| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.80(b) | The grass in the front and back yards was 2 feet high. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | Plan of Correction:
PDSI implemented the following:
1. PDSI received a copy of an invoice from the lawn company that services 1616 Yorktowne Drive. The lawn was mowed May 4, 2016; May 9, 2016; May 15, 2016; May 24, 2016 & May 31, 2016 in the month of May 2016 (Attachment #22).
2. The gate was removed from the fence in the backyard to ensure there is no problem entering and exiting through the yard. Per the lawn maintenance service, they were having a difficult time getting their equipment through the gate to complete this portion of the yard, therefore the gate was removed in order for easier access (Attachment #23).
3. The PDSI Community Home Review was revised to include a question regarding yard maintenance when completing home reviews (Attachment # 17).
4. Mangers were trained on the revised version of the Community Home Review on 6/10/2016 & 6/13/2016 (Attachment #18).
5. Validation- A community home review was completed on 6/14/2016 for Enfield Drive and 6/13/2016 for Thornbridge Rd & Yorktowne Drive (Attachment #19). |
07/19/2016
| Implemented |
| 6400.101 | The gate in the back yard could not open entirely due to the grass being too high. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| Plan of Correction:
PDSI implemented the following:
1. PDSI received a copy of an invoice from the lawn company that services 1616 Yorktowne Drive. The lawn was mowed May 4, 2016; May 9, 2016; May 15, 2016; May 24, 2016 & May 31, 2016 in the month of May 2016 (Attachment #22).
2. The gate was removed from the fence in the backyard to ensure there is no problem entering and exiting through the yard (Attachment #23).
3. The PDSI Community Home Review was revised to include a question regarding yard maintenance and egresses when completing home reviews (Attachment # 17).
4. Mangers were trained on the revised version of the Community Home Review on 6/10/2016 & 6/13/2016 (Attachment #18).
5. Validation- A community home review was completed on 6/14/2016 for Enfield Drive and 6/13/2016 for Thornbridge Rd & Yorktowne Dr (Attachment #19). |
07/19/2016
| Implemented |
| 6400.104 | The fire notification letter sent 2/7/2013 stated individual #2 is independent with evacuation; however he refused to participate 4 out of 5 drills this year | 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.
| Plan of Correction:
PDSI implemented the following:
1. Program Specialists were trained on PDS fire drills and individual fire drill department letters on 6/10/2016 & 6/9/2016 (Attachment #20).
2. The fire letter was updated to include accurate information in regards to individual #2¿s evacuation independence. The letter was sent to the fire department on 6/9/2016 (Attachment #21).
3. PDSI¿s Does it Match form was updated on 6/7/2016 to include a section for program specialists to review their fire drills and ensure all documents match the independence level they are showing per recent fire drills (Attachment #4).
4. Program Specialists were trained on the use of the Does it Match form to ensure all of their documentation matches throughout all books (Attachment #5).
5. Validation- Does it Match forms were completed for Individual #1, Individual #2 as well as a third individual DS (Attachment #6). |
07/19/2016
| Implemented |
| 6400.106 | The furnace was inspected on 7/28/2014 and not again until 8/14/2015. | 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.
| Plan of Correction:
PDSI implemented the following:
1. PDSI formulated a Furnace Inspection Procedure on 6/6/2016 to outline when furnace inspections will be scheduled and completed (Attachment #13).
2. Managers were retrained on 6400 regulations in terms of furnace inspections and PDSI¿s Furnace Inspection Procedure on 6/10/2016 & 6/13/2016 (Attachment #14).
3. Furnace inspections for 2016 were immediately scheduled to be completed within the month of June 2016 (Attachment #15).
4. Furnace inspections were completed for Enfield, Thornbridge, as well as the rest of the homes in June & July 2016 (Attachment #16).
5. The PDSI Community Home Review was revised to include a question regarding furnace inspections when completing home reviews (Attachment # 17).
6. Mangers were trained on the revised version of the Community Home Review on 6/10/2016 & 6/13/2016 (Attachment #18).
7. Validation- A community home review was completed on 6/14/2016 for Enfield Drive and 6/13/2016 for Thornbridge Rd & Yorktowne Dr (Attachment #19). |
07/19/2016
| Implemented |