Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00225022 Renewal 05/24/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.151(f)Individual #1's annual assessment, completed 11/5/2022, was sent to the plan team on 11/5/2022 for Individual #1's annual ISP meeting that was held on 11/29/2022.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual meeting.The ISP Meetings will be added to the Program Specialist's calendar on her computer with a reminder set 30 days prior to the meeting to send out the Annual Assessment. 05/30/2023 Implemented
SIN-00188830 Renewal 06/16/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.21(u)Individual #1, date of admission 6/8/78, Individual #2, date of admission 8/30/90, Individual #3, date of admission 7/1/93 and Individual #4, date of admission 11/1/10, were not informed and explained individual rights and the process to report a rights violation.The facility shall inform and explain client rights and the process to report a rights violation to the individual, and persons designated by the client, upon admission to the facility and annually thereafter.Elcam established a Individual Rights policy that is read to the individual when they begin employment or services. The policy is then placed in their files. 06/18/2021 Implemented
SIN-00147365 Renewal 12/14/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.82(b)The facility had an annual fire safety inspection on 07/13/17 and then again on 08/16/18.Facilities shall have an annual onsite fire safety inspection by the local fire department or other fire safety authority or shall notify the local fire department or other fire safety authority in writing annually of address of the facility and the number and disabilities of the clients served. Documentation of the fire safety inspection or the written notification shall be kept on file.JKrupa (Safety Consulate) was contacted on 12/17/2018 via email to explain the state regulation. A request was made by Elcam, Inc. to add to the Annual Safety Projects and Objectives to include that the Annual Safety Inspection needs to be completed by August 15 of each year. The Direct Support staff will also be trained on state regulation 2390.82(b) to help ensure that this violation does not happen again. [Immediately, the CEO shall develop a tracking, notification and monitoring system to ensure timely completion of the annual fire safety inspection. (DPOC by AES,HSLS on 1/3/19)] 12/17/2018 Implemented
2390.87Individual #1, date of initial admission 3/12/18, was instructed initially in general fire safety and in the use of fire extinguishers on 10/22/18.Staff, and clients as appropriate, shall be instructed upon initial admission or initial employment and reinstructed annually in general fire safety and in the use of fire extinguishers. A written record of the training shall be kept.Individual #1 was trained in fire safety on 10/22/2018 during the annual fire safety training for 2018. All rehires will be trained on the day of their rehire date. The Direct Support staff will be trained on state regulation 2390.87 to help ensure that this does not happen again. A rehire will also have an Induction and Training Record complete the day of their return. [At least quarterly for 1 year the CEO or designee shall audit all individuals' fire safety training to ensure completion, timely. (DPOC by AES,HSLS on 1/3/19)] 10/22/2018 Implemented
2390.151(a)Individual #1, date of initial admission 3/12/18, did not have an initial assessment completed.Each client 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.Individual#1's annual assessment was complete 12/17/2018. The Induction and Training record which is completed the first day of employment or for a rehire will now include (Annual Assessment) completed within 60 days of admission. The Direct Support staff will be trained on the state regulation 2390.15(a) to help ensure that this violation does not happen again. [Immediately, the CEO or designee shall educate the program specialist of the responsibilities of the program specialist position as per 2390.33b(1)-(19) and the completion of aforementioned training documentation. At least quarterly for 1 year the CEO or designee shall audit all individuals' assessment to ensure completion, timely. (DPOC by AES,HSLS on 1/3/19)] 12/27/2018 Implemented
2390.151(d)Program Specialist #1 did not sign Individual #2's assessment dated 10/17/18.The program specialist shall sign and date the assessment.Individual #2's assessment was signed 12/14/2018. The facility is looking into an automated signature system if it is applicable to state regulations. The Direct Support Staff will be trained on the state regulation 2390151(b) to help ensure that this regulation does not happen again. Program Specialist #2 will also review all assessment's for each individual when completed annually. [At least quarterly for 1 year, the CEO or designee shall audit all individuals' completed assessments to ensure the program specialist signed and dated the assessments. (DPOC by AES,HSLS on 1/3/2019)] 12/14/2018 Implemented
2390.156(d)Program Specialist #1 did not provide Individual #1's ISP review documentation completed on 06/18/18, 08/08/18, and 11/10/18 to the plan 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 quarterly review was sent to the team on 12/27/2018. The date completed and date sent were added to the cover sheet for the quarterly reports for all the individuals on 12/17/2018 to ensure that the quarterly reports are sent within the state regulations. The Executive Director will review the quarterly reports before they are distributed. The Direct Support Staff will be trained on the state regulation 2390.156(d) to ensure future compliance. [Immediately and upon hire, the Executive Director shall educate the Program Specialist(s) of their responsibilities as per 2390.33(b)(1)-(19). Documentation of the training shall be kept. Documentation of aforementioned audits by the Executive Director of the documentation that the program specialist provided individuals' ISPs review documentation as required shall be kept. (DPOC by AES, HSLS on 1/3/19)] 12/17/2018 Implemented
SIN-00127646 Renewal 01/03/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.156(a)The program specialist completed an ISP review for Individual #1 and Individual #2 on 7/2/17 and then again on 10/31/17. The program specialist completed an ISP review for Individual #3 on 2/28/17 and then again on 6/5/17. 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 client every 3 months or more frequently if the client's needs change which impacts the services as specified in the current ISP.1. On 1/8/208 the Program Specialist added the three months of the Quarterly Report to the top of the form for reference to help double check the time frame of the reports. 2. On 1/8/2018 the Program Specialist also started doing the Quarterly Reports all on the SAME DATE of the month to help reference the time frame of the reports. 3. On 1/12/18 the Program Specialist from the Community Center (2380) reviewed all the Quarterly Reports and found another two reports that were out of the time line. The reports have been completed. 4. A monthly reminder has also been added to the Program Specialist's computer as another added check list. 5. The Executive Director will review all Quarterly Reports for the up coming year to make sure all they are all in the proper time frames. 6. The new Quarterly Report with the added dates will also be mailed for your review. [Documentation of the audits by the Executive Director shall be kept. (AS 1/25/18)] 01/26/2018 Implemented
SIN-00106116 Renewal 01/04/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.151(a)The assessment for Individual #2, admission date 2/23/16 was completed on 10/15/16. [Repeat Violation 12/1/15]Each client 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.An initial assessment will be completed 60 calendar days after admission to Elcam, Inc. The Program Specialist will present the assessment to the Executive Director to insure completion. The new individual's dates will also be added to the Program Specialists outlook calendar. [Immediately, the executive director shall develop and implement a tracking system and train the program specialist on the tracking system to ensure individuals' assessments are completed, timely. Documentation of the aforementioned review of the assessments by the executive director shall be kept. (AS 1/20/17) 01/19/2017 Implemented
2390.151(f)The program specialist did not provide the assessment dated 10/15/16 for Individual #2 to the SC. The program specialist did not provide the assessment dated 7/3/16 for Individual #3 to the SC. The program specialist did not provide the assessment dated 9/16/16 for Individual #4 to the SC.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).An outlook calendar with reminders has been installed in the Program Specialist's computer to insure the ISP review documentation, including recommendations to the SC or plan lead, as applicable, and plan team members receive within 30 calendar days before the ISP review meeting. [On 1/5/17, the program specialist provided Individual #2, #3 and #4s' assessments to the plan team members as required. Prior to providing assessments to the plan team members, the program specialist will review the individuals' record including ISPs and other information to ensure all team members are provided the assessment as required. Documentation of correspondence shall be kept. At least quarterly for at least 1 year, the Executive Director shall review individuals' assessments and correspondence documentation and tracking system (outlook calendar) to ensure individuals' assessments are sent to all plan team members, timely and documentation of correspondence is kept and available for review by the Department upon request. (AS 1/20/17)] 01/19/2017 Implemented
2390.153(5)Individual #1 does not have a protocol to address social, emotional and environmental needs. Individual #1 is prescribed Buspirone for anxiety, Lexapro for anxiety/depression and Abilify for schizophrenia, bipolar disorder and depression. A protocol to address the social, emotional and environmental needs of the client, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness.The social, emotional and environmental needs of the individual has been added to the ISP. The attached documentation has been sent to each team member. The Executive Director will review all newly developed ISP's for all the appropriate sections of the ISP's. [On 1/23/17, the program specialist developed a protocol to address the social, emotional and environmental needs of Individual #1. Immediately, the executive director or designated management staff person shall review all individuals' ISPs to ensure all individuals prescribed medication to treat symptoms of a diagnosed psychiatric illness have a protocol to address social, emotional and environmental needs of the client. Documentation of all reviews shall be kept. (AS 1/23/17)] 01/19/2017 Implemented
2390.156(d)The program specialist did not provide the ISP review documentation completed 5/30/16 for Individual #2 to the SC and plan team members. [Repeat Violation 12/1/15] 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.An outlook calendar with reminders has been installed in the Program Specialist's computer to insure the ISP review documentation, including recommendations to the SC or plan lead, as applicable, and plan team members receive within 30 calendar days before the ISP review meeting.[On 1/5/17, the program specialist provided Individual #2, ISP review completed 5/30/16 to the plan team members as required. Prior to providing ISP reviews to the plan team members, the program specialist will review the individuals' record including ISPs and other information to ensure all team members are provided the ISP reviews as required. Documentation of correspondence shall be kept. At least quarterly for at least 1 year, the Executive Director shall review individuals' ISP reviews and correspondence documentation and tracking system (outlook calendar) to ensure individuals' assessments are sent to all plan team members, timely and documentation of correspondence is kept and available for review by the Department upon request. (AS 1/20/17)] 01/19/2017 Implemented
SIN-00087211 Renewal 12/01/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.124(5)The record for Individual #1, admitted 2/15/2008 did not include a physical examination. Each client's record must include the following information: Physical examinations.The Program Specialist will now act as these individuals Program Leads for ISP's. The Program Specialist will also prepare all necessary documentation such as Annual Assessments, Physicals, Quarterly's, and ISP's. All of this documentation will be included in the individuals files for documentation.[Immediately, PS will obtain a physical examination for Individual #1. Immediately, CEO or designee will review all individuals' records to ensure all records have a physical examination and will obtain as needed. CEO will in the next 3 months review the records for the individuals who the PS is now responsible for acting as plan lead to ensure all required documentation is completed and accurate in the individuals' records. CEO will continue to review a 25% sample of all individuals' records at least quarterly for 1 year to ensure all individuals' records contain all required documents including but not limited to physical examinations, assessments, ISPs, documentation of correspondence that ISP review documentation was sent to the entire plan team members. (AS 12/23/15)] 12/24/2015 Implemented
2390.151(a)The most recent assessment for Indivdiual #1 was last completed on 10/24/2014.Each client 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.The Program Specialist will now act as these individuals Program Leads for ISP's. The Program Specialist will also prepare all necessary documentation such as Annual Assessments, Physicals, Quarterly's, and ISP's. All of this documentation will be included in the individuals files for documentation.[Immediately, PS will complete an assessment for Individual #1. Immediately, CEO or designee will review all individuals' records to ensure all records have a current assessments and will complete as needed. CEO will in the next 3 months review the records for the individuals who the PS is now responsible for acting as plan lead to ensure all required documentation is completed and accurate in the individuals' records. CEO will continue to review a 25% sample of all individuals' records at least quarterly for 1 year to ensure all individuals' records contain all required documents including but not limited to physical examinations, assessments, ISPs, documentation of correspondence that ISP review documentation was sent to the entire plan team members. (AS 12/23/15)] 12/24/2015 Implemented
2390.152(b)The facility serves eleven individuals who do not receive services through an SCO and are not receiving services in a facility or home licensed under 2380, 6400, or 6500. The Program Specialist did not assume the role as plan lead for the aforementioned individuals.When a client is not receiving services through an SCO and is not receiving services in a facility or home licensed under Chapters 2380, 6400 or 6500 (relating to adult training facilities; community homes for individuals with mental retardation; and family living homes), the vocational facility program specialist shall be the plan lead.The Program Specialist will now act as these individuals Program Leads for ISP's. The Program Specialist will also prepare all necessary documentation such as Annual Assessments, Physicals, Quarterly's, and ISP's. All of this documentation will be included in the individuals files for documentation.[Immediately, CEO or designee will review all individuals' records to ensure the PS has completed all required documentation as a plan lead. CEO will in the next 3 months review the records for the individuals who the PS is now responsible for acting as plan lead to ensure all required documentation is completed and accurate and up to date and present in the individuals' records. CEO will continue to review a 25% sample of all individuals' records at least quarterly for 1 year to ensure all individuals' records contain all required documents including but not limited to physical examinations, assessments, ISPs, documentation of correspondence that ISP review documentation was sent to the entire plan team members. (AS 12/23/15)] 12/24/2015 Implemented
2390.156(d)The ISP Review Documentation for Individual #2 completed on 1/20/15 was not sent to plan team members within 30 calendar days after the ISP review Meeting. [Repeat Violation 11/5/14] 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 Program Specialist will now print out the email when it is sent to participants. This letter will be placed in the individuals file for documentation verification..[Immediately, CEO or designee will review all individuals' records to ensure the PS has completed all required documentation as a plan lead. CEO will in the next 3 months review the records for the individuals who the PS is now responsible for acting as plan lead to ensure all required documentation is completed and accurate and up to date and present in the individuals' records. CEO will continue to review a 25% sample of all individuals' records at least quarterly for 1 year to ensure all individuals' records contain all required documents including but not limited to physical examinations, assessments, ISPs, documentation of correspondence that ISP review documentation was sent to the entire plan team members. (AS 12/23/15)] 12/24/2015 Implemented
SIN-00066245 Renewal 11/04/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.87Staff person #1 most recently completed training in general fire safety and in the use of fire extinguishers on 7-1-13 and 7-21-14.Staff, and clients as appropriate, shall be instructed upon initial admission or initial employment and reinstructed annually in general fire safety and in the use of fire extinguishers. A written record of the training shall be kept.The Program Specialist will review the list of individuals and staff for the annual training with the current employees and staff on the worksheets. This will verify all the names are present for training. This procedure will be done before each annual training. 11/27/2014 Implemented
2390.124(1)The records of Individual's #1, #2, and #5 did not include the individual's place of birth.Each client's record must include the following information: The name, sex, admission date, birthdate and place, social security number and dates of entry, transfer and discharge.The place of birth has been added to Elcam's form "Employment Record." See attached in email. The Administrative Assistant completed the new form on 11/14/14. [The program specialist or designee will audit all individual's records to ensure the place of birth is documented in the record in addition to all requirements per 2390.124 within 60 days upon receipt of the plan of correction. (CHG 12/2/14)] 11/14/2014 Implemented
2390.151(e)(5)The assessment for Individual #2, completed on 3-24-14, did not include the individual's ability to self-administer medications. The assessment for Individual #3, completed on 11-8-13, did not include the individual's ability to self-administer medications. The assessment for Individual #4, completed on 2-5-14, did not include the individual's ability to self-administer medications. The assessment must include the following information: The client's ability to self-administer medications.A new Assessment Form was created to include, "the clients ability to self-administer medications." See attached in email. The Program Specialist completed this on 11/12/14. [The program specialisty or designee will audit all individuals assessments and all individuals current assessments will be updated to reflect all required components including the ability to self administer medications within 60 days upon receipt of the plan of correction. (CHG 12/2/14)] 11/12/2014 Implemented
2390.156(d)The ISP review documentation for Individual #2 completed on 6-28-13 and 9-30-13 were not sent to the plan team members within 30 calendar days after the ISP review meeting. 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 Program Specialist will email this letter to the team members as verification instead of mailing the information. The Program Specialist will save the email in a designated folder on her computer. [Form was developed for documentation of compliance with regulation. The program specialist will monitor the completion of the form for all individuals once every three months. (CHG 12/2/14)] 11/27/2014 Implemented
2390.156(e)The program specialist for Individual #1 did not notify plan team members 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 will email the team members of the option to decline the ISP review documentation instead of mailing the information. The Program Specialist will retain this email in a designated folder on her computer. [Form developed to document compliance with regulation. The program specialist will monitor the completion of the form to decline the review of ISP documentation for all individuals once every three months. (CHG 12/2/14)] 11/27/2014 Implemented
SIN-00054769 Renewal 10/03/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2390.61The second toilet from the door, located in the women's bathrooom, does not flush. The third sink from the door was not draining and has been disconnected. Floors, walls, ceilings and other surfaces shall be in good repair and free of visible hazards.The second toilet from the door in the women's bathroom was repaired. The third sink in the women's bathroom has been replaced with a new one. See attached pictures. 11/01/2013 Implemented
2390.62Each bathroom is equipped with bars of lava soap that is used by multiple Individuals in the facility.Sanitary conditions shall be maintained in bathrooms, kitchens, dining areas and first aid areas.The lava soap has been removed from all the restrooms. The new battery operated soap dispensors have been installed. See attached pictures. 11/01/2013 Implemented
2390.81The staff office in the workshop area of the facility was equipped with a pad lock and latch. Stairways, hallways and exits from rooms and from the facility shall be unobstructed.The pad lock has been removed from the staff office door. The door has been replaced with a new door knob and lock. See attached pictures. 11/01/2013 Implemented
2390.113(e)The Placement Service documentation for Individual #1 was not being maintained in the Individual's record.(e) The facility shall maintain a written record of placement service components specified in this section.A procedure has been implemented for any individual entering into supportive employment. 1. A meeting will be conducted with the individual about a job opportunity. 2. The potential employer will be informed of the individuals dis abilities. 3. The employer will inform Elcam of the a job description. 4. The individual's progress will be documented monthly once they start the job. See attached paper work. 11/01/2013 Implemented
2390.124(10)The most recent ISP for Individual #2 is not in the Individual's record. The Annual plan was last updated on 9/12/13 and the most recent plan in the record is dated 8/31/12.Each client's record must include the following information: (10) A copy of the current ISPThe Program Specialist will get a copy of the signature page at the ISP meeting to document the ISP. See attached. [Current ISP was placed in Individual #2s record. The program specialists will audit all individuals records to ensure that they contain a current ISP. (CHG 11/14/13)] 11/01/2013 Implemented
2390.151(a)The facility serves fifteen Individuals who do not receive services through an SCO and are not receiving services in a facility or home licensed under Chapters 2380, 6400 or 6500. An assessment has not been completed for the aforementioned Individuals.(a)  Each client 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.A new procedure has been implemented for the nine Mental Health individuals with out an initial assessment. The Program Specialist will here after provide an initial assessment. see attached paper work. [The program specialist will update the assessments annually and as needed. The Director will audit a sample of the individual records monthly to ensure that they contain the required assessments and support plans. (CHG 11/14/13)] 11/01/2013 Implemented
2390.152(b)The facility serves fifteen Individuals who do not receive services through an SCO and are not receiving services in a facility or home licensed under Chapters 2380, 6400 or 6500. The Program Specialist did not assume the role as plan lead for the aforementioned individuals.(b) When a client is not receiving services through an SCO and is not receiving services in a facility or home licensed under Chapters 2380, 6400 or 6500 (relating to adult training facilities; community homes for individuals with mental retardation; and family living homes), the vocational facility program specialist shall be the plan lead.The Program Specialist will also act as the plan lead for these individuals. She will do the Initial Assessment and the Annual Assessments. The job description for the Program Specialist will also be changed to include these responsibilities. See attached paper work. [The Director will audit a sample of individual records monthly to ensure that they contain the required assessments and support plans. (CHG 11/14/13)] 11/01/2013 Implemented
SIN-00206598 Renewal 06/14/2022 Compliant - Finalized
SIN-00166623 Renewal 11/25/2019 Compliant - Finalized