Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00228139 Renewal 07/24/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.110(e)The smoke detector is not interconnected.If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. In regard to violation 55 PA Code Chapter 6400.110(e) Eastwick Family Services contractor has adjusted the smoke alarm to ensure they are interconnected. All staff were retrained on how to check smoke detectors after each fire drill to ensure the smoke detectors are interconnected. 08/01/2023 Implemented
SIN-00211701 Renewal 07/26/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)Poisonous material (cleaning supplies) was not kept locked in kitchen cabinet beneath the sink. (The lock was present but not secured.)Poisonous materials shall be kept locked or made inaccessible to individuals. In regards to violation cited in code 55 PA Code Chapter 6400.62(a) Eastwick Family Services House Manager has locked the lock on the poisonous material cabinet and has instructed and retrained all staff that the lock must be locked at all times. A picture was sent on 7/29/2022 to an ODP representative correcting this error. 07/30/2022 Implemented
6400.82(f)There was no mirror located in the basement bathroom.Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. In regards to violation cited on code 55 PA Code Chapter 6400.82(f) Eastwick Family Services CEO has purchased a mirror for the basement mirror and it is now installed. 07/30/2022 Implemented
6400.104Notifications to the fire department do not indicate the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. Notifications were not dated so it could not be determined if the document was current.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. In regards to violation cited in code 55 PA Code Chapter 6400.104 Eastwick Family Services Program Specialist has revised the letter to the fire department and resent it. The letter now is dated and indicates the location of each bedroom of the individuals who need assistance evacuating. 07/30/2022 Implemented
6400.106Furnace inspections provided were not dated; couldn't be determined when inspected.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. In regards to violation cited in code 55 PA Code Chapter 6400.106 Eastwick Family Services CEO has contacted the HVAC Technician and requested he revisit the homes and revise his receipts, so they reflect the most recent date of inspection. 08/30/2022 Implemented
6400.144Individual 1 is a diabetic and his log is not being completed accurately. The staff is not logging the correct numbers and at times logging numbers that is not on the meter. In a few incidents the meter may show 219 and the staff is recording 119, as the instructions show any readings above 120 staff is to call the program specialist, and this is not happening.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. In regards to violation cited in code 55 PA Code Chapter 6400.144 Eastwick Family Services Program Specialist has retrained the staff on how to properly document the sugar readings for individual 1. 08/30/2022 Implemented
6400.165(b)Individual 1's Medication DEEP SEA NASAL SPRAY was empty and logged as administered, medication is not being kept current.A prescription order shall be kept current.In regard to violation cited under code 55 PA Code Chapter 6400.165(b) Eastwick Family Services Program Specialist has refilled this prescription and it was added to the med box for individual 1. A photo of the medication was taken, and it was submitted to an ODP representative on 7/29/2022. 08/30/2022 Implemented
SIN-00192767 Renewal 07/29/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(d)Poisonous material was stored with food items located in the basement. The poisonous material was not kept locked and made accessible to individual.Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces.In regards to 55 PA Code Chapter 6400.62 (d) Eastwick Family Services has ensured that all Poisonous materials will be be kept separate from food, food preparation surfaces and dining surfaces. They will remain locked and not accessible to the individual. All staff were retrained on this regulation. 09/07/2021 Implemented
6400.77(b)The first aid kit did not contain a thermometer or tweezers at time of inspection. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. in regards to 55 PA Code Chapter 6400.77 (b) Eastwick Family Services has purchased all new first aid kits to ensure they are complete and contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, and scissors. 09/17/2021 Implemented
6400.106The annual furnace inspection was not completed at time of inspection.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. In regards to 55 PA Code Chapter 6400.106 Eastwick Family Services has had our furnaces inspected and cleaned by a professional furnace cleaning company and will keep written documentation of inspection and cleaning on file. 10/15/2021 Implemented
6400.111(a)There was no fire extinguisher located in the basement at time of inspection.There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. In regards to 55 PA Code Chapter 6400.111 (a) Eastwick Family Services has made sure there is now at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. Staff and Program Specialist were retrained on this regulation. 09/27/2021 Implemented
6400.111(f)The fire extinguisher located on the second was not inspected and approved annually by a fire safety expert. The fire extinguisher was last inspected 2018 and 2019. A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. In regards to 55 PA Code Chapter 6400.111 (f) Eastwick Family Services has contacted a fire safety expert to come out and inspect and approve our extinguishers. The date of the inspection is on the extinguisher. 10/18/2021 Implemented
6400.112(e)A sleep drill was not completed every 6 months.A fire drill shall be held during sleeping hours at least every 6 months. In regards to 55 PA Code Chapter 6400.112 (e) Eastwick Family Services has retrained all staff and program specialist on the importance of sleep drills and the regulation on them being done every 6 months. All houses now are in compliance with this regulation. 09/03/2021 Implemented
6400.141(a)A Physical examination was not completed annually, last physical exam in Individual #1 file is dated 5/10/2019. A physical examination must be signed and dated by a physician and include Tuberculin, health maintenance needs, physical limitations, medical information and include if individual is free of communicable diseases. (The agency has scheduled a Physical for 7/21/2021 but no verification that physical was completed. No proof of physical being completed for 2020).An individual shall have a physical examination within 12 months prior to admission and annually thereafter. in regards to 55 PA Code Chapter 6400.141(a) Eastwick Family Services Program Specialist has made sure that all of our individuals have an updated physical and will not be accepted into our program without one. We have retrained our Program Specialist on keeping all physical forms filed away better so that we have proof of all appointments. 08/12/2021 Implemented
6400.181(d)The program specialist did not sign and date the Annual assessment dated 11/20/2020.The program specialist shall sign and date the assessment. In regards to 55 PA Code Chapter 6400.181(d) The program specialist has signed and date the all assessments. 09/08/2021 Implemented
6400.181(e)(14)The assessment dated 11/20/2020 did not mention if Individual #1 had the ability to swim.The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. In regards to 55 PA Code Chapter 6400.181(e)(14) The program Specialist has updated the assessment to include whether the individual has the ability to swim. We will always make sure all assessments include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. 10/05/2021 Implemented
6400.18(i)The following open incidents were not finalized within 30 days and not reported in writing through the Department's information management system requesting an extension. All for Individual #1 Incident ID: 8455488 (Discovery date: 07/31/2018) Incident ID: 8644758 (Discovery date: 01/16/2020) Incident ID: 8679694 (Discovery date: 04/04/2020)The home shall finalize the incident report through the Department's information management system or on a form specified by the Department within 30 days of discovery of the incident by a staff person unless the home notifies the Department in writing that an extension is necessary and the reason for the extension.In regards to 55 PA Code Chapter 6400.18(i) Eastwick Family Services has hired a new Incident Manager to finalize the incident report through the Department's information management system or on a form specified by the Department within 30 days of discovery of the incident. 11/01/2021 Implemented
6400.163(h)The medication K-Y Jelly Gel for Ind. Lykeh Mumford was found in the medication box at time of inspection, the medication had expired on 03/2021.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.In Regards to 55 PA Code Chapter 6400.163(h) Eastwick Family Services has done an inspection on all medication boxes and destroyed all expired and discontinued medications in a safe manner. All staff were retrained on checking dates of medications daily. 10/15/2021 Implemented
6400.165(c)The medications TRIAMCINOLON 0.1% OIN and MILK OF MAGNESIUM is on the individuals MAR and not on site at time of inspection.A prescription medication shall be administered as prescribed.In regards to 55 PA Code Chapter 6400.165(c) Eastwick Family Services staff were all retrained on prescription medications and how they should be administered as prescribed. 10/10/2021 Implemented
SIN-00170715 Renewal 02/10/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.65There is neither an exhaust in the kitchen or a window.Living areas, recreation areas, dining areas, individual bedrooms, kitchens and bathrooms shall be ventilated by at least one operable window or by mechanical ventilation. In order to be incompliance with 55 PA Code Chapter 6400.65 Eastwick Family Services will install a Over the Range Microwave over the stove with a built in Mechanical Ventilation System. This will be installed 30 days from March 13, 2020. Eastwick has passed prior inspections at this site and had never been cited for not having operable ventilation due to the close proximity of the back door located directly in between the kitchen and dining area. In order to prevent this violation from reoccurring, Eastwick's repairman will install a Mechanical Ventilation system that will filter out dust, dirt and maintain sanitary conditions. 04/13/2020 Implemented
6400.72(c)The top deadbolt lock on the kitchen door leading outside was inoperable. Outside doors shall have operable locks.In order to be incompliance with 55 PA Code Chapter 6400.72(c) Eastwick has replaced the deadbolt lock with a new lock that is now operating correctly. We have also notified all direct support staff and house managers to check all doors at the beginning of every shift to ensure that they are secure and operable. In order to prevent this violation from reoccurring all staff must be retrained within 30 days of March 13, 2020 to also document on their daily shift chore list that this task was completed. 04/13/2020 Implemented
6400.110(e)The smoke detectors in the basement were not interconnected with the rest of the homes detectors.If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. In order to be in compliance with 55 PA Code Chapter 6400.110(e) Eastwick Family Services will repair and replace the basement smoke detector with 30 days of March 13, 2020. It was determined that due to active construction in the basement the smoke detectors were not functioning properly. Eastwick's Executive Director will ensure that once the construction is complete, the basement smoke detector is repaired or replaced in the abovementioned timeframe. In order to prevent future occurrences of this violation, Eastwick will ensure all smoke detectors are the first to be repaired by our maintenance team in the event of any construction project at the sites. 04/13/2020 Implemented
SIN-00146269 Renewal 12/03/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(b)There was no antiseptic in the first aid kit A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. In accordance with 55 PA Code Chapter 6400.77 (b) Eastwick Family Services has corrected the first aid kit by purchasing a new first aid kit that contains the antiseptic ointment. The House Managers have all checked their first aid kits as of December 5, 2018 to ensure they are all fully equipped with not only antiseptic ointment but all the other essential items. In order to prevent future occurrences of this violation, house management have began checking the first aid kit weekly along with site inspections. 12/05/2018 Implemented
SIN-00133754 Unannounced Monitoring 04/17/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.73(a)There were four steps from the basement to the backyard, but there was no handrail. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. In order to be incompliance with 55 PA Code Chapter 64400. 73(a) On May 7, 2018 Eastwick Family Services installed a secure handrail for the four steps from the basement to the backyard. In the future to prevent this violation, Eastwick will ensure all steps exceeding 2 steps will have a well-secured handrail at all site locations. 05/07/2018 Implemented
6400.141(a)Individual #1 was admitted on 8/31/17 and the physical examination was not completed until 3/12/18.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. In order to be in compliance with 55 PA Code Chapter 6400.141 (a), Eastwick Family Services has identified the failure of the physical to be give to us upon admission of the resident. The resident brought to Eastwick without the current physical on file and the clinic he resided in failed to provide such documentation. Eastwick however, did get a physical examination completed on November 3, 2017, however, at the time of inspection this particular physical was not at the office and located at the site. Additionally the physical was completed on the doctor's office form instead of the Annual Physical Examination Form that is ODP approved. Moving forward, Eastwick will not only be sure to obtain the individuals medical exam and physical prior to admission, but we will also ensure that any other physical completed thereafter will be written on the ODP mandated physical form. Additionally, Eastwick will make sure that copies of the form are available in the individuals medical book, onsite and in their office records filed properly to eliminate future violations. Effective June 15, 2018 the program specialist and house manager will have the ODP physical form completed with the exam from 11-3-17. In order to make sure all physical exams are on the correct form and completed entirely, the program specialist and house manager will review all resident medical binders carefully to see all the necessary information is documented. 06/15/2018 Implemented
6400.141(c)(4)Individual #1's physical examination dated 3/12/18 did not document a hearing screening.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. In order to be in compliance with 55 PA Code Chapter 6400.141(c)(4), Eastwick Family Services will now change the practice on how we handle physical exam appointments by ensuring that either the house manager or program specialist escort the direct support staff to all annual physical appointments. The program specialist has also created a letter to be given to the doctor during the exam, this letter will explain ODP regulations regarding the importance and necessity of filling out the Annual Physical Exam Form in its entirety. In regards to individual #1, during his physical exam, he became excessively irritated and aggressive toward the doctor. The doctor was unable to complete the exam under these conditions and staff had to leave the doctor's office without having a completed exam. Moving forward, Eastwick will also write an incident report specifically whenever the individual becomes aggressive during a doctor's appointment that results in the exam being incomplete. Additionally, individual #1 also had a physical exam on 11-3-17 which was not present during the inspection because it was located at the site. The physical from 11-3-17 was not completed on the Annual Physical exam form as required by ODP. However, the physical did show that individual #1 did have a hearing screening that was normal. Eastwick has since trained all direct support staff to utilize the physical exam form at all annual physical appointments. in order to fix this problem moving forward, the program specialist will work closely with office management in order to make sure all pertinent information is available in the individuals services binder and medical binder. Also copies of onsite documents will also be available at the main office at all times for future inspections and reviews. The program specialist and house manager will review all resident medical binders for completeness and compliance and will correct what is needed. Due to his aggression towards the Doctor, Eastwick Family Services will recommend to the Doctor to prescribe a sedative medications to calm individual #1 prior to any doctor appointment. 06/15/2018 Implemented
6400.141(c)(6)Individual #1's physical examination dated 3/12/18 did not document a tuberculin skin test.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. In order to be in compliance with 55 PA Code Chapter 6400.141(c)(6), Eastwick Family Services will now change the practice on how we handle physical exam appointments by ensuring that either the house manager or program specialist escort the direct support staff to all annual physical appointments. The program specialist has also created a letter to be given to the doctor during the exam, this letter will explain ODP regulations regarding the importance and necessity of filling out the Annual Physical Exam Form in its entirety. In regards to individual #1, during his physical exam, he became excessively irritated and aggressive toward the doctor. The doctor was unable to complete the exam under these conditions and staff had to leave the doctor's office without having a completed exam. Moving forward, Eastwick will suggest to his doctor that the individual receives medication treatments prior to his appointments to deter aggressive outbursts that will cause the physical exam to not be completed. Eastwick will also write an incident report specifically whenever the individual becomes aggressive during a doctor's appointment that results in the exam being incomplete. Additionally, individual #1 also had a physical exam on 11-3-17 which was not present during the inspection because it was located at the site. The physical from 11-3-17 was not completed on the Annual Physical exam form as required by ODP. However, this physical did have a tuberculin skin test with a negative result. Eastwick has since trained all direct support staff to utilize the physical exam form at all annual physical appointments. in order to fix this problem moving forward, the program specialist will work closely with office management in order to make sure all pertinent information is available in the individuals services binder and medical binder. Also copies of onsite documents will also be available at the main office at all times for future inspections and reviews. 06/15/2018 Implemented
6400.141(c)(14)Individual #1's physical examination dated 3/12/18 did not document information pertinent it diagnosis in case of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. In order to be in compliance with 55 PA Code Chapter 6400. 141(c)(14) Eastwick has identified the cause of the violation to be that the individual displayed extreme aggression during this doctors appointment on 3-12-18. The doctor refused to complete the exam and staff had to escort the resident from the doctor's office. Moving forward in order to fully document these incidents during a doctor's appointment, Eastwick will also write an incident report specifically whenever the individual becomes aggressive during a doctor's appointment that results in the exam being incomplete. The program specialist will suggest to the doctor that the individual receive medication treatments to decrease his aggressive behaviors during doctor's appointments and avoid the exam being incomplete. Eastwick will review all resident medical binders to ensure all the required compliance documents are in place, while correcting anything required. 06/15/2018 Implemented
6400.167(b)Individual #1's Milk of Magnesia sus 1200/15 take 1 tablespoonful at 8pm, Ketoconazole 2% cream apply to toes on both feet at 8pm, and Urea 40% lotion apply to both heels at 8pm had not been administered as prescribed from 4/1/18-4/18/18. Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant.In order to be incompliance with 55 PA Code Chapter 6400. 167(b) Eastwick identified the cause of the violation to be that individual #1's listed medications are prescribed on a bi-monthly basis and when it runs out the house manager cannot get a appointment soon enough prior to the medication running out. Additionally, Eastwick program specialist identified that the cream medications are being used too heavily which causes the cream tube to empty too soon. The program specialist has notified the direct support staff who administer medication to use the cream more sparingly so that it will last the full month. Moving forward, the house manager has been notified to schedule the bi- monthly doctor's appointment far enough in advance so that the medication doesn't run out prior to filling the next prescription. The program specialist will monitor all mediations to ensure they last through the month. When a medication is nearing it's completion, the house manager and /or program specialist will request a refill or schedule a doctor's appointment to obtain the prescription. 06/15/2018 Implemented
6400.168(a)Staff person #1's medication administration training was incomplete, it did not include hand washing and gloving skills test and the four observations. Staff person #2's medication administration training was incomplete, it did not include hand washing and gloving skills test and the four observations. Staff person #3's medication administration training was incomplete, it did not include hand washing and gloving skills test and the four observations. Staff person #4's medication administration training was incomplete, it did not include hand washing and gloving skills test and the four observations. Staff person #5's medication administration training was incomplete, it did not include hand washing and gloving skills test and the four observations. In a home serving eight or fewer individuals, a staff person who has completed and passed the Department's Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications. In order to be in compliance with 55 PA Code Chapter 6400. 168 (a) On April 18, 2018 Our Medication Trainer completed 2 additional practicum observations for 1 staff person. Additionally, this staff person's hand washing and gloving skills test was present at the time of licensing and inspection, however it was overlooked due to poor file arrangement. On April 19, 2018 our Medication Trainer completed 2 additional practicum observations for 3 staff persons . Additionally, all 3 person's hand washing and gloving skills test was present at the time of licensing and inspection, however it was overlooked due to poor file arrangement. After determining the cause of this violation, Eastwick has changed the format in how we arrange Medication Administration Training files. We developed an easier system in order to allow future inspections to be easily conducted with all the appropriate documentation in a organized manner. Eastwick will review all staff medication training records to ensure they are in compliance and we will correct what is required. 04/19/2018 Implemented
SIN-00123434 Renewal 10/27/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)There were no sleep drills held from September of 2016 through September of 2017.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. In order to be in compliance with 55 PA Code Chapter 6400.112 (c), Eastwick Family Services had scheduled a sleep drill for 11-4-17 at 1am. The house manager conducted the sleep drill and ensured the following information was correctly documented on the fire drill form: date, time, time of evacuation, exit route used, problems encountered and whether the smoke detector was in operation. Moving forward, Eastwick's new fire safety policy will include sleep drills to be done every 3 months. 12/08/2017 Implemented
6400.112(d)There was no exit documented on the fire drill from 1/31/17. Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. In order to be in compliance with 55 PA Code Chapter 6400.112 (d), Eastwick Family Services will ensure that the house manager thoroughly completes all fire drill forms and submits the form to the main office for inspection. Moving forward, the program specialist will inspect the fire drill to ensure that it is completely filled out in it's entirety including the exit locations during the fire drill. The program specialist will ensure that the house manager ensures the individuals are able to evacuate the entire building within 2 1/2 minutes as specified by the qualified fire safety expert who is not employed by Eastwick. The house manager conducting the fire drill will allow the staff to assist the individuals during the fire drill because staff must always be present with the individual in the home at all times. 12/08/2017 Implemented
6400.112(f)There was no evacuation time recorded on the fire drill from 2/22/17.Alternate exit routes shall be used during fire drills. In order to be in compliance with 55 PA Chapter 6400.112 (f), Eastwick Family Services will ensure that the house manager who conducts the fire drill completely fill out the fire drill form including the evacuation time. Afterwards the house manager will now be required to submit a copy of the fire drill form to the program specialist at the main office for review and inspection. Moving forward, Eastwick program specialist will ensure that the house manager utilizes alternate exit routes during fire drills and fills out the fire drill form in its entirety. 12/01/2017 Implemented
6400.113(a)Individual #1 did not have fire safety training in his record. An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually 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 home. In order to be in compliance with 55 PA Code Chapter 6400.113 (a), Eastwick Family Services trained Individual #1 including all other individuals residing at the home on November 2, 2017 for 2 Hours on Fire Safety. Moving Forward Eastwick's new Fire Safety Policy now requires all new individuals to be trained on Fire Safety upon admission and annually thereafter. Individual # 1 and the other residents will retake Fire Safety training again on November 2, 2018. Individuals were instructed in their primary language of English. Upon Admission, the new resident/ individual's primary language will utilized for their Fire Safety Training. Eastwick Program Specialist and House Managers are trained annually in Fire Safety by a Nationally Qualified Fire Safety Instructor and are able to train consumers on the curriculum. 12/08/2017 Implemented
6400.141(c)(6)Individual #1 did not have a TB test conducted since admission on 9/01/17. The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. In order to comply with 55 PA Code Chapter 6400.141 (c)(6), Eastwick Family Services will make sure that all physicals include TB test. All individuals before being admitted into the Residential programs will complete a Tuberculin skin test by Mantoux method. If result is negative individual will be require to complete such test every two years. If the test is positive the individual will be require to take an initial chest X-ray with results being noted. Individual # 1will complete TB test within 60 days. 02/11/2018 Implemented
6400.141(c)(10)Individual #1's annual physical dated 4/5/17 did not indicate whether or not they were free from communicable disease. The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. Eastwick Family Services will train staff accompanying individual to physical appointment to make sure Doctor include in the physical exam the information that individual is free from communicable disease. Individual #1 physical exam will be corrected in 60 days. 02/11/2018 Implemented
6400.141(c)(13)Individual #1's annual physical dated 4/5/17 did not list allergies. The physical examination shall include: Allergies or contraindicated medications.Eastwick Family Services will train staff accompanying individual to physical appointment to make sure Doctor include in the physical exam the Allergies or contraindicated medications. Individual #1 physical exam will be corrected in 60 days. 02/11/2018 Implemented
6400.141(c)(14)Individual #1's annual physical dated 4/5/17 did not indicate information pertinent to diagnosis in case of an emergency. The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Eastwick Family Services will train staff accompanying individual to physical appointment to make sure Doctor include in the physical exam the information diagnosis and treatment in case of an emergency. Individual #1 physical exam will be corrected in 60 days. 02/11/2018 Implemented
SIN-00084545 Initial review 10/06/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(b)Scissors and a thermometer were absent from the first aid kit. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. Eastwick Family services immediately purchased scissors and a thermometer and placed it in the first aid kit box on 10/06/2015. Eastwick will do a monthly check of all first aid kits during the monthly fire drill to ensure that all necessary items are in the box and to remain in compliance with 55 PA Code Chapter 6400.77 (b). The Residence Manager will be responsible for making sure this plan of action is completed. 10/07/2015 Implemented
SIN-00095383 Renewal 05/09/2016 Compliant - Finalized