Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.67(a) | The dresser located in Individual 2's bedroom was missing knobs. | Floors, walls, ceilings and other surfaces shall be in good repair. | In regards to violation cited in code 55 PA Code Chapter 6400.67(a) Eastwick Family Services CEO has purchased a new dresser for Individual 2. |
08/30/2022
| Implemented |
6400.67(b) | The dryer filter had lint the size of a golf ball. | Floors, walls, ceilings and other surfaces shall be free of hazards. | In regards to violation cited under code 55 PA Code Chapter 6400.67(b)Eastwick Family Services House Manager has cleaned the lint trap in the dryer and has retrained all the staff on the importance of keeping it clean. |
07/30/2022
| Implemented |
6400.77(b) | The first aid kit did not contain a thermometer. | 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 violation cited under code 55 PA Code Chapter 6400.77(b) Eastwick Family Services House Manger has purchased a Thermometer to be placed into the Aid Kit. |
08/15/2022
| Implemented |
6400.77(c) | A first aid manual was not located in the first aid kit. | A first aid manual shall be kept with the first aid kit. | In regard to violation cited under code 55 PA Code Chapter 6400.77(c) Eastwick Family Services House Manager has inserted a manual in the first Aid kit. |
08/15/2022
| Implemented |
6400.101 | The basement back door exit is obstructed, staff stated the exit is under construction. There is no pathway leading out. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| In regards to violation cited under code 55 PA Code Chapter 6400.101 Eastwick Family Services CEO has hired a contractor to create a pathway leading out the backdoor so that the back door is not obstructed. |
11/30/2022
| Implemented |
6400.104 | Notifications 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 under code 55 PA Code Chapter 6400.104 Eastwick Family Services Program Specialist has revised and resent the letters to the fire department dated and stating the location of the bedroom for each individual who needs assistance evacuating. |
08/12/2022
| Implemented |
6400.144 | Individual 1's Medication PROCTOFOAM HC 1% was signed as administered by staff, when questioned staff admittedly stated the medication was not administered as prescribed. | 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 under code 55 PA Code Chapter 6400.144 Eastwick Family Services Program Specialist has retrained all staff on the importance of medication administration to prevent any future errors. |
10/10/2022
| Implemented |
6400.15(b) | The following areas were not measured for compliance or recorded all were left blank on the self-assessment: a) 66-lighting in the home to assure safety was not measured-left blank on assessment; b) 67(a)-(b)-surfaces in the home not measured to be in good repair, and free of hazards-left blank on assessment; c) 72(a)-(c)-screens, windows, and doors, not measured for compliance-left blank on assessment. | (b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance. | In regards to violation cited under code 55 PA Code Chapter 6400.15(b) Eastwick Family Services CEO has retrained all management on Self Inspection Tools and the importance of filling them out completely. |
08/15/2022
| Implemented |
6400.166(b) | All 8pm prescribed medications for Individual 1 were not signed as administered on the MAR. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | In regards to violation cited under code 55 PA Code Chapter 6400.166(b) Eastwick Family Services medication trainer has retrained staff on medication importance and how to properly record medication on the MARS |
10/10/2022
| Implemented |