Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00245834 Renewal 06/12/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(b)Documents provided noted that Staff #2 received fire safety training on 3/15/22 and again on 8/3/23. This exceeds the required annual time frame.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).The previous Employee Development Manager had not been accurately maintaining the annual training trackers. They also were not ensuring that trainings were being properly documented and filed in the employees training file. As of 10/3/23, the previous Employee Development Manager is no longer employed by Dayspring Homes. An HR Generalist was hired on 10/9/23 and has taken over the training department under the supervision of the Director of Human Resources. Training compliance has significantly improved since the HR Generalist began managing training. 10/09/2023 Implemented
6400.51(a)(1)Staff #1, Operations Director, has a documented hire date of 7/3/23. Certificate of completion of training on Individual Rights was dated 9/29/23. Management, program, administrative and fiscal staff persons shall complete all components of orientation within 30 days after hire.Prior to working alone with individuals, and within 30 days after hire, the following shall complete the orientation as described in subsection (b): Management, program, administrative and fiscal staff persons.The previous Employee Development Manager had not been accurately maintaining the annual training trackers. They also were not ensuring that trainings were being properly documented and filed in the employees training file. As of 10/3/23, the previous Employee Development Manager is no longer employed by Dayspring Homes. An HR Generalist was hired on 10/9/23 and has taken over the training department under the supervision of the Director of Human Resources. Training compliance has significantly improved since the HR Generalist began managing training. 10/09/2023 Implemented
SIN-00235628 Renewal 12/19/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.72(b)There were 3 office spaces across from the laundry area of the home. The first office did not have a screen in the window, the next two offices directly across from the laundry room window screens had significant rips and tears in it. Screens, windows and doors shall be in good repair. Maintenance was made aware and all damaged or missing screens were repaired or replaced by 1/3/24. The Site Supervisors and Program Manager we retrained on this regulation on 1/15/24. 01/03/2024 Implemented
SIN-00216000 Renewal 12/26/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.151(c)(3)Staff #3's physical examination completed on 6/21/2021 did not document whether the staff is free of communicable disease. The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. The member of the Human Resources Department that reviewed this physical did not notice that the communicable disease section was not completed. The physical exam form was sent back to the physician to be corrected; the corrected form was received on 12/29/22. 12/29/2022 Implemented
SIN-00201811 Unannounced Monitoring 03/02/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.52(c)(2)Staff #9 did not receive annual training in the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Child Protective Services Law (23 Pa.C.S. § § 6301---6386). Staff #7 did receive annual training in 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). Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations. (Repeat violation from 1/11/21)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 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 # 9 completed this training on 8/17/21 04/15/2022 Implemented
6400.52(c)(5)Staff #9 did not receive annual training in the safe and appropriate use of behavior supports if the person works directly with an individual. (Repeat violation from 1/11/21)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.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 # 9 will need to complete this training by 4/15/22 04/15/2022 Implemented
6400.52(c)(6)Staff #9 did not receive annual training in Implementation of the individual plan if the person works directly with an individual.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual.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 # 9 completed this training on 3/25/22 04/15/2022 Implemented
6400.169(a)Staff #9 did not complete the annual course renewal requirements for medication administration. Previous training dates are recorded as 11/3/20. (Repeat violation from 1/11/21)A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration).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 #9 will need to complete this training by 4/15/22 04/15/2022 Implemented
SIN-00197669 Renewal 12/13/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency did not complete a self-assessment of the home. (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
6400.143(a)Individual #1 has missed a gynecological exam, mammogram exam, and eye exams due to refusal to wear a mask. There is no documented attempts to train the individual about the need for health care.If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. Individual #1 was able to successfully complete her mammogram appointment on 12/17/21. She did not wear a mask during the procedure but the medical provider arranged for special precautions to be put in place so she could have the test completed. She has not yet been able to successfully attend her GYN or eye exams as of this time due to her inability to wear a mask and her medical provider not accepting her in the office without a mask. Information will be added to her current desensitization plan regarding her inability to tolerate a mask on her face and staff will document any attempts made to encourage her to wear a mask or to educate her of the need to wear a mask so she is able to receive the required care. The Program Supervisor will also contact Individual #1¿s health care providers who require her to wear a mask to receive treatment to see if alternate arrangements can be made such as scheduling to be the first or last appointment of the day or if any additional precautions can be put in place for her or the medical staff so that she can receive the required care. The Program Supervisor will also contact the Support Coordinator to ensure that the updated information regarding the inability to tolerate a mask is included in the ISP. 02/28/2022 Implemented
6400.51(b)(1)Staff #1 date of hire was 4/5/2021 and he did not have the application of person-centered practices, community integration, individual choice, and supporting individuals to maintain relationships in their orientation training record. (repeat violation 1/12/21)The orientation 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
6400.51(b)(3)Staff #1's date of hire was 4/5/2021 and did not have Individual Rights training in their orientation training records. (repeat violation 1/12/21)The orientation 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
6400.51(b)(4)Staff #1's date of hire was 4/5/2021 and did not have recognizing and reporting incidents in their orientation training records. (repeat violation 1/12/21)The orientation must encompass the following areas: recognizing and reporting incidents.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)(1)Staff #2 and Staff #3 did not have the application of person-centered practices, community integration, individual choice, and supporting individuals to maintain relationships in their annual training record.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 #2 and Staff #3 did not have Individual Rights in their annual training record.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-00181614 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
6400.112(d)A sleep fire drills dated 6/22/20 and 6/19/20 exceeded the allowed evacuation time of 2 ½ minutes. All drills shall be within the allotted time or within the period of time specified in writing within the past year by a fire safety expert.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 employee 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.: Dayspring Management staff will be retrained in the licensing requirements and expectations to maintain compliance with regulation 6400.112 (d) by 3/12/21. Additionally, successful asleep drills were held on 6/23/20- 2 minutes and 19 seconds ; 9/22/20-2 minutes and 24 seconds and 12/12/20- 2 minutes and 10 seconds. Dayspring management staff is aware of the challenges the staff and individuals experience during an asleep drill and have worked with the local fire marshal to address challenges and request an extended evacuation time. The local fire marshal did not grant an extended evacuation time. All four residents who live at this home require assistance to evacuate the home. Two of the residents require the use of a lift system to get out of bed during a drill. Dayspring purchased a new home and is in process of preparing that home for residents but due to Covid-19 pandemic has not yet been able to open the home. GH, a resident who currently lives at Hazel Street will be moving to the new home which will ease the amount of assistance required to residents at Hazel Street during asleep fire drills. 03/12/2021 Implemented
6400.34(a)The record of Individual #1 contained a signed copy of her rights dated 12/13/20. This document did not contain a review of all rights as specified in 6400.32. A review of all rights as outlined is required. Regulations that were missing from the documentation of rights include: 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
6400.51(b)(1)Staff #1, date of hire 3/10/20, did not complete the required orientation trainings to encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.The orientation 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 orientation training curriculum will be reviewed and revised to ensure that all required orientation training topics as listed in 6400.51 (b)(1) are included in the orientation training provided to all employees. The Director of HR and the Compliance Manager will be responsible to ensure that the Dayspring orientation training curriculum is updated and revised by 3/12/21. Staff #1 will receive training in the updated orientation training curriculum. The Director of HR will be responsible to ensure that the training occurs for all new employees initially. The Compliance Manager and Director of HR will be responsible to ensure ongoing compliance. 03/12/2021 Implemented
6400.51(b)(2)Staff #1, date of hire 3/10/20, did not complete the required orientation trainings to 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 Adult Protective Services Act (35 P.S.§§ 10210.101-10210.704) and applicable protective services regulations.The orientation 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 orientation training curriculum will be reviewed and revised to ensure that all required orientation training topics as listed in 6400.51 (b)(2) are included in the orientation training provided to all employees. The Director of HR and the Compliance Manager will be responsible to ensure that the Dayspring orientation training curriculum is updated and revised by 3/12/21. Staff #1 will receive training in the updated orientation training curriculum. The Director of HR will be responsible to ensure that the training occurs for all new employees initially. The Compliance Manager and Director of HR will be responsible to ensure ongoing compliance. 03/12/2021 Implemented
6400.51(b)(3)Staff #1, date of hire 3/10/20, did not complete the required orientation trainings to encompass the following areas: Individual Rights.The orientation must encompass the following areas: Individual rights.The current Dayspring orientation training curriculum will be reviewed and revised to ensure that all required orientation training topics as listed in 6400.51 (b)(3) are included in the orientation training provided to all employees. The Director of HR and the Compliance Manager will be responsible to ensure that the Dayspring orientation training curriculum is updated and revised by 3/12/21. Staff #1 will receive training in the updated orientation training curriculum. The Director of HR will be responsible to ensure that the training occurs for all new employees initially. The Compliance Manager and Director of HR will be responsible to ensure ongoing compliance. 03/12/2021 Implemented
6400.51(b)(4)Staff #1, date of hire 3/10/20, did not complete the required orientation trainings to encompass the following areas: recognizing and reporting incidents.The orientation must encompass the following areas: recognizing and reporting incidents.The current Dayspring orientation training curriculum will be reviewed and revised to ensure that all required orientation training topics as listed in 6400.51 (b)(4) are included in the orientation training provided to all employees. The Director of HR and the Compliance Manager will be responsible to ensure that the Dayspring orientation training curriculum is updated and revised by 3/12/21. Staff #1 will receive training in the updated orientation training curriculum. The Director of HR will be responsible to ensure that the training occurs for all new employees initially. The Compliance Manager and Director of HR will be responsible to ensure ongoing compliance. 03/12/2021 Implemented
SIN-00162984 Renewal 09/20/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(c)There was a spray bottle filled with an unknown liquid found under the kitchen sink with other cleaning supplies. The bottle was hand-lettered "vinegar" and the liquid smelled mildly of vinegar and also a cleaning-product scent.Poisonous materials shall be stored in their original, labeled containers. Dayspring Management staff will be retrained in the licensing requirements and expectations to maintain compliance with regulation 6400.62 (c) by 11/29/19. Additionally, the bottle of unknown liquid was removed and disposed of by the Quality Manager at the time of discovery. 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
6400.112(d)Three unsuccessful attempts were made during the month of March 2019 to conduct a fire drill during sleeping hours; all three drills exceeded the maximum evacuation time of 2 and 1/2 minutes. The drills were as follows: 3/14/19 - 3 minutes and 12 seconds; 3/23/19 - 3 minutes and 17 seconds; and 3/30/19 - 2 minutes and 48 seconds. The home does not have an extended evacuation time.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.Dayspring Management staff will be retrained in the licensing requirements and expectations to maintain compliance with regulation 6400.112 (d) by 11/29/19. Additionally, successful asleep drills were held on 6/25/19- 2 minutes and 7 seconds and on 9/30/19-2 minutes and 14 seconds. Dayspring management staff is aware of the challenges the staff and individuals experience during an asleep drill and have worked with the local fire marshal to address challenges and request an extended evacuation time. The local fire marshal did not grant an extended evacuation time. All four residents who live at this home require assistance to evacuate the home. Two of the residents require the use of a lift system to get out of bed during a drill. Dayspring has recently purchased a new home and is in process of preparing that home for residents. GH, a resident who currently lives at Hazel Street will be moving to the new home which will ease the amount of assistance required to residents at Hazel Street during asleep fire drills. 11/29/2019 Implemented
6400.163(h)A bottle of the cough medicine Robafen with a prescription label indicating that it was prescribed for Individual #1, was found in the medication storage area, but had been discontinued and was not listed on the current MAR.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.: Dayspring Management staff will be retrained in the licensing requirements and expectations to maintain compliance with regulation 6400.163 (h) by 11/29/19. Additionally, the nurse removed the bottle of Robafen from the medication storage area and the medication will be discontinued by the doctor. The agency nurse will be responsible to complete monthly medication reviews for each program and will be responsible to ensure that any issues identified are addressed and resolved or corrected. Supervisors of all programs will be expected to complete the Residential Book Review form on a quarterly 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 Book Review form for all programs on a quarterly basis as well. The Director of Operations, Nursing, and Quality Manager will be responsible for continued monitoring and ongoing compliance. 11/29/2019 Implemented
SIN-00140632 Renewal 08/29/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.104There are four individuals in the home and the fire department notification letter was never updated. It was from 10-27-17 and stated there are three individuals in the home even though a fourth person moved in back on 11-27-17.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 430 Hazel Street will be updated to reflect the current needs and living situation for participants living in the home and will then be sent to the local fire department by 11/30/18. The CEO will be responsible for updating this letter and sending it to the fire department. The updated letter will also be placed in the fire drill log book in the home. 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
6400.141(c)(14)Information pertinent to diagnosis and treatment in case of emergency was not on Individual #2's annual physical form.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Individual #2¿s annual physical form will be updated to include the required information by 11/30/18. Additionally, the Operations Manager will be responsible for ensuring that all Management staff are retrained in the licensing requirements to ensure compliance with regulation 6400.141 (c ) (14) by 11/30/18. The agency Nurse will be responsible to ensure that staff are using the correct participant physical form which includes this information. The agency Nurse will be responsible to ensure continued monitoring to ensure compliance. 11/30/2018 Implemented
6400.181(f)Individual #1's assessment was not sent to the SC and team at least 30 days prior to the ISP meeting.(f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). Dayspring Management staff will be retrained in the licensing requirements and expectations to maintain compliance with regulation 6400.181(f) by 11/30/18. Additionally, the Operations Manager will develop a schedule for each home which will include the date each participants ISP is due as well as when the annual assessment is due to be completed. The Program Manager will be responsible to ensure that each Supervisor maintains ongoing compliance with this regulation by ensuring that they use the agency ISP checklist form when preparing for an upcoming ISP. The ISP checklist form includes the requirement that the annual assessment be completed one month prior to the ISP meeting and is to be sent to the team at that time. The Operations Manager and Program Managers will be responsible to ensure that Management staff are trained in this expectation and for continued monitoring to ensure compliance. 11/30/2018 Implemented
SIN-00124283 Renewal 10/31/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(c)There were no records of fire drills being held from 11/2016-1/2017 in this residence's Fire Book.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. Dayspring Management staff will be retrained in the licensing requirements and expectations to maintain compliance with Chapter 6400 regulation 6400.112 (c) by 1/31/18. The Operations Manager and Program Specialists will be responsible to ensure ongoing compliance with this regulation. 01/31/2018 Implemented
6400.112(d)There were 3 failed Sleep fire drills this past year: 3/29/17 at 10:36PM (4 minutes & 22 seconds); 4/3/17 at 10:28PM (5 minutes & 12 seconds); and 8/17/17 at 11:45PM (3 minutes & 15 seconds). 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. Dayspring Management staff will be retrained in the licensing requirements and expectations to maintain compliance with Chapter 6400 regulation 6400.112 (c) by 1/31/18. Successful asleep drills were held on 6/15/17 and 9/17/17. Dayspring Homes is currently in compliance with this regulation. Strategies and plans have been developed and put in place to assist participants in evacuating and practice drills have been held and have been successful. Dayspring Homes will continue to monitor asleep drills at this residence to ensure compliance with the evacuation times. Attempts to obtain an extended evacuation time have not been successful due the local fire chief being unresponsive. If the need arises again, this may be explored in the future. The CEO, Operations Manager and Program specialist will be responsible to ensure ongoing compliance with this regulation. 01/31/2018 Implemented
SIN-00105290 Renewal 11/15/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)There is a ramp in the back of this residence that is used as an exit during fire drills. It is concaved in the center. When standing at the top of the ramp looking down, it appears to be tilting towards the left. Floors, walls, ceilings and other surfaces shall be in good repair. Dayspring Homes will ensure that the ramp is replaced and is in good repair. Dayspring Homes has received an estimate for the repairs. The estimated start date of the project is March 27, 2017. The delay in starting the project is due to the winter season and unpredictable weather. Dayspring Homes will ensure that the ramp is not used by individuals until it is repaired. There is another accessible exit that can be utilized during fire drills or in an emergency situation. The Program Specialist will ensure that all staff at the Hazel Street location are trained in this expectation by 1/31/2017. 02/28/2017 Implemented
6400.112(e)From 4/24/2015 to 12/29/2015, no fire drills during sleeping hours took place. A fire drill shall be held during sleeping hours at least every 6 months. Dayspring Management staff will be retrained in the licensing requirements and expectations to maintain compliance with Chapter 6400 regulation 6400.112 (e) by 2/28/2017. Dayspring Homes fire drill log was updated in 2015 to require asleep fire drills to be conducted every 3 months. All Dayspring Management staff will be retrained in this expectation. The CEO, Operations Manager, Program Specialist will be responsible for retraining of staff. All retraining will be completed by 2/28/2017. 02/28/2017 Implemented
6400.141(c)(9)Individual #3 is 63 years old. He had a prostate exam on 7/17/2015. He didn't have another prostate exam until 11/1/2016, which exceeds the annual requirement.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 6400.163 (c) by 2/28/2017. Additionally, the Nurse Consultant has developed a system for tracking medical appointments for each individual and is completing monthly appointment reminder forms for each program. Dayspring Management staff will be trained in the purpose of this new tracking system and the ongoing expectations for the use of the system and forms. The CEO, Operations Manager, Program Specialist will be responsible for retraining of staff. The Nurse Consultant will be responsible for training in the medical appointment tracking system and the monthly appointment reminder forms. All retraining will be completed by 2/28/2017. 02/28/2017 Implemented
6400.163(c)Individual #3 had 3 month psychiatric medication reviews on 6/17/2015, 12/30/2015, 3/30/2016, 5/26/2016, and 8/31/2016. The timeframe between 6/17-12/30/2015 exceeds the 3 month requirement. If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Dayspring Management staff will be retrained in the licensing requirements and expectations to maintain compliance with Chapter 6400 regulation 6400.163 (c) by 2/28/2017. Additionally, the Nurse Consultant has developed a system for tracking medical appointments for each individual and is completing monthly appointment reminder forms for each program. Dayspring Management staff will be trained in the purpose of this new tracking system and the ongoing expectations for the use of the system and forms. The CEO, Operations Manager, Program Specialist will be responsible for retraining of staff. The Nurse Consultant will be responsible for training in the medical appointment tracking system and the monthly appointment reminder forms. All retraining will be completed by 2/28/2017. 02/28/2017 Implemented
SIN-00089985 Unannounced Monitoring 12/21/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.18(b)Staff #2 witnessed verbal abuse on 11/7/2015 of Individual #1, but it was not reported until 11/18/2015 which is in violation of agency policy. Written policies and procedures on the prevention, reporting, investigation and management of unusual incidents shall be developed and kept at the home. Staff # 2, the initial reporter of the incident, received pre-service orientation training on 8/31/15; 9/2/15 and 9/4/15 which included training on recognition of incidents, documentation of incidents and timely reporting of incidents. After the confirmed incident of verbal abuse, the Operations Manager , Debbi Dougherty, conducted retraining on 12/10/2015 for staff # 2 in the areas noted above. In addition to this retraining, retraining was also conducted for two additional staff, one was a witness to the incident and the second was the program manager the incident was reported to. All staff are trained annually in recognition of incidents, documentation of incidents and timely reporting of incidents. 12/10/2015 Implemented
6400.33(a)On the afternoon 11/07/2015, Individual #1 was subjected to verbal abuse by staff #1 during an outing.An individual may not be neglected, abused, mistreated or subjected to corporal punishment. At the conclusion of the investigation it was determined to be a founded incident of verbal abuse. The investigation was reviewed by risk Management and at that time it was decided to terminate staff #1's employment. Staff #1 was terminated on 1/4/2015. Staff # 1 was trained annually in Abuse Prevention and Incident Reporting. The most recent annual training was conducted on 5/15/2014. All staff receive training annually in Abuse Prevention and Incident Reporting. All Management staff receive additional training in the areas at the Manager Annual Refresher. 12/04/2015 Implemented
SIN-00086253 Renewal 10/21/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(7)Individual #1 has a DOB of 3/10/1971. Individual #1¿s physicals dated 12/18/2014 and 9/24/15 do not indicate that a gynecological examination was completed. The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. The individual is scheduled to have her GYN / pap test and examination on January 12, 2016 at 2:30 pm. the Individual will see Rebecca McClure, CNRP at the Women's Health Care Office located Physician's Office Bldg. in West Reading, Pa. (610-898-7000). Additionally, Dayspring Homes has developed a pre-admission checklist to ensure compliance of required medical regulatory requirements prior to admission into Residential Community Home services. 01/12/2016 Implemented
6400.142(a) There are no dental examination records on file for individual #1. An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. The provider had the dental exam / dental hygiene plan on 10/20/2015. Dayspring Homes has developed a pre-admission checklist to ensure compliance of required medical regulatory requirements prior to admission into Residential Community Home services. 12/01/2015 Implemented
SIN-00122697 Renewal 10/31/2017 Compliant - Finalized