Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00188807 Renewal 06/15/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.59(b)At 12:50 PM, the hot water measured 131 degrees Fahrenheit, at the sink nearest to the entry door in the women's restroom.Hot water temperatures in areas accessible to individuals may not exceed 120°F.A lock box will be pursued. The lock box will be installed on the outside dial to control who has access to regulating the temperature. 06/25/2021 Implemented
2380.21(u)Individual #1, date of admission 4/27/21, Individual #2, date of admission 1/8/20, Individual #3, date of admission 10/3/17 and Individual #4, date of admission 6/7/16 were not informed and explained individual rights and the process to report a rights violation.The facility 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 facility and annually thereafter.Elcam has created an Individual Rights Policy. The Individual Rights policy was read to all the individuals in the facility. The copy is placed in their file. 07/01/2021 Implemented
SIN-00190260 Renewal 06/15/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.59(b)At 12:50 PM, the hot water measured 131 degrees Fahrenheit, at the sink nearest to the entry door in the women's restroom.Hot water temperatures in areas accessible to individuals may not exceed 120°F.A lock box will be pursued. The lock box will be installed on the outside dial to control who has access to regulating the temperature. 06/25/2021 Implemented
2380.21(u)Individual #1, date of admission 4/27/21, Individual #2, date of admission 1/8/20, Individual #3, date of admission 10/3/17 and Individual #4, date of admission 6/7/16 were not informed and explained individual rights and the process to report a rights violation.The facility 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 facility and annually thereafter.Elcam has created an Individual Rights Policy. The Individual Rights policy was read to all the individuals in the facility. The copy is placed in their file. 07/01/2021 Implemented
SIN-00141262 Renewal 09/06/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.59(b)The hot water temperature at the sink in the men's restroom adjacent to the supply closet in the activity room measured 124.7 degrees Fahrenheit at 12:09 PM.Hot water temperatures in areas accessible to individuals may not exceed 120°F.On September 6, 2018, the hot water tank temperature gauge was turned down because the inspector found it to be 124.7 degrees. The temperature may have been this high due to the temperature gauge being bumped as it is in the supply closet. The water temperature was checked three times the next day and it did not exceed 120 degrees. The water temperature will be checked daily by the program specialist or the activity aide. The temperature will be documented on a check sheet along with the time it was checked and the initials of the staff checking it. The water temperature will be checked in alternate rooms of the Community Center and documented as well. The water temperature check sheet was created and implemented on September 10, 2018. This check sheet is hanging in the supply closet next to the hot water tank. [Immediately, the CEO or designee shall educate all staff persons responsible for measuring hot water temperatures in the facility on the aforementioned procedures and the procedure for adjusting hot water temperatures as needed. At least monthly, the CEO or designated management staff person shall audit the documentation of the hot water measurements to ensure completion and that the temperatures in areas accessible to individuals may not exceed 120°F. Documentation of audits shall be kept. (DPOC by AES, HSLS on 9/21/19)] 09/21/2018 Implemented
SIN-00121654 Renewal 09/22/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.91(a)Individual #1, first day of attendance 1/7/17, was instructed in general firesafety, evacuation procedures, responsibilities during fire drills, and the designated meeting place outside the building on 1/10/17.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.On October 2, 2017 the Program Specialist added "on the first day in attendance" to the Induction and Training Record. All individuals will be retrained in fire safety even if they were previously trained in the Prevocational Program. The Program Specialist will document this on the Induction and Training Record and it will be reviewed quarterly by the Executive Director. This documentation was also mailed to you for your review. [For the next 5 newly admitted Individuals, the Executive Director shall audit the aforementioned record and the fire safety training to ensure all individuals are instructed in general fire safety, 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 as required. Documentation of all audits shall be kept. (AS 10/6/17)] 10/02/2017 Implemented
2380.111(c)(10)Individual #1's physical examination, completed 1/23/17, and Individual #2's physical examination, completed 7/25/17, did not include medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.On September 25, 2017 the Program Specialist reviewed all the individuals physical to make sure all the appropriate sections were completed. She found six physicals that needed returned to the Supports Coordinators for completion. This was verified by the Program Specialist on the Prevocational side. All the physicals are now completed and returned to Elcam. Also, on October 2, 2017 the Executive Director developed a policy concerning the appropriate information necessary on the physical examination and the protocol if the information is not identified. I mailed the attached policy and training verification. The training will be conducted annually with the other staff training curriculum necessary for the Office of Developmental Programming. The Executive Director will also review the physicals quarterly to ensure the program is working effectively.[Documentation of audits shall be kept. AS 10/6/17)] 10/02/2017 Implemented
2380.181(a)Individual #2 had an assessment completed on 10/2/15 and then again on 10/28/16.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.On January 3, 2017 Elcam's IT Manager developed a calendar in the Program Specialists computer to alert them of any assessments, monthly notes, and quarterly notes that need completed each month. I mailed a paper version, but the computer version was shown to the licensing personnel during the inspection. The program is developed to repeat annually to assure ongoing continuity. The Executive Director will also review the assessments quarterly to make sure this program is working effectively. [Documentation of audits shall be kept. (AS 10/6/17)] 09/25/2017 Implemented
SIN-00085388 Renewal 09/24/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.59(b)At 11:58 AM, the hot water temperature in the women's room sink measured at 126.5 degrees Fahrenheit.Hot water temperatures in areas accessible to individuals may not exceed 120°F.The Program Specialist (Jennifer Weisner) checks the water temperature in both restrooms, the kitchen, and the arts and crafts sink in the Community Center on a monthly basis now (starting 11/30/15). This was done on a weekly basis since the installation of a new hot water tank until 11/30/15. The following staff have been trained on the 2380.59 regulations on 10/30/15: Kimberly Cashmer, Elyse Long, Jodi Bailey, Harold Yale, Whitney Mertz, Jennifer Weisner, and Jennifer Greenthaner.[During the monthly water check if the temperature exceeds 120 degrees F.; the checks will be done weekly until all water temperatures are below 120 degree F for at least 2 weeks. Documentation of all water checks will be documented and reviewed by CEO or designee at least quarterly.(AS 12/8/15) 10/30/2015 Implemented
2380.62The telephones located in the kitchen, computer room and conference room, did not have the phone numbers for the nearest fire and ambulance posted near them. Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be posted on or by each telephone in the facility with an outside line.All Emergency Number are posted by the phones. Not only the 911 number but also the following: Elk Count Communications Center: 772-0000, Poison Control Hotline: 1-800-222-1222 St.. Mary's Ambulance: 911, Crystal Fire Department: 911, St. Mary's Police: 781-1315 (non emergency), PA State Police: 776-6136, and Penn Highlands Hospital-Elk: 788-8000. Jen Weisner (Program Specialist) now is including non-emergency numbers along with 911.[CEO or designee will check each telephone at least quarterly to ensure required telephone numbers are present. Documentation of checks will be kept for review by CEO if not completed by CEO. (AS 12/8/15)] 10/23/2015 Implemented
2380.89(f)The fire drills conducted between 9/29/14 and 8/26/15 were not held on any Tuesdays. Several individuals attend the program only on Tuesdays.Fire drills shall be held on different days of the week and at different times of the day.The Executive Director created a Fire Drill Yearly Spread Sheet with all the months with a varied of days of the week, and a variety of different times of the day. The Program Specialist (Jennifer Greenthaner) have and will continue to follow the spread sheet. She also has to sign off the day, time, and the initials of who conducted the training. All staff have been trained. Jennifer Greenthaner, Jennifer Weisner, Amber Colello, and Kimberly Cashmer. [CEO and PS will create a procedure to ensure all fire drill are unannounced to all who are participating in the drill if using a "Fire Drill Yearly Spread Sheet." 10/28/2015 Implemented
2380.91(a)Individual #1, admission date 11/21/14, and Individual #2, admission date 2/4/15, did not have fire safety training until 7/1/15.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.The Program Specialist will conduct Fire Extinguisher Training, Lockout/Tagout Training, and Hazardous Communication Training the first day of their program. This was also added to the checklist on the Induction and Training Record. An individual will not be permitted to start any program until this checklist is completed by the Program Specialist (Jennifer Weisner). [CEO or designee will review the "Induction and Training Rcord" for the next 5 new Individual admissions to ensure required trainings are being completed timely and documented. (AS 12/8/15 10/30/2015 Implemented
2380.111(a)Individual #1, admission date 11/21/14, had a physical examination completed on 12/27/13 and then again on 5/12/15.Each individual shall have a physical examination within 12 months prior to admission and annually thereafter.An Induction and Training Record-checklist was created by the Program Specialist which will not allow anyone to start the program without a Physical, with up to date TB and DTap Vaccinations, a Psychological Evaluation, Lifetime Medical History, and an Activities Limitation List. The following staff were trained on 10/30/15 on the Induction Training Record and the 2380.111 section of the regulations: Kimberly Cashmer, Jodi Bailey, Elyse Long, Jennifer Weisner, Harold Yale, Whitney Mertz, and Jennifer Greenthaner.[CEO or designee will review the "Induction and Training Record" for the next 5 new individual admissions to ensure required documentation including physical examinations is being completed timely and documented. [Program specialist will develop a tracking system to ensure all required elements of physical examinations are completed timely and individual can be informed of when required annual physical examinations are due. CEO will review annual physical examinations at least quarterly for the next 6 months to ensure timeliness and completion.(AS 12/8/15) 10/30/2015 Implemented
2380.111(c)(3)Individual #3, admission date 5/18/08, had a Tdap on 2/27/03 and then not again until 1/16/14.The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.The Program Specialist (Jennifer Weisner) reviewed all the individuals files to make sure all immunizations, vision and hearing screening and tuberculin skin testing is completed, signed and dated by a registered nurse or licensed practical nurse of a licensed physician, certified nurse practitioner or certified physician's assistant. [Program specialist will develop a tracking system to ensure all required elements of physical examinations are completed timely and timely notification to individuals of when required annual physical examinations including immunizations are due. CEO will review annual physical examinations at least quarterly for at least the next 6 months to ensure timeliness and completion.(AS 12/8/15) 10/23/2015 Implemented
2380.111(c)(5)Individual #1, admission date 11/21/14, had a Tuberculin skin test read on 12/28/12 and not again until 8/19/15. Individual #3, admission date 5/18/08, had a Tuberculin skin test read on 3/14/12 and then not again until 10/7/14.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 Program Specialist (Jennifer Weisner) reviewed all the individuals files back in the Community Center to make sure all immunizations, vision and hearing screening and tuberculin skin testing was completed, signed, and dated by a registered nurse or a licensed practical nurse instead of a licensed physician, certified nurse practitioner or certified physician's assistant. The Tuberculin skin testing must be conducted every 2 years. This was also added to the Induction and Training Record that must be completed by the Program Specialist before any individual can start a program. This will also be reviewed by the Program Specialist annually.[CEO or designee will review physcial examinations and Induction and Training Record for the next 5 new individual admissions to ensure all required documentation including Tuberculin tesing are being completed timely and thoroughly. Program specialist will develop a tracking system to ensure all required elements of physical examinations including Tuberculin testing are completed timely and timely notification to the individual as to when required annual physical examinations including immunizations are due. CEO will review annual physicals examinations at least quarterly for the next 6 months to ensure timeliness and completion. Documentation of all CEO and PS reviews shall be kept. (AS 12/8/15)] 10/30/2015 Implemented
SIN-00067813 Renewal 09/23/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.181(e)(10)The assessment for Individual # 1, dated 6/17/14, did not include a lifetime medical history. The assessment must include the following information: A lifetime medical history.A Lifetime Medical History as been completed for individual #1. (See attached) A Lifetime Medical History has been added to the checklist for Initial Intake that needs signed by the Program Specialist and reviewed and the Executive Director. [All individual records will be reviewed to assure the assessments include a lifetime medical history. (AS 10/20/14)] 10/14/2014 Implemented
2380.181(f)The Program Specialist did not provide the assessment completed for Individual #2 to the SC and plan team 30 calendar days prior to the ISP meeting held on 7/23/14.The program specialist shall provide the assessment to the SC or plan lead, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § §  2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).The document was added to the file which states all team members names and addresses to whom the annual review documentation is sent. This document is signed and dated. (see attached form). 10/14/2014 Implemented
2380.186(b)The ISP review for Individual #2 for the review period of August through September 2014 was not dated. The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP.The letter sent to individual #2's team members was not dated in August of 2013. The recent letter in June of 2014 was dated and distributed to the team members. The dated letter to all team members was added to the checklist of forms needed at Initial Intake (see attached) to be signed by the Program Specialist and reviewed by the Executive Director. 10/14/2014 Implemented
SIN-00052368 Renewal 07/30/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.173(5(ii)1. The invitation to the annual Individual Support Plan meeting for Individual #3, dated 1/10/2013, was not included in the Individual's record. 2. The invitation to the annual Individual Support Plan meeting for Individual #1, dated 10/03/2012, was not included in the Individual's record.Each individual's record must include the following information: (5)  A copy of the invitation to: (ii)   The annual update meeting.The Program Specialist will maintain a copy of the invitation to the annual Invitation Support Plan meeting for each individual in the individual's records at the Center. [The CEO/Director will perform an audit of individual records once every two months to ensure (1) that invitations to the ISP meetings are included in each individual record, (2) that the assessments are signed and dated by the program specialist, (3) that there is documentation to show that the program specialist provided the assessment to the SC and plan team members at least 30 calendar days prior to the ISP meeting, (4) to ensure that that there is documentation to show that the program specialist provided the ISP review documentation to the SC within 30 calendar days after the completion of the review, and (5) that the program specialist notified the plan team members of the option to decline the ISP review documentation. Documentation shall be kept. (CHG 8/21/13)] 08/21/2013 Implemented
2380.181(d)1. The annual assessment of Individual #1 was not dated by the Program Specialist. 2. The annual assessment of Individual #3 was not dated by the Program Specialist.(d)  The program specialist shall sign and date the assessment.The Program Specialist and individual will both sign and date the annual assessment form of the individual. The modified annual assessment form includes a space for both signature and date for the Program Specialist and the individual. [The CEO/Director will perform an audit of individual records once every two months to ensure (1) that invitations to the ISP meetings are included in each individual record, (2) that the assessments are signed and dated by the program specialist, (3) that there is documentation to show that the program specialist provided the assessment to the SC and plan team members at least 30 calendar days prior to the ISP meeting, (4) to ensure that that there is documentation to show that the program specialist provided the ISP review documentation to the SC within 30 calendar days after the completion of the review, and (5) that the program specialist notified the plan team members of the option to decline the ISP review documentation. Documentation shall be kept. (CHG 8/21/13)] 08/21/2013 Implemented
2380.181(f)The Program Specialist did not provide the annual assessment of Individual #1 to the Supports Coordinator at least 30 calendar days prior to the annual Individual Support Plan meeting dated 10/03/2012. Repeat Violation- 05/30/2012(f)  The program specialist shall provide the assessment to the SC or plan lead, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § §  2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).The Program Specialist will provide a copy of the annual assessment of the individual more than 30 calendar days prior to the annual Individual Support Plan meeting. [The CEO/Director will perform an audit of individual records once every two months to ensure (1) that invitations to the ISP meetings are included in each individual record, (2) that the assessments are signed and dated by the program specialist, (3) that there is documentation to show that the program specialist provided the assessment to the SC and plan team members at least 30 calendar days prior to the ISP meeting, (4) to ensure that that there is documentation to show that the program specialist provided the ISP review documentation to the SC within 30 calendar days after the completion of the review, and (5) that the program specialist notified the plan team members of the option to decline the ISP review documentation. Documentation shall be kept. (CHG 8/21/13)] 08/21/2013 Implemented
2380.186(d)The Individual Support Plan review documentation for Individual #1, reviewing the months of May, June, and July 2012, was not provided to the Supports Coordinator within thirty days of completion of the review.(d)  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 meetingThe Program Specialist will provide a copy of the Individual Support Plan review documentation for each individual to the Supports Coordinator within 30 days of completion of the review. [The CEO/Director will perform an audit of individual records once every two months to ensure (1) that invitations to the ISP meetings are included in each individual record, (2) that the assessments are signed and dated by the program specialist, (3) that there is documentation to show that the program specialist provided the assessment to the SC and plan team members at least 30 calendar days prior to the ISP meeting, (4) to ensure that that there is documentation to show that the program specialist provided the ISP review documentation to the SC within 30 calendar days after the completion of the review, and (5) that the program specialist notified the plan team members of the option to decline the ISP review documentation. Documentation shall be kept. (CHG 8/21/13)] 08/21/2013 Implemented
2380.186(e)1. The Program Specialist did not notify the plan team members of Individual #3 of the option to decline the Individual Support Plan review documentation. 2. The Program Specialist did not notify the plan team members of Individual #1 of the option to decline the Individual Support Plan review documentation.(e)  The program specialist shall notify the plan team members of the option to decline the ISP review documentation.The Program Specialist will provide each team member of each individual the option to decline the Individual Support Plan review documentation. [The CEO/Director will perform an audit of individual records once every two months to ensure (1) that invitations to the ISP meetings are included in each individual record, (2) that the assessments are signed and dated by the program specialist, (3) that there is documentation to show that the program specialist provided the assessment to the SC and plan team members at least 30 calendar days prior to the ISP meeting, (4) to ensure that that there is documentation to show that the program specialist provided the ISP review documentation to the SC within 30 calendar days after the completion of the review, and (5) that the program specialist notified the plan team members of the option to decline the ISP review documentation. Documentation shall be kept. (CHG 8/21/13)] 08/21/2013 Implemented
SIN-00265174 Renewal 05/01/2025 Compliant - Finalized
SIN-00245289 Renewal 05/07/2024 Compliant - Finalized
SIN-00224974 Renewal 05/24/2023 Compliant - Finalized
SIN-00206597 Renewal 06/14/2022 Compliant - Finalized
SIN-00161702 Renewal 08/27/2019 Compliant - Finalized
SIN-00077935 Renewal 02/16/2017 Compliant - Finalized
SIN-00101131 Renewal 09/22/2016 Compliant - Finalized