Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
2380.89(a) | No fire drill was held during the month of May 2017. | An unannounced fire drill shall be held at least once a month. | The administrative secretary at the main office of Ganister Station will receive and review monthly fire drills in order to assure they are completed on a monthly basis. The program specialist received training in the regulatory requirements with respect to fire drills being completed in timely fashion. fire drill was held in December(Attachment J). |
12/28/2017
| Implemented |
2380.111(c)(3) | Individual #1's physical dated 12/13/2016 did not include immunizations. | The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | Individual #1 had a physical completed 12/8/17 with her primary care physician, which includes immunizations as recommended by the US Public Health Service, Center for Disease Control (Attachment I). All individuals physicals were reviewed to assure immunizations are listed, as required. The program specialist received training in the required immunizations for individuals. |
12/08/2017
| Implemented |
2380.111(c)(7) | Individual #1's physical dated 12/13/2016 did not include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. It was blank. Individual #2's physical dated 5/22/2017 did not include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. It was 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. | Individual #1's physical was up-dated 12/13/17 to include health maintenance needs, medication regimen, and the need for blood work (Attachment I ). The program specialist was trained in the regulatory requirements of each individuals physical. All individual files were reviewed to assure compliance. |
12/13/2017
| Implemented |
2380.111(c)(10) | Individual #1's physical dated 12/13/2016 did not include medical information pertinent to diagnosis and treatment in case of an emergency. It was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The physical for individual #1 was completed 12/8/17 and the medical information pertinent to diagnosis and treatment in the event of an emergency was amended 12/13/17 (Attachment I). A review of all individual physicals was completed to assure regulatory compliance. The program specialist was trained in the regulatory requirements of individual physicals. |
12/13/2017
| Implemented |
2380.181(e)(5) | Individual #2's assessment dated 7/6/17 did not include the ability to self-administer medication. | The assessment must include the following information: The individual¿s ability to self-administer medications. | The assessment for individual #2 was revised to include their ability to self-administer medications (Attachment F) The supports coordinator was contacted, via email, in order to have the ISP up-dated. All records of individuals in attendance were reviewed to assure regulatory compliance. The program specialist received trained in the regulatory requirements of 2380 181(e)(5). |
12/28/2017
| Implemented |
2380.183(7)(i) | Individual #2's ISP dated 9/29/2017 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. | The assessment for individual #2 was amended to include the potential in vocational programming (Attachment E1, E2). The Supports coordinator was provided a request to have the information from the assessment included in the ISP. A review of the other individuals in attendance at Ganister Station was completed to assure regulatory compliance. The program specialist was trained on the requirements of 183 (7) (I) (Attachment B). |
12/28/2017
| Implemented |
2380.183(7)(iii) | Individual #2's ISP dated 9/29/2017 did not include 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. | The assessment for individual #2 was amended to include their potential to advance in competitive community-integrated employment (Attachment G ). The supports coordinator was provided the amended assessment for inclusion into the ISP. (Attachment H ). Future reviews will include revision, as appropriate. The program specialist received training on regulation 2380 183(7)(iii). |
12/28/2017
| Implemented |
2380.186(a) | Individual #1's ISP review was completed on 9/29/2017, covering the review period of 6/1/2017 to 8/30/2017, was late. Should have been completed by 9/14/2017. The ISP review completed on 6/20/2017 covering the period of 3/1/2017 to 5/30/2017 was completed late. Should have been completed by 6/14/2017. ISP review completed 12/20/2016 covering the period of 9/1/2016 to 11/30/2016 was completed late. Should have been completed by 12/15/2016. Individual #2's ISP review completed 9/29/2017, covering the period of 6/6/17 to 8/30/17, was late. Should have been completed by 9/14/2017. | The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the facility licensed under this chapter with the individual every 3 months or more frequently if the individual¿s needs change which impact the services as specified in the current ISP. | A spread sheet has been completed to track dates when the ISP is due in order that future reviews are completed in a timely manner (Attachment A). The program specialist was trained in the regulatory requirements of 2380 186(a) (Attachment B) |
12/28/2017
| Implemented |
2380.186(b) | Individual #1's ISP review covering the period of 12/1/2016 to 2/28/2017 was not dated by the program specialist or individual. Unable to determine when ISP review was completed. Individual #2's ISP review dated 9/29/2017 was not dated by the individual. | The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. | Individual's #1 and #2 ISP reviews were reviewed and dated by the individuals, however following licensing. The most recent review is attached and was completed in accordance with regulation. (Attachments C1, C2, C3, C4 ). All ISP reviews for individuals in attendance at Ganister Station were reviewed for regulatory compliance. The program specialist was trained in the regulatory guidelines (Attachment B). |
12/28/2017
| Implemented |
Article X.1007 | Ganister Station Mineral Point is required to meet all requirements of Article X of the Public Welfare Code and of the applicable statutes, ordinances and regulations (62 P.S. § 1007) including criminal history checks and hiring policies for the hiring, retention and utilization of staff persons in accordance with the Older Adult Protective Services Act (OAPSA) (35 P.S. § 10225.101 -- 10225.5102) and its regulations (6 Pa. Code Ch. 15). Staff #3 was hired on 09/13/2017; the criminal history check was requested on 09/14/2017. | When, after investigation, the department is satisfied that the applicant or applicants for a license are responsible persons, that the place to be used as a facility is suitable for the purpose, is appropriately equipped and that the applicant or applicants and the place to be used as a facility meet all the requirements of this act and of the applicable statutes, ordinances and regulations, it shall issue a license and shall keep a record thereof and of the application. | The Human Resources Department of Ganister Station will submit criminal record requests and review prior to a formal offer for employment. |
12/28/2017
| Implemented |