Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00160802 Renewal 10/08/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(1)Individual #1's physical dated 2/5/19 did not include previous medical history.The physical examination shall include: A review of previous medical history.Program Specialist sent a fax to Individual #1's doctor's office (Julie Reitnaurer, PA-C) on October 8, 2019 (Attachment D3 & D4) asking her to complete the section: previous medical hisotry on individual #1's physical that was not completed during the time of the physical. Two additional faxes were sent on October 15, 2019 (Attachment D5 &D6) and again on October 17, 2019 (Attachment D7 & D8). Julie Reitnaurer sent a fax back on October 17th, 2019 with the completed section on Individual #1's physical. Julie Reitnaurer, PA-C wrote "ADHD, Bipolar D/O, and Intellectual Disability" in the section: previous medical history(Attachment D1 & D2) . Program Specialist also completed a Medical History Summary dated on June 12, 2019 (Attachment D9 & D10). In the Section: Past Medical History, it states the following: "Mabel has maintained overall generally good physical health throughout her life. She takes medication for a mood disorder and anxiety. Mabel has had no major surgery's, emergency room visits, or need for ongoing medical care at this point in her life." 10/17/2019 Implemented
2380.111(c)(8)Individual #1's physical dated 2/5/19 did not include physical limitations.The physical examination shall include: Physical limitations of the individual.Program Specialist sent a fax to Individual #1's doctor's office (Julie Reitnaurer, PA-C) on October 8, 2019 (Attachment D3 & D4) asking her to complete the section: recommendations modifications/limitations for activities and exercises on individual #1's physical that was not completed during the time of the physical. Two additional faxes were sent on October 15, 2019 (Attachment D5 &D6) and again on October 17, 2019 (Attachment D7 & D8). Julie Reitnaurer sent a fax back on October 17th, 2019 with the completed section on Individual #1's physical. Julie Reitnaurer, PA-C wrote "None" in the section: recommendations modifications/limitations for activities and exercises (Attachment D1 & D2) . 10/17/2019 Implemented
2380.111(c)(10)Individual #1's physical dated 2/5/19 did not include information in case of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.Program Specialist sent a fax to Individual #1's doctor's office (Julie Reitnaurer, PA-C) on October 8, 2019 (Attachment D3 & D4) asking her to complete the section: include information in case of an emergency on individual #1's physical that was not completed during the time of the physical. Two additional faxes were sent on October 15, 2019 (Attachment D5 &D6) and again on October 17, 2019 (Attachment D7 & D8). Julie Reitnaurer sent a fax back on October 17th, 2019 with the completed section on Individual #1's physical. Julie Reitnaurer, PA-C wrote "None" in the section: include information in case of an emergency (Attachment D1 & D2) . 10/17/2019 Implemented
2380.181(e)(12)Individual #2's assessment dated 9/4/19 did not include recommendations for services.The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment.Program Specialist completed an addendum to Individual #2's assessment that was originally dated for September 4, 2019. The addendum was completed on October 8, 2019 and the following information was added to the assessment (Attachment C6): Recommendation for: Training: Joe will continue to benefit form life skills training at programming. He has developed his own daily routine and is provided with supports and reminders to complete tasks such as cleaning up after lunch and washing his hands after using the restroom. Programming: Joe enjoys day programming and reports that he is attending two days a week. Services: Joe will continue to benefit from his current service providers."Program Specialist reviewed updated changes with Individual #2 and sent copies to all team members on October 8, 2019 (Attachment C8). 10/08/2019 Implemented
2380.181(e)(13)(v)Individual #2 assessment dated 9/4/19 did not include progress and growth in recreation.The assessment must include the following information: The individual' s progress over the last 365 calendar days and current level in the following areas: Recreation.Program Specialist completed an addendum to Individual #2's assessment that was originally dated for September 4, 2019. The addendum was completed on October 8, 2019 and the following information was added to the assessment (Attachment C6): "Recreation: Current Performance: Joe Participates in table games, community outings, and listening to music on the computer. Progress in the past year: This was Joe's initial assessment." Program Specialist reviewed updated changes with Individual #2 and sent copies to all team members on October 8, 2019 (Attachment C8). 10/08/2019 Implemented
2380.183(a)(3)Individual #1's ISP meeting held on 719/19 did not have a DSP.The individual plan shall be developed by an interdisciplinary team, including the following: The individual's direct care staff persons.Individual #1 recently had her Annual Review meeting therefore her next Annual review meeting will not be held until July of 2020. The next Annual Review Meeting was held for SW on October 9, 2019. There was no DSP available for the Annual Review Meeting, therefore Program Specialist asked DSP staff, Dana Rodkey to write a summary of any concerns and comments (Attachment B) that needed to be discussed during the Annual Review Meeting. In the event that a DSP cannot attend a meeting, Program Specialist will continue to ask a DSP to write a summary report of anything that needs to be discussed during the meeting. This summary report will be completed prior to the meeting being held. 10/09/2019 Implemented
2380.183(b)Individual #1's ISP meeting held on 7/19/19 did not have 3 individuals plus Mable present at the meeting.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.Individual #1 recently had her Annual Review Meeting and her next review meeting will not be held until July 2020. The next Annual Review Meeting was held for SW on October 9, 2019. Program Specialist ensured that at least three individuals were present during his Annual Review Meeting. Program Specialist received the Individual Support Plan Signature Form (Attachment A). This includes five individuals (including SW) that attended the Annual Review Meeting. 10/09/2019 Implemented
SIN-00141517 Renewal 10/11/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.36(h)The training records for staff #1 were incomplete. They did not include the training source and the length of the training.Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept.The current training records are complete and include the training source, length of training, and staff attendance, Applicable certificate will be retained and kept within the staff personnel file. It should be noted that a clerical staff person has been hired, and job responsibilities include accurate training records be maintained.(Attachment C). 10/31/2018 Implemented
2380.186(d)There is no date when individual #1 ISP review 10/3/18 was sent to team members.The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC or plan lead, as applicable, and plan team members within 30 calendar days after the ISP review meeting.The form letter (Attachment A) has been amended to include a designated area for the program specialist to enter the date that ISP reviews are sent to team members. (Attachment A). The program specialist at Mineral Point location is no longer employed by Ganister Station. The new program specialist will be trained on the appropriate process, as part of the training process. 10/31/2018 Implemented
SIN-00124933 Renewal 11/22/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC 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.1007Ganister 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
SIN-00101812 Renewal 12/09/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(a)A bottle of Germ X was unlocked in a cabinet in the craft area. The bottle states if swallowed contact posion control. Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.All poisonous materials have been locked and are therefore inaccessible when not in use. The program specialist will be responsible for oversight and monthly checks to assure compliance with regulation. The checklist is attached, 12/30/2016 Implemented
2380.89(a)There was no fire drill conducted in September 2016. An unannounced fire drill shall be held at least once a month.Fire drills since September, 2016 have been held monthly. It is the responsibility of the program specialist to review all fire drills to assure future compliance. A review sheet has been developed for tracking purposes and shall be maintained by the program specialist. 12/30/2016 Implemented
2380.111(c)(5)The tuberculin skin test for individual #2 was completed on 2/5/14 and 10/6/16. 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.The individual was counseled 2/3/2016 after refusal of the tuberculin skin test. He later agreed and in fact had the skin test completed at his next physical., 10/6/2016. Prior to his next physical, due 10/6/2018, he will be counseled in the importance of the testing. 12/30/2016 Implemented
2380.124(b)Individual #3's medication log for 12/7/16 did not include initals after medication adminsitration for Clonazepam .5mg. The information specified in subsection (a) shall be logged immediately after each individual¿s dose of medication.The staff responsible for medication administration on 12/7/16 has been registered for retraining. The program specialist and medication trainer has registered the staff for on line training. 01/31/2017 Implemented
2380.181(e)(4)Individual #2's assessment dated 2/2/16 states supervision as 1:6 and the ISP states supervision as 1:3. The assessment must include the following information: The individual¿s need for supervision.On 12/21/2016, the program specialist emailed the support coordinator for individual #2 to request the ISP be revised to reflect the current, correct supervision ratio. Additionally, the assessment was up-dated to include the need for the change and current status. Attachment B 12/30/2016 Implemented
2380.181(e)(14)Individual #1's assessment dated 7/6/16 did not include knowledge of water safety and ability to swim. The assessment must include the following information: The individual¿s knowledge of water safety and ability to swim.The program specialist completed a revision to the assessment to include an assessment of the individuals knowledge of water safety and ability to swim. (Attachment C) In order to prevent future occurrences, it will be the responsibility of the program specialist supervisor to review all completed assessments to assure all requirements have been satisfied. 12/30/2016 Implemented
2380.183(7)(i)Individual #1 and 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.The program specialist emailed the support coordinator for individuals 1 and 2 and requested the ISP's be revised to include an assessment of the potential to advance in vocational programming for both individuals. In order to prevent future occurrences, it will be the responsibility of the program specialist supervisor , to review all incoming ISP's to assure all required components are present in the plan. 12/30/2016 Implemented
2380.183(7)(iii)Individual #1's ISP did not include an assessment of the potential to advance in competitive comunity 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 program specialist emailed the individuals supports coordinator to request the ISP be revised to include an assessment of the potential to advance in competitive integrated employment. To prevent future occurrences, the program specialist supervisor will be responsible to review all completed ISP's to assure compliance. 12/30/2016 Implemented
SIN-00236324 Renewal 01/04/2024 Compliant - Finalized
SIN-00217588 Renewal 01/17/2023 Compliant - Finalized
SIN-00198489 Renewal 01/04/2022 Compliant - Finalized
SIN-00180485 Renewal 11/04/2020 Compliant - Finalized
SIN-00081400 Initial review 07/16/2015 Compliant - Finalized