Motor and communication skills.Individual #2 assessment has be updated and now includes a summary of progress in the last 365 days on motor and communication skills. Attachment B: Completed Assessment Individual 1. Reminders have been added to our assessment to assure completion of this section. Attachment E: Assessment with additions. {Partially Implemented] 05/15/2013 Implemented
2380.181(e)(13)(v)The assessment for Individuals 1 and 2 does not include progress in the area of recreation.(e)  The assessment must include the following information: (13)  The individual's progress over the last 365 calendar days and current level in the following areas: (v)   Recreation.Individual #1 & #2 assessment has be updated and now includes a summary of progress in the last 365 days in Recreation. Attachment B & C: Assessments for Ind 1 & 2. Reminders have been added to our assessment to assure completion of this section in the future. Attachment E: Assessment with additions. [Partially Implemented] 05/15/2013 Implemented
2380.181(e)(13)(vi)The assessment for Individual #3 does not include the current level of functioning in the area of community integration.(e)  The assessment must include the following information: (13)  The individual's progress over the last 365 calendar days and current level in the following areas: (vi)   Community-integration.Individual #3 assessment has be updated and now includes a summary of the current level of function in the area of community integration. Attachment D: Assessments for Ind #3. Reminders have been added to our assessment to assure completion of this section in the future. Attachment E: Assessment with additions. [Partially Implemented] 05/15/2013 Implemented
SIN-00218328 Renewal 01/23/2023 Compliant - Finalized
SIN-00178607 Renewal 11/02/2020 Compliant - Finalized