Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00228138 Renewal 07/24/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The bathroom door was missing the knob preventing the door to close and individuals to have privacy.Floors, walls, ceilings and other surfaces shall be in good repair. In regards to violation 55 PA Code Chapter 6400.67(a) Eastwick Family Services has a contractor to maintain our properties, the contractor has installed a doorknob on the bathroom door which now allows the bathroom door to shut completely. 07/26/2023 Implemented
6400.67(a)The ceiling located in the bedroom #2, was damaged and in need of repair.Floors, walls, ceilings and other surfaces shall be in good repair. In regards to violation 55 PA Code Chapter 6400.67(a) Eastwick Family Services contractor has repaired and painted the ceiling in bedroom #2. 07/26/2023 Implemented
6400.67(b)Flammable material (paint, thinner) was stored close to furnace which could be a fire hazard. Floors, walls, ceilings and other surfaces shall be free of hazards.In regards to violation 55 PA Code Chapter 6400.67(b) Eastwick Family Services House manager has removed all paint from near the furnace. The director and the HR Manager have retrained the staff and house manager on the importance of fire hazards and keeping all objects away from the furnace. 07/26/2023 Implemented
6400.71Emergency numbers were not on or near the telephone located in the staff office.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. In regards to violation 55 PA Code Chapter 6400.71 Eastwick Family Services House Manager has placed the Emergency Contact Phone number list in the staff office by the phone. The Director and Manager has inspected all homes to ensure the emergency numbers are by all phones. 07/26/2023 Implemented
6400.141(a)Individual #2 7/6/23 physical is incomplete, missing much of the information required: a medical history review, an immunization record, a review of allergies, a current TB test result, vision and hearing screening information, and a review of special diet instructions, information pertinent to diagnosis, and activity restrictions. The physical was also not signed and dated by a doctor.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 house manager called the primary care doctor and scheduled an appointment for Individual #2 to go back to their Primary Care Dr and have the physical form filled out completely. The appointment is for 9/6/2023. The house manager was retrained by the director on reviewing medical forms before leaving appointments to ensure they are filled out completely. 09/06/2023 Implemented
6400.142(c)Individual #2 has not had a dental visit since 11/1/2021.A written record of the dental examination, including the date of the examination, the dentist's name, procedures completed and follow-up treatment recommended, shall be kept. In regards to 55 PA Code Chapter 6400.142(c) Eastwick Family Services Program Specialist scheduled a dental appointment for individual #2 they visited the dentist for her annual appointment on 7/27/2023. 07/27/2023 Implemented
6400.142(g)Individual #2 dental hygiene plan is undated.A dental hygiene plan shall be rewritten at least annually. In regards to violation 55 PA Code Chapter 6400.142(g) Eastwick Family Services Program Specialist corrected the Dental Hygiene Plan for individual #2 and it is now dated. 07/27/2023 Implemented
6400.32(r)There were no locks on the individuals bedroom doors.An individual has the right to lock the individual's bedroom door.In regards to violation 55 PA Code Chapter 6400.32(r) Eastwick Family Services contractor has installed new doorknobs on all the individual's bedrooms to ensure each individual has the right to lock their door. 07/27/2023 Implemented
6400.181(f)Individual #2 record does not contain verification that their 10/16/22 assessment was shared with their team at least 30 days prior to their 7/14/23 ISP meeting.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.In regards to violation 55 PA Code Chapter 6400.181(f) Eastwick Family Services director has retrained the program specialist on keeping records of all invites to individual #2 team members 30 days prior to meetings. 07/28/2023 Implemented
6400.213(1)(i)Individual #2 record does not contain their eye color.Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.In regard to violation 55 PA Code Chapter 6400.213(1)(i) Eastwick Family Services Program Specialist has corrected the face sheet for individual # 2 to now contain their eye color. 07/30/2023 Implemented
SIN-00211700 Renewal 07/26/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The rug located in Individual 1 and 2's bedroom needs repaired or replacement.Floors, walls, ceilings and other surfaces shall be in good repair. In regards to violation cited under 55 PA Code Chapter 6400.67(a) Eastwick Family Services CEO has had the carpet replaced in the bedroom for individual 1 &2. 08/12/2022 Implemented
6400.81(k)(6)There is no mirror in the bedroom for Individual 1.In bedrooms, each individual shall have the following: A mirror. In regards to citation listed under 55 PA Code Chapter 6400.81(k)(6) Eastwick Family Services CEO has purchased a mirror for the bedroom of individual 1, the mirror is now located in the bedroom. 08/12/2022 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 regard to citation listed under code 55 PA Code Chapter 6400.104 Eastwick Family Services Program Specialist has revised the letter to the fire department and resent it making sure that it is dated and the location of each room with individuals needing assistance evacuating is listed. 08/12/2022 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 regard to violation cited under code 55 PA Code Chapter 6400.106 Eastwick Family Services CEO has contacted the HVAC technician and requested that he revisit the residential homes and revise the receipt so that it reflects the date the furnace inspections were complete. 08/30/2022 Implemented
6400.110(e)The home has three stories and the automatic smoke detector located on the main floor is not interconnected. After the inspection, the agency replaced the smoke detectors. On 7/29/22, the new smoke detectors were tested and were found to be 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 cited under code 55 PA Code Chapter 6400.110(e) Eastwick Family Services CEO has fixed the smoke detectors and ensured they were interconnecting. On 7/29/2022 We did a video conference with a representative from ODP to ensure this correction was made. 07/29/2022 Implemented
6400.163(d)Individuals' medication was not kept in a locked area (One med box is damaged and is unable to be locked) This was corrected at time of inspection.) (The door that house the medication is in need of repair)Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.In regards to violation cited under code 55 PA Code Chapter 6400.163(d) Eastwick Family Services house manager has purchased a new medication box and lock and we submitted a photo of this to an ODP representative. 07/29/2022 Implemented
6400.165(b)(PRN) (ROBAFEN DM LIQUID) not in Individual 1's Med Box. (PRN) (ACETEMINOPHEN 325mg) not in Individual 1's Med box.A prescription order shall be kept current.In regards to violation cited under code 55 PA Code Chapter 6400.165(b) Eastwick Family Service Program Specialist has called the pharmacy to refill this PRN and it was placed in the medication box immediately. This error was corrected on 7/29/2022. 07/29/2022 Implemented
SIN-00192766 Renewal 07/29/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.65The bathroom skylight is inoperable. There was not a chain or cord to open the ceiling window to ventilate the bathroom.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 response to 55 Pa Code Chapter 6400.65 regarding the skylight being inoperable in the bathroom, Eastwick Family Services did repaired the chain on October 13, 2021. independent contractor was hired to complete the violation. 10/13/2021 Implemented
6400.66The basement needs adequate lighting. There is also no light in the back entrance of the home.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents. In regards to 55 PA Code chapter 6400.66 violation regarding adequate lightings in the basement and the backyard, Eastwick Family Services did install new light in the back yard and a light was installed in the basement. An independent Contractor was hired to do the electrical work. 09/24/2021 Implemented
6400.77(b)The first aid kit did not have tweezers or tape 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 response to 55 Pa Code Chapter 6400.77(b) violation regarding tweezer and tape being missing in the first aid kit,, Eastwick purchased all new completed first aid kit that contains the tweezer and the tape. 08/02/2021 Implemented
6400.106An 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
6400.112(c)The fire drills dated 4/30/21 and 5/28/21 for 7139 Radbourne Rd, Upper Darby did not list the time the drill was completed.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 regards to 55PA Code Chapter 6400.112(c) Eastwick Family Services has retrained all residential staff at this location on how to properly complete the fire drill forms making sure all forms have the date, time, the amount of time it took to evacuate, the exit route used, if all smoke detectors are in working order and any problems that may have been encountered. 10/18/2021 Implemented
6400.112(e)The home at 7139 Radbourne Rd did not have sleep drills 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 trained all staff on the importance of sleep drills and how they must be completed every 6 months in order to ensure the safety of our consumers and to stay compliant with this code. We also have trained our Program Specialist to do a monthly check on the fire drill forms to make sure a sleep drill is being completed every 6 months. 10/21/2021 Implemented
6400.141(a)Individual #1 annual physical exam is overdue, it was due on 6/1/2021.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 will ensure that the program Specialist will look over each file of potential admissions and make sure they have a physical before being accepted into our program. She will keep a record through excel to ensure we are keeping track of upcoming appointments for our current individuals and that no appointments will be over due. 09/12/2021 Implemented
6400.141(c)(6)Individual #1 TB test is overdue, last TB test was completed on 6/3/2019.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 regards to 55 PA Code Chapter 6400.141 (c) (6) Eastwick Family Services has retrained all staff and Program Specialist on the policy and regulations regarding the TB shot. We have explained the Physical form to our staff and showed them the section for TB. We have explained the importance of not leaving the doctors office until they have reviewed the physical form and made sure the Dr filled in and completed the necessary portions. 09/30/2021 Implemented
6400.142(a)Individual # 1 last dental exam was completed on 5/26/2020 and is currently overdue.An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. In regards to 55 PA Code Chapter 6400.142 (a) The Program Specialist has been retrained on the importance of necessary appointments for all residential consumers and all necessary appointments have all been made and are now up to date. 10/15/2021 Implemented
6400.142(f)Individual #1 did not have a written dental plan at time of inspection.An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. In regards to 55 PA Code Chapter 6400.142 (f) Eastwick Family Services Program Specialist has made sure a dental plan or written documentation saying they have achieved dental hygiene has been added to all individuals' charts. 09/30/2021 Implemented
6400.151(a)Staff # 1's physical was completed after her date of hire. The date of hire is 3/1/21 and the physical exam was completed on 7/8/21. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. In regards to 55 PA Code Chapter 6400.151 (a) Eastwick Family Services hiring manager was retrained on the hiring policy and the regulation regarding staff physicals being done before the date of hire. 09/02/2021 Implemented
6400.181(d)Individual # 1 annual assessment was not signed or dated by program specialist.The program specialist shall sign and date the assessment. In regards to 55 PA Code Chapter 6400.181 (d) the Program Specialist has reviewed all files and signed all annual assessments. 09/02/2020 Implemented
6400.46(b)The agency did not have a fire expert at time of inspection. Therefore the staff were not currently trained in fire safety.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).In regards to 55 PA Eastwick Family Services has hired an independent contractor who is an expert in fire safety and she will be conducting our annual fire safety trainings from now on. 09/24/2021 Implemented
6400.181(f)The assessment for individual # 1 was not sent the plan team members 30 days prior to meeting.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.In regards to 55 PA Code Chapter 6400.181 (f) Eastwick Family Services has retrained our program specialist she will now provide the proper 30 calendar days notice prior to an individuals plan meeting. 09/29/2021 Implemented
SIN-00170714 Renewal 02/10/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(c)The self- assessment dated 3/22/19 did not evaluate staffing and training regulation 6400: 42 to 46h.A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year. In order to be in compliance with 55 PA Code Chapter 6400.15 (c) Eastwick determined that the house managers who performed the self assessments neglected to fill out the entire assessments due to lack of understanding the forms and how to respond appropriately. In order to prevent this citation from reoccurring, Eastwick will re-train all house managers on how to complete quarterly self assessments for each site. Within 30 days of March 13, 2020 Eastwick will conduct this re-training and have all managers re-submit new self assessments. 04/13/2020 Implemented
6400.64(a)There was grease build up under the microwave above the range. There was grease build up on the blinds adjacent to the range.Clean and sanitary conditions shall be maintained in the home. In order to be in compliance with 55 PA Code Chapter 6400.64(a) Eastwick will instruct direct support staff and house managers to clean areas where grease builds up thoroughly. In order to ensure that this chore is completed, house managers have been instructed to spot check all sites prior to performing self - assessments to see that all areas are clean and sanitized for the safety of all individuals. Eastwick will create a microwave and stove cleaning log to be posted in the kitchens of all sites and for every shift to maintain responsibility for. In order to prevent this citation from reoccurring, Eastwick's house managers will have to check this new microwave and stove cleaning log daily when making rounds in order to keep direct support staff accountable for this chore specifically. Within 30 days of March 13, 2020, Eastwick will see that this task is completed through sanitation retraining for the staff at all sites. 04/13/2020 Implemented
6400.67(a)There was a hole near the front door where the doorbell was replaced.Floors, walls, ceilings and other surfaces shall be in good repair. In order to be in compliance with 55 PA Code Chapter 6400.67(a) Eastwick Family Services will repair or replace the doorbell and hole near the front door within 30 days of March 13, 2020. Eastwick's repairman was in the middle of active construction during the site inspection. The door bell needed repair due to a wire shortage that took place the day prior to the inspection. In order to prevent a reoccurring citation, Eastwick will instruct the maintenance team to temporarily cover the hole until the new door bell is installed. 04/13/2020 Implemented
6400.110(a)all of the smoke detectors on the second floor were not working. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. In order to be in compliance with 55 PA Code Chapter 6400.110(a) Eastwick determined that the smoke detector on the second floor was working prior to the inspection but the CEO tried to tighten it and accidentally broke it. Since it was determined that the smoke detector was operable prior to this accident, Eastwick had the smoke detector replaced and repaired right away the same day of the site inspection. Eastwick will ensure that the CEO, house manager and all direct support staff are careful when smoke detectors are being inspected, all staff have been notified through a Memo to handle with care moving forward in order to prevent a reoccurring violation. 04/13/2020 Implemented
6400.112(d)The evacuation time for the fire drill conducted on 7/15/19 was listed as 3 minutes 20 seconds , the drill on 3/20/19 as 4 minutes,3 seconds, and the drill on 2/28/19 as 3 minutes, which all of them exceeded the 2 1/2 minute maximum time.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 employee 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.55 PA Code Chapter 6400.112(d) The evacuation time for the fire drill conducted on 7/15/19 was listed as 3 minutes 20 seconds , the drill on 3/20/19 as 4 minutes,3 seconds, and the drill on 2/28/19 as 3 minutes, which all of them exceeded 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 employee 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. 04/13/2020 Implemented
SIN-00146268 Renewal 12/03/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The deck at the main floor entrance has dark green vegetation growth that is slippery. There was thick grease on the walls above the kitchen stoveClean and sanitary conditions shall be maintained in the home. In accordance with 55 PA Code Chapter 6400. 64(a) Eastwick Family Services has had our maintenance team clean and correct the damage to the main floor deck. The program coordinator will now routinely inspect the deck for discoloration due to normal wear and tear in order to report it at it's beginning stages. Once the deck begins to loose its natural wood coloring, maintenance will be notified within 48 hours as thus is our updated policy in regards to clean and sanitary sites. To avoid future occurrences the direct support staff will receive additional training by January 31, 2019 to ensure they are trained in properly cleaning the kitchen stove, as well as all of site areas. Staff will be trained on what to report at the site that they can not clean or sanitize themselves. For example if the deck requires cleaning with a special wood polish, the staff will notify the house manager and the house manager will notify the maintenance team within 24 hours. The maintenance team will have 24 hours to respond and repair/clean the reported area. Failure to complete this process in the correct order will result in written disciplinary notices to all staff who neglect to report the damage on any shift. 01/31/2019 Implemented
6400.67(a)There was water damage on the ceiling, the floor and the walls of the enclosed front porch. [REPEATED NON-COMPLIANCE 4/17/18]Floors, walls, ceilings and other surfaces shall be in good repair. In accordance with 55 PA Code Chapter 6400.67 (A) Eastwick Family Services has corrected and repaired the ceiling , floor and walls that had water damage. The Executive Director had the maintenance team make this correction on December 4, 2018. In order to avoid another repeat violation, Eastwick Office Manager has created a water damage inspection log to be used weekly by direct support staff and house management when inspecting the entire house. In the first week of the month, all sites will now be specifically inspected for water damage on floors, walls, ceilings and other surfaces. Moving forward this procedure is now apart of our routine inspections. 12/04/2018 Implemented
6400.106A furnace Inspection was not completed for the homeFurnaces 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 accordance with 55 PA Code Chapter 6400.106 Eastwick Family Services has corrected this violation by having a full inspection completed on December 4, 2018 by Dean's Heating and Cooling Service. The office manager has also created a policy to annually have furnace cleaning for all sites containing a furnace. This policy will prevent future violations from re-occurring. 12/04/2018 Implemented
SIN-00133753 Unannounced Monitoring 04/17/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(b)The laundry area in the basement had multiple spider webs.There may not be evidence of infestation of insects or rodents in the home. In order to be in compliance with 55 PA Code Chapter 6400.64 on April 20, 2018 Eastwick Family Services cleaned all spider webs from the basement and met with all staff members to show them how to safely remove spider webs. Eastwick also added this tasks to the staff shift chore list for overnight staff to complete twice a week. Eastwick identified the reason for the spider webs and sealed off the basement areas of entry where they were crawling through. Eastwick additionally had pest control inspect the basement on May 1, 2018 to ensure this problem doesn't occur again. Eastwick has increased it's pest control services from every 3 months to monthly for ongoing monitoring. 04/20/2018 Implemented
6400.64(e)The trash can in the kitchen did not have a lid.Trash receptacles over 18 inches high shall have lids. In order to be in compliance with 55 PA Code Chapter 6400.64 On April 20, 2018 Eastwick re-attached the trash can lid as well as bought additional trash cans with lids. Eastwick also notified all staff members to remember to replace the trash lid when taking trash out. Moving forward Eastwick has added this task to the chore list for staff members to be in compliance during every shift. 04/20/2018 Implemented
6400.67(a)Individual #1's bedroom bureau drawer was missing, and the dresser was missing 3 knobs. Individual #1's bedroom window's had a rod hanging and torn blinds, and curtains hanging on the heater.Floors, walls, ceilings and other surfaces shall be in good repair. In order to be in compliance with PA 55 Code Chapter 6400. 67(a) On May 4, 2018, Eastwick Family Services replaced Individual #1's bedroom bureau drawer and 3 missing knobs. Additionally, Individual #1's curtains and rod was replaced and blinds removed. The curtains are now hanging above the heater and a shorter length. Eastwick determined the cause of the violation to be that Individual # 1 displays aggressive behavior and tends to destroy her curtains and dresser drawers when angry. In order to avoid future violations, Eastwick has developed a plan of action for staff to follow consistently when Individual #1 begins this behavior. Through ongoing monitoring and re-direction of this behavior staff have been reporting less aggressive behaviors of Individual #1 that result in property damage. Direct Support staff will also document when this behavior occurs in the individuals daily log. the house manager will present the behavior to the individuals behavior specialist for a plan to be created on how to re-direct the behavior so that it can decrease or be eliminated entirely. Direct support staff will practice ongoing monitoring of the individuals bedroom during every shift and assist with maintaining the bureau drawers and knobs, window curtain rods and blinds. Direct support staff will document these behaviors in the individuals daily logs. The house manager will review the daily logs and inform the individuals behavior specialist to create a plan of action to decrease or eliminate the behavior entirely. If the individual continue to exhibit this behavior of removing the knobs of the furniture, Eastwick will replace all furniture in the individual room with knob less furniture. 05/04/2018 Implemented
6400.67(b)The living room ceiling approximately 2 feet was buckling. Floors, walls, ceilings and other surfaces shall be free of hazards.In order to be in compliance with 55 PA Code 6400.67 (b) On May 7, 2018 Eastwick Family Services had our maintenance team remove excess bulking and paint from the ceiling and repaired the ceiling before repainting it. Eastwick identified the source of the problem and had maintenance fix it so that it doesn't occur in the future. Moving forward Eastwick also notified staff to inspect the ceiling frequently to ensure it remains intact and to report any new paint falling off or bulking they notice to their house manager to contact maintenance. To make sure that issue of this nature is resolve in a timely manner, the maintenance team will do a weekly walk through of each residential home. 05/07/2018 Implemented
6400.72(b)In the basement the exit screen door did not close, and the boiler room door was off the tracks. Screens, windows and doors shall be in good repair. In order to be in compliance with 55 PA Code Chapter 6400.72 (b) On May 4, 2018 Eastwick Family Services replaced the basement exit screen door with a completely secured door that closes entirely. The basement exit door was subject to weatherization and often tightens and loosens when weather is cold or humid. The boiler room door often needed to be placed back on track if staff shut the door too fast. To eliminate this, the boiler room door and the back exit door of the basement has also been replaced entirely with a secured door that is in good repair. Moving forward, Eastwick will ensure all doors, screens and windows remain in good repair by completing monthly maintenance inspections at all site locations. 05/04/2018 Implemented
6400.76(a)There was a large amount of lint on the floor by the dryer. Furniture and equipment shall be nonhazardous, clean and sturdy. In order to be in compliance with 55 PA Code Chapter 6400.76 (a) On May 7, 2018 Eastwick Family Services purchased a new dryer filter for the dryer in the basement. Our Maintenance team determined the root of the excessive lint problem to be from the broken vent and filter. Moving forward, Eastwick will ensure that Maintenance and direct support staff check the vent and filter on the dryer to make sure it is tightly secured and intact. Eastwick also added this tasks of lint removal to the staff chore checklist to be enforced. 05/07/2018 Implemented
6400.77(b)The first aid kit in the home did not have antiseptic. 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 order to be in compliance with 55 PA Code Chapter 6400.77(b) On May 4, 2018, Eastwick Family Services purchased a fully equipped first aid kit with antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, and scissors. Moving forward, Eastwick has added a first aid checklist to be completed weekly by each shift to ensure all of the first aid components are in stock at all site locations. 05/04/2018 Implemented
6400.81(k)(2)Individual #2's bed at the right bottom side appeared to be slanted.In bedrooms, each individual shall have the following: A clean, comfortable mattress and solid foundation. In order to be in compliance of 55 PA Code Chapter 6400. 81(k)(2), On May 7, 2018 Eastwick purchased a brand new bed frame and mattress that has a sturdy and comfortable foundation. Eastwick determined that Individual # 2 has a behavior of jumping up and down the bed like a trampoline. when she does this it remove the bed frame from under the mattress.. In order to prevent future violations, Eastwick has notified all staff members to check the foundations of all consumers beds to ensure they are intact. Eastwick will work with this individual to help her reduce this behavior by giving her other option for recreation. Direct support staff will check on her furniture daily to make sure all frames are together. 05/07/2018 Implemented
6400.81(k)(3)Individual #1's bedroom did not have sheets and pillow cases on the bed.In bedrooms, each individual shall have the following: Bedding, including pillow, linens and blankets appropriate for the season.In order to be in compliance with 55 PA Code Chapter 6400.81 (k) (3) On April 19, 2018, Eastwick Family Services bought Individual # 1 two new sets of sheets and bedding. Eastwick staff members also assisted the Individual with re-making her bed. On May 7, 2018 Eastwick purchased a new bed mattress for Individual #1 as well. Eastwick determined the cause of the violation to be that Individual #1 wets the bed frequently and when she has an accident, she removes all her bedding to be washed in the laundry room. Moving forward to prevent future violations, Eastwick has bought additional bed wetting matts and extra bedding sheets and pillow cases, and comforters to rotate during accidents weekly. Eastwick will also monitor the situation and have staff develop bedtime routines that decrease bed wetting overnight. Direct support staff will also document this behavior on the daily logs in order for the house manager to review the patterns of when the behavior occurs. When the individual's behavior specialist visits monthly, the house manager will utilize the daily log documentation for the behavior specialist to create a plan to address and decrease the behavior. Direct support staff will make sure the individuals have bedding and pillows at all times. 04/19/2018 Implemented
6400.162(a)Individual #1's medication box had a sample medication for Myrbetrig, which it did not have a script or label.The original container for prescription medications shall be labeled with a pharmaceutical label that includes the individual's name, the name of the medication, the date the prescription was issued, the prescribed dose and the name of the prescribing physician. In order to be in compliance with 55 PA Code Chapter 6400.162 (a) Eastwick identified this medication violation as a lack of knowledge about sample medications. Our program specialist has informed house managers and direct support staff of this violation and a refresher class took place in order to re-train staff on acceptable medication labels and prescriptions for sample medications. Moving forward Eastwick program specialist and house manager will make sure that any medication given from a doctor during a medical visit is properly labeled with individual's name, the name of the medication, the date the prescription was issued, the prescribed dose and the name of the prescribing physician. Alternatively, staff can also ask the doctor for a prescription label. Eastwick program specialists in conjunction with office support will review all resident MAR logs and prescription to ensure compliance and make corrections as required. 06/15/2018 Implemented
6400.165Individual #1's medication Flovent was not logged as administered on 4/2/18, 4/7/18, and 4/17/18, and there was no documentation of why it was not administered.Documentation of medication errors and follow-up action taken shall be kept. In order to be in compliance with 55 PA Code Chapter 6400.165 , On April 20th Eastwick Family Services has retrained direct support staff and house managers on how to properly document when a resident refuses to take medication. To eliminate staff leaving refusals blank, the staff must write the letter "R" for Refused in the MAR. Moving forward, whenever there is a refusal staff will not only document the "R" on the MAR based on the date, time and medication, but an additional form for refusals will be created by June 1st that will also be used to explain how staff tried to re-direct the resident through encouraging them to take the medication prior to the refusal. This will be called a "Desensitization Plan" used during the refusal of medication administration for all residents. This follow up action plan will also be used to explain other medication errors other than refusals. The form will be attached to all MARs upon completion on June 15th. 06/15/2018 Implemented
6400.167(b)Individual #'1s medication Flovent HFA 110mcg inhale 1 puff 2 times a day at 8am and 8pm were not logged as administered on 4/2/18, 4/7/18, and 4/17/18. 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 in compliance with 55 PA Code Chapter 6400.167 (b) , On April 20th Eastwick Family Services has retrained direct support staff and house managers on how to properly document when a resident refuses to take medication. To eliminate staff leaving refusals blank, the staff must write the letter "R" for Refused in the MAR. Moving forward, whenever there is a refusal staff will not only document the "R" on the MAR based on the date, time and medication, but an additional form for refusals will be created by June 1st that will also be used to explain how staff tried to re-direct the resident through encouraging them to take the medication prior to the refusal. This will be called a "Desensitization Plan" used during the refusal of medication administration for all residents. Program Specialist will do a weekly MAR check and document any issue and take appropriate actions to resolve it. All Direct staff, at the beginning of each shift will be require to do full medication check and MAR review before the start of each shift, and document such check. 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. Staff person #6's medication administration training was incomplete, it did not include hand washing and gloving skills test and the four observations. Staff person #7'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 18-19, 2018 Our Medication Trainer completed 2 additional practicum observations for 7 staff persons totaling the required 4 practicum observations. Additionally, all 7 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. After determining the cause of this violation, Eastwick has changed the format in how we arrange Medication Administration Training and record keeping. Eastwick will also monitor and review all resident files to make sure they are in compliance and make corrections as needed. Documentations in files will be arrange in a more simplify manner for easy access. 04/19/2018 Implemented
6400.181(a)Individual #1's record did not have an assessment on file. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. In order to be in compliance with 55 PA Code Chapter 6400.181(a), In order to be in compliance with 55 PA Code Chapter 6400. 186 (a), Eastwick Family Services has determined the cause of the repeated violation and has implemented a policy to immediately address the repeated violations. The new policy will involve the over view of all related documents by the Quality Review Specialist on a monthly basis. A further review of all documentations such as monthly, quarterly reviews and assessments will be conducted by the Executive Director on the monthly and quarterly basis. The Program Specialist will be attending required trainings to help her improve in filing and completing documentation in timely fashion. 06/15/2018 Implemented
6400.186(a)Individual #1's record had 2 three month reviews in the file, which there should have been 4 three month reviews. REPEATED NON-COMPLIANCE 10/27/17.The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. In order to be in compliance with 55 PA Code Chapter 6400. 186 (a), Eastwick Family Services has determined the cause of the repeated violation and has implemented a policy to immediately address the repeated violations. The program Specialist has completed the 2 missing quarterly reviews needed for the individual. The new policy will involve the over view of all related documents by the Quality Review Specialist on a monthly basis. A further review of all documentations will be conducted by the Executive Director on the monthly and quarterly basis. The Program Specialist will be attending require trainings to help her improve in filing documentation in timely fashion. 05/07/2018 Implemented
6400.186(c)(1)Individual #1's record did not have any monthly documentation in the file. REPEATED NON-CONPLIANCE 10/27/17.The ISP review must include the following: A review of the monthly documentation of an individual's participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the residential home licensed under this chapter. In order to be in compliance with 55 PA Code Chapter 6400. 186 (c)(1) Eastwick has identified the reasons for the repeat violation to be improper time management of the Program Specialist in completing all documentations. . Eastwick Family Services will have the program Specialist attend training to enhance her ability to manage her time properly to make sure documentations are completely in a timely fashion. . Moving forward, Eastwick will implement a three layer review process in order to monitor the completion of monthly progress notes. The Program Specialist will complete the monthly progress note on a monthly basis. Quality Review Specialist will do a secondary check to make sure that all monthlies are complete in a timely fashion.. Effective June 15th, Eastwick will began this new practice to prevent future occurrences. 06/15/2018 Implemented
SIN-00123433 Renewal 10/27/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Staff #2 was hired 6/28/16 and did not complete a criminal background check until 7/21/16. An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire. In order to be in compliance with 55 PA Code Chapter 6400.21 (a), Moving forward, Eastwick Family Services will require all potential employees to complete criminal background that will be submitted to the State Police for processing prior to the staff working with any individual. If a potential employee has not lived in the State of Pennsylvania for the past two years, the potential employee will be required to complete an FBI fingerprint background check. As part of this policy, a consent form will be signed by the potential employee allowing Eastwick to implement the back ground check. 12/01/2017 Implemented
6400.112(e)There were no sleep drills held from September of 2016 through September of 2017.A fire drill shall be held during sleeping hours at least every 6 months. In order to be in compliance with 55 PA Code Chapter 6400.112 (e), Eastwick Family Services had scheduled a sleep drill for 11-30-17 at 4am. The house manager will conduct the sleep drill and ensure the following information is 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. 12/31/2017 Implemented
6400.112(h)There was not a meeting place mentioned in the fire drills dated 9/8/16 and 10/11/16. Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.In order to be in compliance with 55 PA Code Chapter 6400.112 (h) Moving forward, Eastwick Family Services will ensure that the house manager conducting the fire drill completely fills out the fire drill form and submits it to the program specialist for inspection and review. The program specialist will ensure that all individuals are trained and aware of the designated meeting place during fire drills/fire emergencies. Additionally, the program specialist will make sure the meeting place is filled out on the fire drill forms as well as all other sections on the fire drill form. 12/01/2017 Implemented
6400.113(a)Individual #1 did not have fire saftey training since admission on 3/31/17. 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. 12/04/2017 Implemented
6400.141(c)(6)Individual #1 did not have a TB test since admission on 3/31/17. 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 include as part of it admission policy regarding physical examination, that all individual be tested for tuberculosis. This test include the Mantoux skin testing, and if the result is positive, an initial chest X-Ray will be implemented. This test will be carryout every 2 years there after. Individual coming into the home who have had previous Mantoux and result is negative, and it is less than two years may be admitted until the two years cycle is completed. Individual #1 will complete the TB test by 02/11/2018. 02/11/2018 Implemented
6400.141(c)(12)Individual #1's annual physical dated 3/27/17 did not indicate physical limitations. The question on the physical was left blank. The physical examination shall include: Physical limitations of the individual. Eastwick Family Services will implement a policy that will require all direct support staff to make sure medical Doctor filling out the physical form to properly fill in all require spaces including physical limitations of individuals. Individual #1 will have a completed physical including notification of Physical limitations by 02/11/2018. 02/11/2018 Implemented
6400.141(c)(14)Individual #1's annual physical dated 3/27/17 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. In order to comply with ODP 55 Pa Code Chapter 6400.141(c)(14), Eastwick Family services will implement a policy to make sure that medical Doctor doing physical include information pertinent to diagnosis in case of an emergency. Staff accompanying individuals to such appointments will be train to review all require sections of the physical to make sure the Doctor has fully completed the form. The plan of correction will be completed by 02/11/2018. 02/11/2018 Implemented
6400.142(a)There was no dental exam for individual #1 since admission on 3/31/17. An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. In order to be in compliance with 55 PA Code Chapter 6400.142 (a), the Program Specialist will make sure that all adult residential clients have a dental examination completed annually. Moving forward, the Program Specialist shall implement this policy as part of the health needs of the individual resident in the 6400 homes. In regards to Individual # 1, a dental examination was completed prior to inspection, but the form was at the residence. This examination was completed on 9-13-2017. 12/01/2017 Implemented
6400.142(f)There was no assessment for individual #1 since admission on 3/31/17. An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. The program Specialist will create a dental hygiene plan for all individual in the residential homes, unless otherwise noted by the team that the individual has completed or achieve hygiene independence. As per individual #1 the plan has been completed. The implementation of this plan will be carryout by the direct support staff on a daily basis. 11/30/2017 Implemented
6400.151(a)Staff #1 was hired on 9/22/17 and had not yet had a physical completed. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. In order to comply with ODP 55 PA Code Chapter 6400.151(a), Eastwick Family Services will implement as part of its hiring policies to include all potential hire to complete full physical Examination before coming in contact with individual participants. Going forward all potential employee will be require to submit a physical examination that is less than a year old, or be required to complete one with Eastwick Family Services. 11/30/2017 Implemented
6400.184(a)Individual #1's ISP dated 5/11/17 did not include a sign in sheet. The plan team shall participate in the development of the ISP, including the annual updates and revisions under § 6400.186 (relating to ISP review and revision). Eastwick Family Services will participate in all ISP development meetings, and will make sure there is signature sheets to verify participation. Eastwick will continue to participate in all updates meeting including, annual updates and revisions in order to comply with 6400.184(a). 11/30/2017 Implemented
6400.186(a)Individual #1's record contained one 90 day review of the ISP dtaed 5/11/17 but did not cover the goals from that plan. The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. In order to comply with ODP 55 Pa Code Chapter 6400.186(a), Eastwick Family Services will implement an ISP policy that requires review of ISP every three months or 90 days. The Program Specialist will do the three months review and update the expected outcome in the ISP ass needed. The review may be done more frequently if the individual needs changes, and such change impact the services. The review will include the expected outcome of the individual outcome plan. 12/31/2017 Implemented
6400.186(c)(1)Individual #1's record did not contain any montly reviews. The ISP review must include the following: A review of the monthly documentation of an individual's participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the residential home licensed under this chapter. In order to comply with ODP 55 PA Code Chapter 6400.186(c)(1), Eastwick Family Services will complete a monthly review of all ISP,. The review will be in line with the outcome summary of the plan, it will include the progress or lack of progress of each individual in the residential licensed home. 12/31/2017 Implemented
SIN-00095382 Renewal 05/09/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.101The swing door on the basement exit was difficult to open, creating a potential obstructed egress.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. Who will be responsible: The Program Specialist will be responsible for the plan of correction What will be corrected: Eastwick Family Services will replace the swing door on the basement exit of 7139 Radbourne Rd, Upper Darby, Pa, 19082 to ensure that it is easily accessible with a new door. A certified carpenter will install the new swing door and will make sure that it is easy to open. When will the Plan of Correction be implemented: This violation will be corrected on 06/30/2016 Plan to prevent future occurrence: The Program Specialist will conduct a monthly monitoring of all 6400 homes to make sure that all stairways, halls, doorways, passageways and exits are completely unobstructed and are in line with 55 PA CODE CHAPTER 6400.101 . A Monthly Maintenance checklist form will be utilized and filed for record keeping purposes. In the event the findings of the inspection show that there is a maintenance issue, arrangements will be made with certified professionals to correct the issue the same day. 06/30/2016 Implemented
SIN-00084544 Initial review 10/06/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(a)The shower did not have water pressure.A home shall have hot and cold running water under pressure. Eastwick Family Services replaced the shower knob and tested it to make sure it is fully functioning. The water pressure is working as specified and in accordance with 55 PA code Chapter 6400.68.The water temperature has also been monitored and is found to be within 55 PA Chapter 6400.68 guidelines as well. The Residence Manager and or Direct Support Staff will do a weekly check to ensure the shower is functioning properly, and will also test for water pressure and temperature on a daily basis. 10/07/2015 Implemented
6400.77(b)A thermometer was 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 a thermometer and placed it in the first aid kit box. 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 and or the Direct Support Staff will be responsible for making sure this plan of action is completed. 10/07/2015 Implemented