Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00245831 Renewal 06/12/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)Floors, walls, ceilings and other surfaces shall be free of hazards. The exterior deck located off of the second floor bedroom occupied by Individual #2 had loose boards that were missing nails, moved and lifted up when walked on and could pose a safety hazard. The deck provides access to exterior stairs that lead to the ground at the rear of the home, and is an evacuation route from the second floor of the home. Floors, walls, ceilings and other surfaces shall be free of hazards.Maintenance was made aware of this concern and will be repairing any loose boards no later than 7/1/24. 07/01/2024 Implemented
6400.112(e)A fire drill shall be held at least every six months during sleeping hours. A fire drill during sleeping hours was held on 9/30/2023 at 11:50 PM, and the next drill during sleeping hours was held on 4/03/2024 at 12:00 AM. The time span between the two drills was seven months.A fire drill shall be held during sleeping hours at least every 6 months. The plan of correction listed below was put into place on 1/1/24, following Dayspring¿s licensing inspection on 12/22/23. When this plan of correction was put into place, the Director of Operations and Director of Quality and Compliance did not realize that the new fire drill schedule would cause the first asleep drills in 2024 to be slightly late in some of the programs. Currently, the asleep drills are in compliance. There was an asleep drill on 4/3/24 at 12:00am and the next asleep drill is scheduled for 10/1/24 at 2:00am. PREVIOUS POC: The Director of Operations created a fire drill schedule for 2024 that went into effect on 1/1/24. The new schedule outlines a specific day and time that the fire drill must be conducted each month. After the drill is completed, the Site Supervisor is expected to review the fire drill documentation within 1 business day. If there are any issues with the fire drill, the Site Supervisor will assign staff to re-do the drill within 24 hours. Any issues with the fire drill will be immediately reported to the Program Manager and/or Director of Operations so the management team can evaluate the situation and address any potential safety concerns. All fire drill records will be sent to the office with the end of month paperwork each month for the Director of Operations or the Program Manager to complete a final review. This new schedule and review system will ensure that the drills are being completed within the correct timeframes, are documented accurately, and repeated promptly if there are any issues. 01/01/2024 Implemented
6400.32(r)Individual #1's current Individual Support Plan (ISP), last updated on 5/24/2024, states that the individual "has a door lock and knows how to manipulate it." The ISP did not state that the individual had declined a door lock. The individual's bedroom door did not have a functioning door lock at the time of the inspection. The door had an older-style skeleton key lock which had been filled in to disable the locking mechanism as keys were not available for the lock.An individual has the right to lock the individual's bedroom door.The Director of Quality and Compliance audited all door locks in August 2023. At that time, it was identified that Individual #1's ISP stated that he had a lock; however, he did not have a functioning lock on his bedroom door, nor did he ever express interest in a lock. The Director of Quality and Compliance reported this discrepancy to the Supports Coordinator, the previous Site Supervisor and the previous Program Manager upon discovery. At that time, the Supports Coordinator, Site Supervisor and Program Manager were to have a team meeting with Individual #1 to determine if he would like to have a lock so the ISP or lock could be updated. It is unknown if this meeting ever occurred and those members of Individual #1's team have since left. The Director of Quality and Compliance reached out to Individual #1's current team following licensing inspection to request that this concern be taken care of. It was determined that Individual #1 is not interested in having a lock on his bedroom door. Additionally, he is declining with dementia and the team feels that it would be a health and safety hazard for him to have a lock on his door. His ISP was updated on 6/25/24. 06/25/2024 Implemented
SIN-00235625 Renewal 12/19/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(d)The fire drill conducted on 3/14/23 at 1:00 am recorded an evacuation time of 6 minutes and 23 seconds. This exceeds the requirement. 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 employe 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. At the time this drill was conducted, one of the individuals in the home was recovering from a major injury and was not able to transfer or ambulate as quickly as he normally can. This is likely what impacted the evacuation time of this fire drill. Also, during this time the house was in transition of supervisors so a thorough review of the fire drill may have been missed, resulting in the fire drill not being repeated. Since this occurred, no other fire drills have exceeded 2.5 minutes. All Site Supervisors and the Program Manager were retrained on fire drill requirements on 1/15/24. 01/01/2024 Implemented
6400.112(h)The fire drill conducted on 11/30/23 at 7:42 pm did not include the meeting place as this section of the form was left blank. Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill.This was a simple oversight when the Site Supervisor reviewed the fire drill. Thankfully, every other fire drill within the last year has included the meeting place. This citation was addressed directly with the Site Supervisor of this home. All Site Supervisors and the Program Manager were retrained on fire drill requirements on 1/15/24. 01/01/2024 Implemented
SIN-00215997 Renewal 12/26/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(c)Poisons shall be stored in their original labeled container. A spray bottle containing a clear liquid was found with a hand-written label stating "hydrogen peroxide" over the original label that stated that the bottle contained Zep cleaning/disinfecting solution. Two bottles were found in the second floor kitchen of the home with a red-colored cleaning solution. One of the bottles had an original label that stated it contained "Dawn antibacterial apple blossom scent" dish detergent, and the other bottle was labeled "Novo lemon-scented antibacterial foaming hand soap."Poisonous materials shall be stored in their original, labeled containers. During the height of the COVID-19 pandemic when cleaning supplies and N95 masks were difficult to obtain, staff were spraying their N95 masks with hydrogen peroxide to sanitize them between uses. Due to the spray bottles of hydrogen peroxide not being available, hydrogen peroxide needed to be poured into another spray bottle. The team is unsure what the red liquid was, but believes it also may have been cleaning solution prepared during the height of COVID-19 when cleaning materials were not easily accessible. This home has two kitchens, one on each floor. The upstairs kitchen where these items were stored is rarely used, so these items were overlooked and never disposed of. The hydrogen peroxide and red cleaning solution were disposed as soon as they were found during the licensing inspection. 12/27/2022 Implemented
6400.67(a)Surfaces shall be in good repair. An upper cabinet in the second-floor bathroom had a door with a broken hinge.Floors, walls, ceilings and other surfaces shall be in good repair. The management team was not aware of the broken hinge until the inspector discovered it during the licensing inspection. The hinge was repaired on 12/21/22. 12/21/2022 Implemented
6400.110(e)The home has three stories, and the smoke detectors were not 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. This home is a unique home that was split into two separate units in the past, upstairs and downstairs. These units were licensed separately up until September 2021 when Dayspring decided to license them as one home instead of two. The previous Compliance Manager was responsible for ensuring that when this licensed changed all regulations were still being met. Dayspring¿s Office Manager contacted an electrician to assess the home and evaluate if hardwiring the alarms is possible. The electrician visited the home on 1/12/23 and determined that hardwired smoke alarms could be installed. At this time, the electrician has ordered materials and will be scheduling the installation when the supplies are received. Barring any unforeseen circumstances, we anticipate this job to be complete by 2/28/23. 02/28/2023 Implemented
6400.46(b)Staff #2 did not receive annual fire safety training. Staff #2 completed fire safety training on 1/15/21 and not again until 3/13/22. This will be a violation for the training being late.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).The Dayspring team is well aware that training has been a deficiency of ours over the last few years for various reasons. The Human Resources Department has worked diligently on staff training over that last year and has made great progress with getting staff training back on track; however, there have still been some minor training issues as the team has worked on improving our staff training. At this time, the staff identified is current in fire safety training. 02/13/2023 Implemented
SIN-00201794 Unannounced Monitoring 03/02/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(c)Staff #4 did not receive training in first aid techniques prior to working with individuals.Program specialists and direct service workers and at least one person in a vehicle while individuals are being transported by the home shall be trained before working with individuals in first aid techniques.In response to citations received during our 2020 and 2021 inspections, Dayspring HR department and management team began the process of reviewing and revising our training curriculums as well as the training process/program to ensure that all required training topics as listed in chapters 6100 and 6400 regulations are included in the training provided to all staff. The new training packets have been completed and the revised training program has now been implemented. The Annual Employee Development Training Packet encompasses all required annual training areas to ensure compliance with 6100 and 6400 regulations. The training packet includes a list of all required annual trainings with instructions on how each training is to be completed- instructor led/blended, on demand etc., what documentation is needed to show the training was successfully completed- test after training, training summary or certificate etc. The packet is an all-inclusive resource for staff to utilize to complete their trainings and ensure that all training requirements are met. A thorough review of all employee annual training records was conducted to identify areas of non-compliance. The Employee Development/HR department contacted employees whose records showed they did not meet all annual training requirements. The HR department explained the new training process and program that has been implemented and provided each employee with an Annual Employee Development Training Packet. The expectations for completing all outstanding trainings and submitting documentation of completed trainings to HR by the specified deadline was reviewed and explained to each employee. The Employee Development/ HR departments have been receiving documentation of completed trainings from employees and are tracking the progress for each employee to ensure that all employee records meet the regulatory requirements and are in compliance within 30 days. Dayspring received the POC from ODP on 3/18/22 and has implemented a plan to ensure all annual training requirements are met and all employee records are in compliance by 4/15/22. The employees from the sample reviewed during the inspection on 3/2/22 have completed the following annual trainings Staff # 4 completed this training on 11/6/20 04/15/2022 Implemented
SIN-00197666 Renewal 12/13/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)There was no record of the agency completing a self-assessment. (repeat violation 1/12/21)The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. In response to the citation received in 2020, a self-assessment schedule was developed to track when assessments are to be completed for all programs. The Compliance Manager will review that schedule to ensure that the information is accurate and will make any needed corrections based on the current COC dates for all programs. The new schedule will then be used to track when all self ¿assessments are required to be completed. The Compliance Manager and Director of Operations will then develop an improved process/system that ensures the assessments are completed within the required timeframes. 02/28/2022 Implemented
6400.52(c)(1)Staff #5 did not receive annual training on the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships during the 7/1/20-6/30/21 training year. (repeat violation 1/12/21)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 response to citations received during last year¿s inspection, Dayspring management began the process of reviewing and revising our orientation and annual training curriculums as well as the training process/program to ensure that all required orientation/annual training topics as listed in chapter 6400 regulations are included in the training provided to all staff. Due to unforeseen circumstances we were unable to accomplish this task in its entirety and the training curriculum and training process/program are still being revised. An orientation training packet and an annual training packet are being developed that will be provided to all staff at the time of hire and annually thereafter. The training packets will include a list of all required orientation/annual trainings with instructions on how each training is to be completed- in person, on line etc., what documentation is needed to show the training was successfully completed- test after training, training summary etc. The packets will be an all-inclusive resource for staff to consult throughout the training year to ensure that all training requirements are met. 02/28/2022 Implemented
6400.52(c)(3)Staff #5 did not receive annual training on Individual rights during the 7/1/20-6/30/21 training year. (repeat violation 1/12/21)The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.In response to citations received during last year¿s inspection, Dayspring management began the process of reviewing and revising our orientation and annual training curriculums as well as the training process/program to ensure that all required orientation/annual training topics as listed in chapter 6400 regulations are included in the training provided to all staff. Due to unforeseen circumstances we were unable to accomplish this task in its entirety and the training curriculum and training process/program are still being revised. An orientation training packet and an annual training packet are being developed that will be provided to all staff at the time of hire and annually thereafter. The training packets will include a list of all required orientation/annual trainings with instructions on how each training is to be completed- in person, on line etc., what documentation is needed to show the training was successfully completed- test after training, training summary etc. The packets will be an all-inclusive resource for staff to consult throughout the training year to ensure that all training requirements are met. 02/28/2022 Implemented
SIN-00181610 Renewal 01/11/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)There was not a self assessment of the home completed 3-6 months prior to the expiration date of the agency's certificate of compliance.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. Dayspring Management staff will be retrained in the licensing requirements and expectations to maintain compliance with regulation 6400.15(a) by 3/12/21. Additionally, the Compliance Manager will develop a schedule to track when all self- assessments for Dayspring are to be completed. The current Certificate of Compliance for Dayspring 6400 programs is dated 9/23/20 - 9/23/21. The self- assessments for these programs will be completed between March 2021 and June 2021 to ensure compliance with this regulation. Director of Operations and the Compliance Manager will be responsible to ensure that the self- assessments are completed. The Compliance Manager will be responsible for continued monitoring to ensure ongoing compliance. 03/12/2021 Implemented
6400.141(c)(9)The physical dated 7/1/20 did not include a prostate examination.The physical examination shall include: A prostate examination for men 40 years of age or older. Dayspring Management staff will be retrained in the licensing requirements and expectations to maintain compliance with Chapter 6400 regulation 6400.141(c) (9) by 3/12/21. Individual # 1¿s Program Specialist/ Supervisor will be responsible for scheduling a prostate exam with his PCP as soon as possible. Documentation of that exam will be kept in the medical records at the home. The Program Specialist will be responsible to submit all individuals physical examination forms to the Director of Operations and the Compliance Manager for review within 5 days of the physical being completed. The Director of Operations and the Compliance Manager will be responsible for ensuring ongoing compliance. 03/12/2021 Implemented
6400.34(a)The record of Individual #1 contained a signed copy of his rights dated 1/27/20. This document did not contain a review of all rights as specified in 6400.32. A review of all rights as outlined is required. Rights missing from the signed documentation included: Chapter 6400.32. (e) An individual has the right to make choices and accept risks. (f) An individual has the right to refuse to participate in activities and services. (k) An individual has the right to participate in the development and implementation of the individual plan. (n) An individual has the right to unrestricted and private access to telecommunications. (p) An individual has the right to choose persons with whom to share a bedroom. (r) An individual has the right to lock the individual's bedroom door. (t) An individual has the right to access food at any time. (s) An individual has the right to have a key, access card, keypad code or other entry mechanism to lock and unlock an entrance door of the home.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.Dayspring policy 6.6 Program Participants Rights, Responsibilities and Resources will be updated and revised to include the updated regulatory rights as described in 6400.34 (a). The updated and revised policy will then be reviewed with all individuals and the documentation of that review will be kept in the records at the home. The policy will be reviewed with all individuals annually thereafter. The Compliance Manager and Director of HR will be responsible to ensure that Dayspring policy 6.6 Program Participants Rights, Responsibilities and Resources is updated and revised by 3/12/21. The Program Specialist and Director of Operations will be responsible to ensure that policy is then reviewed with all individuals and that the documentation is kept in the record at the home. The Program Specialist, Compliance Manager and Director of Operations will be responsible to ensure ongoing compliance. 03/12/2021 Implemented
6400.52(c)(1)Staff #1 did not have the required annual training to encompass the following area: the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.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.The current Dayspring annual training curriculum will be reviewed and revised to ensure that all required annual training topics as listed in 6400.52 (c)(1) are included in the annual training provided to all employees. The Director of HR and the Compliance Manager will be responsible to ensure that the Dayspring annual training curriculum is updated and revised by 3/12/21. All current employees will receive training in the updated training curriculum during the current training year. The Director of HR will be responsible to ensure that the training occurs for all new employees initially. The Program Specialist and Director of Operations will be responsible to ensure training occurs annually thereafter. The Compliance Manager and Director of HR will be responsible to ensure ongoing compliance 03/12/2021 Implemented
6400.52(c)(2)Staff #1 did not have the required annual training to encompass the following area: 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.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.The current Dayspring annual training curriculum will be reviewed and revised to ensure that all required annual training topics as listed in 6400.52 (c)(2) are included in the annual training provided to all employees. The Director of HR and the Compliance Manager will be responsible to ensure that the Dayspring annual training curriculum is updated and revised by 3/12/21. All current employees will receive training in the updated training curriculum during the current training year. The Director of HR will be responsible to ensure that the training occurs for all new employees initially. The Program Specialist and Director of Operations will be responsible to ensure training occurs annually thereafter. The Compliance Manager and Director of HR will be responsible to ensure ongoing compliance. 03/12/2021 Implemented
6400.52(c)(3)Staff #1 did not have the required annual training to include: Individual Rights.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.The current Dayspring annual training curriculum will be reviewed and revised to ensure that all required annual training topics as listed in 6400.52 (c)(3) are included in the annual training provided to all employees. The Director of HR and the Compliance Manager will be responsible to ensure that the Dayspring annual training curriculum is updated and revised by 3/12/21. All current employees will receive training in the updated training curriculum during the current training year. The Director of HR will be responsible to ensure that the training occurs for all new employees initially. The Program Specialist and Director of Operations will be responsible to ensure training occurs annually thereafter. The Compliance Manager and Director of HR will be responsible to ensure ongoing compliance. 03/12/2021 Implemented
6400.52(c)(4)Staff #1 did not have the required annual training to encompass the following area: Recognizing and reporting incidents.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.The current Dayspring annual training curriculum will be reviewed and revised to ensure that all required annual training topics as listed in 6400.52 (c)(4) are included in the annual training provided to all employees. The Director of HR and the Compliance Manager will be responsible to ensure that the Dayspring annual training curriculum is updated and revised by 3/12/21. All current employees will receive training in the updated training curriculum during the current training year. The Director of HR will be responsible to ensure that the training occurs for all new employees initially. The Program Specialist and Director of Operations will be responsible to ensure training occurs annually thereafter. The Compliance Manager and Director of HR will be responsible to ensure ongoing compliance. 03/12/2021 Implemented
6400.52(c)(5)Staff #1 did not have the required annual training to encompass the area: The safe and appropriate use of behavior supports if the person works directly with an individual.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual.The current Dayspring annual training curriculum will be reviewed and revised to ensure that all required annual training topics as listed in 6400.52 (c)(5) are included in the annual training provided to all employees. The Director of HR and the Compliance Manager will be responsible to ensure that the Dayspring annual training curriculum is updated and revised by 3/12/21. All current employees will receive training in the updated training curriculum during the current training year. The Director of HR will be responsible to ensure that the training occurs for all new employees initially. The Program Specialist and Director of Operations will be responsible to ensure training occurs annually thereafter. The Compliance Manager and Director of HR will be responsible to ensure ongoing compliance. 03/12/2021 Implemented
SIN-00162980 Renewal 09/20/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)The doors on the cabinets located above the kitchen stove had a heavy build-up of grease and grime.Clean and sanitary conditions shall be maintained in the home. Dayspring Management staff will be retrained in the licensing requirements and expectations to maintain compliance with regulation 6400.64(a) by 11/29/2019. Additionally, the cabinets in the kitchen were cleaned as of 10/23/19 and pictures of the cabinets will be sent to ODP licensing to show the completed work. To ensure ongoing compliance, the Supervisors of all programs will be expected to complete the Residential Site Review form on a quarterly basis. The Program Managers will be responsible to complete the Program Manager Checklist on a monthly basis. The Director of Operations will review those forms/ checklists as they are completed and will ensure that any issues identified are addressed and resolved or corrected. The Quality Manager will be responsible to review/ complete the Residential Site Review form for all programs on a quarterly basis as well. 11/29/2019 Implemented
6400.67(b)The walls in the bathroom were peeling throughout the room. Wallpaper had been applied over the original tile by a previous owner, and paint had been applied over the wallpaper. The wallpaper and paint were peeling. Floors, walls, ceilings and other surfaces shall be free of hazards.Dayspring Management staff will be retrained in the licensing requirements and expectations to maintain compliance with regulation 6400.67(b) by 11/29/2019. Additionally, a contractor is scheduled to come to the home on 10/25/19 to give an estimate for the repairs that need to be completed in the bathroom. Once the work is completed, pictures will be sent to ODP as documentation of work being completed. We have a goal date of 12/31/19 to have all work completed. The director of Operations and Quality Manager will be responsible to ensure that the repairs are completed and the documentation to show the completed repairs is sent to ODP licensing. 12/31/2019 Implemented
SIN-00140628 Renewal 08/29/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.73(a)There are several steps leading up from the basement to bilco doors on ground level. It would be utilized as an exit should staff or individuals be in the basement for any reason such as laundry. There is no handrail in the stairway. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. Dayspring has contracted with a local contractor to have a railing installed on the basement staircase. We are waiting to receive an estimate for the work. The work is expected to be completed by 11/30/18. The Operations Manager and CEO will be responsible for ensuring that the work is completed by 11/30/18 to ensure compliance with regulation 6400.73(a). 11/30/2018 Implemented
6400.104The notification to the local fire department was not accurate. There are two Dayspring Homes apartments in this building. Each apartment has two individuals living in it for a total of four individuals in the building. Each apartment is licensed separately and each has its own letter to the fire department. Each letter states there are four individuals living in that setting, which implies there are eight people total residing in the building.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. The notification letter to the local fire department for 1541 and 1543 Schuylkill Avenue will be updated to reflect the current needs and living situation for participants living in each apartment and will then be sent to the local fire department by 11/30/18. The CEO will be responsible for updating these letters and sending them to the fire department. The updated letters will also be placed in the fire drill log book in each apartment. These requirements will be reviewed with Dayspring Management staff by 11/30/18. To ensure ongoing compliance with regulation 6400.104, the Operations Manager will review fire notification letters any time there is a change to participant needs or living arrangements. 11/30/2018 Implemented
SIN-00105286 Renewal 11/15/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.168(d)Staff #1 had his initial medication administration practicum with Daysprings Homes on 2/27/2015. He did not have a practicum again until 4/7/2016, which exceeds the annual requirement.A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually. Dayspring Homes currently has one Medications Administration Trainer responsible for maintaining all staff medication administration training requirements. Dayspring Homes will have 2 additional Medication Administration Trainers trained by the end of 2017. Training will begin for the new trainers by 1/31/2017. The online portion of the training is to be completed by 2/28/2017. The face to face portion of the training will be scheduled to be completed as soon as possible according to the dates set by the Medication Administration Train the Trainer program. (We have not yet received the dates for the trainings scheduled for 2017). The Operations Manager will be responsible to ensure that all online training is completed by 2/28/2017 ; and that the face to face portion of the training is scheduled as soon as the dates are received from the Medication Train the Trainer Course program. 02/28/2017 Implemented
SIN-00086249 Renewal 10/21/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.82(f)The bathroom did not contain any soap. Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. The provider will ensure that hand soap is available in all Residential Community Home bathrooms. Additionally, the provider will provide re-training of all program specialist and supervisory staff in the regulatory requirements relating items required to be in bathrooms by December 1, 2015. 12/01/2015 Implemented
SIN-00122693 Renewal 10/31/2017 Compliant - Finalized
SIN-00124279 Renewal 10/31/2017 Compliant - Finalized