| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.32 | The rights document that was signed by Ind. #1 on 12/26/22 did not include rights regarding locks on bedroom doors, providing a key to the home or the right to have access to food at all times. | An individual may not be deprived of rights.
| In regards to violation 55 PA Code Chapter 6400.32 Eastwick Family Services Program Specialist has updated our Individual Rights policy, and all clients will sign it by 9/11/2023. |
09/11/2023
| Implemented |
| 6400.68(b) | The water in the bathtub was measured at 146.3*F. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | In regards to violation 55 PA Code Chapter 6400.68(b) Eastwick Family Services has instructed our contractor to install a mixer on the tub to ensure the water temperature never goes above 120 degrees. The mixer will be installed on 9/15/2023. |
09/15/2023
| Implemented |
| 6400.141(c)(13) | Ind. #1 annual physical dated 2/10/23 did not indicate allergies. The section on the form was left blank. | The physical examination shall include: Allergies or contraindicated medications. | In regards to violation 55 PA Code Chapter 6400.141(c)(13) Eastwick Family Services Program Specialist has contacted Individual #1 Primary Care Doctor to update the physical form to ensure nothing is left blank. The physical was updated on 8/25/2023 |
08/25/2023
| Implemented |
| 6400.142(f) | Ind. #1 record did not contain a dental hygiene plan. | 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 violation 55 PA Code Chapter 6400.142(f) Eastwick Family Services Program Specialist has contacted the dentist to ensure that a dental hygiene plan can be discussed at his next dental appointment to properly update his file. |
09/20/2023
| Implemented |
| 6400.181(e)(2) | Ind. #1 assessment dated 1/16/23 does not address dislikes. Under the section in the document, it is recorded as N/A. | The assessment must include the following information: The likes, dislikes and interest of the individual. | In regards to violation 55 PA Code Chapter 6400.181(e)(2) Eastwick Family Services Program Specialist has updated Individual #1 assessment to ensure that all sections are completed. |
09/11/2023
| Implemented |
| 6400.181(e)(14) | Ind. #1 assessment dated 1/16/23 does not address ability to swim or information regarding water safety. | 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 violation 55 PA Code Chapter 6400.181(e)(14) Eastwick Family Services Program Specialist has updated individual #1 assessment to ensure water safety and their ability to swim. |
09/20/2023
| Implemented |
| 6400.165(b) | The PRN medication (ENEMA) is not in the Ind. Terence Eason med box at time of inspection. | A prescription order shall be kept current. | In regards to violation 55 PA Code Chapter 6400.165(b) Eastwick Family Services House Manager has called the pharmacy to get the PRN filled and placed in the medication box for individual #1 to ensure all meds are kept current. |
07/27/2023
| Implemented |
| 6400.166(b) | Medication (DOCUSATE SOD 100mg) is not sign as administered for the 8am dose on 07/24/2023. | 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 55 PA Code Chapter 6400.166(b) Eastwick Family Services Program Specialist has retrained our staff on the importance of medication record to ensure all medications are recorded at the time it was administered. |
08/01/2023
| Implemented |
| 6400.213(1)(i) | Ind. #1 record did not address his religious affiliation. There was a place on the face sheet but the section was left blank. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | In regards to violation 55 PA Code Chapter 6400.213(1)(i) Eastwick Family Services Program Specialist has updated the Face Sheet to ensure individiual #1 religion affiliation is recorded. |
09/20/2023
| Implemented |