Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.68(b) | Hot water measured in the tub/shower exceeded 120*F; it read 128.3*F. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | In regard to violation cited in code 55 PA Code Chapter 6400.68(b) Eastwick Family Services CEO has contacted the leasing office of the apartment complex and requested the Maintenace tech lower the temperature of the hot water. The tech lowered the water temperature, and it is now NOT exceeding 120F. |
08/12/2022
| 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 Manager bought a thermometer for the first aid kit. |
08/12/2022
| 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 all letters to the fire department. They were dated and stated the exact location of all bedrooms of individuals needing assistance evacuating. |
08/12/2022
| Implemented |
6400.151(a) | Staff Member 1 did not have a physical within a year prior to their employment start date. They started on 3/25/22, and their only physical on file is dated 7/11/22. Staff Member 5's file also does not contain record of a physical from within a year prior to their hire date of 12/8/21 nor from any time after hire. Staff Members 2, 3, and 4 have not had timely physicals; their most recent two physicals were greater than two years apart: Staff Member 2's most recent physicals were dated 1/13/20, and 7/6/22; Staff Member 3's most recent physicals in their file are dated 4/10/19 and 7/7/21; Staff Member 4's most recent physicals are dated 1/23/20 and 7/7/22. | 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 violation cited under code 55 PA Code Chapter 6400.151(a) Eastwick Family Services has ensured all staff now have physicals, Our Human Resource Specialist was retrained on the regulations and in the future will not allow any staff member to work with individuals before having a physical. |
08/12/2022
| Implemented |
6400.44(c)(2) | Staff Member 5 does not have the documented experience required to be a program specialist. The agency provided their bachelor's degree, but their resume does not clearly demonstrate two years' experience working directly with individuals with intellectual disabilities or autism. | A program specialist shall have one of the following groups of qualifications: A bachelor's degree from an accredited college or university and 2 years of work experience working directly with individuals with an intellectual disability or autism. | in regards to violation cited under code 55 PA Code Chapter 6400.44(c)(2) Eastwick Family Services has hired a new Program Specialist with the appropriate credentials to meet the regulation guidelines. |
09/12/2022
| Implemented |
6400.46(b) | The agency does not have documentation that indicates a fire safety expert provided the following staff fire safety trainings: Staff Member 1's on 3/25/22; Staff Member 2's on 9/10/21; Staff Member 3's on 9/17/21; Staff Member 4's on 9/10/21; and Staff Member 5's on 12/15/21. The most recent fire safety expert credential documentation on file is Staff Member 6's, dated 7/14/22. The agency indicated that the staff file and credentials of the previous trainer, Staff Member 7, were removed from the agency after their employment ended and are not available. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | In regard to violation cited under code 55 PA Code Chapter 6400.46(b) Eastwick Family Services CEO has ensured the office manager is a Fire Safety Trainer and will continue to provide the training to staff. The CEO also has a copy of her training for his own record keeping to prevent errors in the future. |
08/30/2022
| Implemented |
6400.46(d) | Staff Member 2's first aid and CPR training are out of date. Their file included Red Cross training from 10/29/19 with a two year expiration, as well as online Relias trainings in first aid and a CPR refresher from 3/28/22. First aid and CPR trainings must have an in-person component. Staff Member 3's CPR and first aid training are out of date. Their record contains a Red Cross training from 10/29/19 with a two year expiration. Staff Members 4 and 5 do not have current first aid or CPR training. Staff Members 4 and 5's documentation was requested but not submitted. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | In regards to violation cited under code 55 PA Code Chapter 6400.46(d) Eastwick Family Services Human Resources has contacted a certified CPR trainer who will come and train all staff. |
12/01/2022
| Implemented |
6400.50(a) | Staff Member 2, 3, and 4's ISP implementation training documentation did not include the date on which it was completed. | Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept. | In regards to violation cited under code 55 PA Code Chapter 6400.50(a) Eastwick Family Services Human Resource Specialist has updated the ISP implementation training, so it reflects the date the training was complete. |
08/12/2022
| Implemented |
6400.52(c)(1) | Documentation provided does not clearly indicate that the CEO received training on the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships during the 2021/2022 training year. Documentation provided of a training addressing this topic on 8/12/21 lists the CEO as both the trainer and training recipient. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | In regards to violation cited under code 55 PA Code Chapter 6400.52(c)(1) Eastwick Family Services CEO has contracted with a trainer who is trained to instruct trainings on application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. this contract was signed and agreed upon on 8/26/2022. Going forward all staff will attend training with our contracted trainer. |
08/26/2022
| Implemented |
6400.52(c)(2) | Documentation provided does not clearly indicate that the CEO received training on the prevention, detection and reporting of abuse, suspected abuse and alleged abuse during the 2021/2022 training year. Documentation provided of a training addressing this topic on 8/12/21 lists the CEO as both the trainer and training recipient. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations. | In regards to violation cited under code 55 PA Code Chapter 6400.52(c)(2) Eastwick Family Services CEO has contracted with a trainer who is trained to instruct trainings on prevention, detection and reporting of abuse, suspected abuse and alleged abuse. this contract was signed and agreed upon on 8/26/2022. |
08/26/2022
| Implemented |
6400.52(c)(3) | Documentation provided does not clearly indicate that the CEO received training on individual rights during the 2021/2022 training year. Documentation provided of a training addressing this topic on 8/12/21 lists the CEO as both the trainer and training recipient. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | In regards to violation cited under code 55 PA Code Chapter 6400.52(c)(3) Eastwick Family Services CEO has contracted with a trainer who is trained to instruct trainings on individual rights this contract was signed and agreed upon on 8/26/2022. |
08/26/2022
| Implemented |
6400.52(c)(4) | Documentation provided does not clearly indicate that the CEO received training on recognizing and reporting incidents during the 2021/2022 training year. Documentation provided of a training addressing this topic on 8/12/21 lists the CEO as both the trainer and training recipient. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | In regards to violation cited under code 55 PA Code Chapter 6400.52(c)(4) Eastwick Family Services CEO has contracted with a trainer who is trained to instruct trainings on recognizing and reporting incidents. this contract was signed and agreed upon on 8/26/2022. |
08/26/2022
| Implemented |