Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00264434 Renewal 04/16/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.71The elevator located in the facility did not have a valid certificate of operation from the Department of Labor and Industry. The certificate of operation posted in the elevator at the time of inspection expired 12/31/2024 and a new certificate has not been issued.If an elevator is present in the facility, there shall be a valid certificate of operation from the Department of Labor and Industry.Dayspring rents our current day program space from Calvary Lutheran Church. The church is responsible for elevator inspections and maintenance. At this time, the church has paid for the inspection and is waiting to hear back from the inspector to schedule. 05/31/2025 Implemented
2380.21(u)Individual rights and the process to report a rights violation was not reviewed and explained to Individual #1 annually. Individual rights were reviewed and explained to Individual #1 on 2/16/2023, then not again until 3/17/2025.The facility 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 facility and annually thereafter.The previous Program Specialist failed to ensure Individual #1¿s rights were reviewed and signed in 2024. As of 7/8/2024, the previous Program Manager is no longer employed by Dayspring Homes. A new Program Specialist was hired on 8/26/24 and has been trained in this requirement. The individual rights were reviewed and signed by Individual #1 on 3/17/25, so she is currently in compliance. 04/17/2025 Implemented
2380.181(f)The annual assessment completed for Individual #2 was not provided to the individual plan team members at least 30 calendar days prior to the individual plan meeting. The annual assessment was completed and sent to the individual plan team members on 7/21/2024 and the individual plan meeting was held on 8/13/2024.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to the individual plan meeting.The previous Program Specialist did not ensure the individual assessment was completed on time. As of 7/8/2024, the previous Program Manager is no longer employed by Dayspring Homes. Individual #2¿s assessment was completed 8/13/24 and is currently in compliance. 05/05/2025 Implemented
SIN-00244506 Renewal 04/24/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.33(c)(3)Staff #1 was hired as a program specialist on 8/29/2023 but did not meet the following qualifications: An associate's degree or 60 credit hours from an accredited college or university and 4 years of work experience working directly with persons with disabilities. Staff #1 had over 4 years of work experience working directly with persons with disabilities, but had only completed 51 credit hours from an accredited college or university.A program specialist shall have one of the following groups of qualifications: An associate's degree or 60 credit hours from an accredited college or university and 4 years of work experience working directly with persons with disabilities.At the time of the Program Specialist¿s interview and onboarding, she reported that she met the 60-credit requirement for her role. When she was on-boarded, the previous Human Resources Assistant did not submit her transcripts to the Director of Human Resources for review and it was overlooked that the transcript received did not total 60 credits. The Director of Human Resources, TH, contacted the Program Specialist, NR, to review her credentials and it was discovered that NR never submitted her transcripts from Berks Technical Institute, which is an accredited college, to Dayspring. NR obtained her transcript from Berks Technical Institute and forwarded it to TH. TH verified the authenticity of the document on 5/23/24 and it has been added to NR¿s employee file. With the addition of the credits from Berks Technical Institute, NR now has a total of 62.5 credits on file. 05/23/2024 Implemented
2380.111(c)(5)Individual #2 had a late tuberculin skin testing. The individual's most recent tuberculin skin testing occurred on 4/17/2023, and the previous occurred on 10/23/2020.The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positive, an initial chest X-ray with results noted.The Director of Quality and Compliance will audit all individual physical exams, including tuberculin testing documentation, no later than 5/31/24. Any individuals with a physical exam that does not meet the regulatory requirements will be suspended by the Program Manager until updated documentation is received. 05/31/2024 Implemented
2380.173(1)(v)Individual #1's record did not contain a current dated picture.Each individual's record must include the following information: Personal information including: A current, dated photograph.Individual #1 has not been attending the day program recently due to personal reasons, so the Program Specialist was not able to immediately get a photograph for her book. A photograph was able to be obtained on 5/17/24 and has been filed. 05/17/2024 Implemented
2380.181(a)An initial assessment was completed on 3/26/2024 which was within 60 calendar days of the individual's admission on 1/26/2024, but the assessment was not complete. The assessment was missing the following: the individual's strengths, needs, preferences, likes, dislikes and recommendations for specific areas of training, vocational programming and competitive community-integrated employment. Individual #2's most recent annual assessment was completed late. The current assessment was completed on 9/15/2023 and the previous was completed on 5/09/2022.Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter.Individual #2¿s assessment was corrected by the Program Manager by 5/17/24. The corrected assessments were then reviewed and approved by the Director of Operations on 5/22/24. 05/22/2024 Implemented
2380.181(e)(12)The annual assessment completed on 1/18/2024 for Individual #3 did not contain recommendations for specific areas of training, vocational programming and competitive community-integrated employment.The assessment must include the following information: Recommendations for specific areas of training, vocational programming and competitive community-integrated employment.Individual #3¿s assessment was corrected by the Program Manager by 5/17/24. The corrected assessments were then reviewed and approved by the Director of Operations on 5/22/24. 05/22/2024 Implemented
2380.125(f)Individual #1 is prescribed medication to treat the symptoms of a diagnosed psychiatric illness and there was not a written protocol as part of the individual plan to address the social, emotional and environmental needs (SEEN plan) of the individual related to the symptoms of the psychiatric illness.If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness.Individual #1 does not take medications at the day program and does not see a psychiatrist. Due to this, the team did not recognize that a SEEN plan was needed. A SEEN plan was completed on 5/16/24. The Director of Quality and Compliance will review each program participants ISP no later than 5/31/24 to ensure everyone with psychiatric medications has a BSP or SEEN plan. 05/16/2024 Implemented
SIN-00222432 Renewal 04/18/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.21(o)At time of inspection the lunches belonging to individuals in the program were locked in the storage closet. Individuals did not have keys or have access to the keys of the storage closet; access would be granted upon request or at scheduled break and lunch times. Individuals shall have right of access to their possessions at all times.An individual has the right of access to and security of the individual's possessions.Due to the fact that several individuals in the program steal food, most of the individuals chose to keep their lunches in a locked closet within the program. The individuals were never required to keep their lunches in this closet, and there are several individuals who chose to keep their lunches elsewhere during the day, which was fine. The Director of Quality and Compliance met with the Program Manager on 4/19/23 to review this violation and let her know that effective immediately, the lunches can no longer be stored in a locked area. Currently, the plan is to continue to use the same closet but to leave it unlocked during the day. If we find that lunches are being stolen from the closet once it is left unlocked, the alternative plan will be to put the lunches in bins located in the main program area where staff can keep an eye on them. 04/20/2023 Implemented
SIN-00205170 Renewal 05/13/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.111(c)(3)Individual #1's physical exam dated 8/5/21 documented their immunization for Tetanus and Diphtheria occurred on 8/6/10 and it's required every 10 years, and there is no documentation that Individual #1 has received their Tetanus and Diphtheria. Individual #2's physical exam dated 7/20/21 documented their immunization for Tetanus and Diphtheria occurred on 5/27/11, and Individual #2's received their next Tetanus and Diphtheria on 5/12/22/ it's required every 10 years therefore it exceeds the requirement.The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333.Individual #1 received his T&D immunization on 5/17/22. Documentation for the T&D immunization has been attached to Individual #1¿s physical exam dated 8/5/21 and will be maintained in his files at the CPS program and in his home. Individual #2 received his T&D immunization on 5/13/22. Documentation for the T&D immunization has been attached to Individual #2¿s physical exam dated 7/20/21 and will be maintained in his files at the CPS program and in his home. 07/29/2022 Implemented
2380.111(c)(7)Individual #1's physical exam dated 8/5/21 did not assess their health maintenance needs, medication regimen and the need for blood work at recommended intervals. This section of Individual #1's physical exam was left blank.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals.The physical exam dated 8/5/21, has been returned to the PCP office for corrections. Information regarding Individual #1¿s health maintenance needs must be completed and documented in section 11 of the form. The corrected form will then be maintained in his files at the CPS program and in his home. 07/29/2022 Implemented
2380.111(c)(8)Individual #1's physical exam dated 8/5/21 did not include physical limitations of the individual. This section of Individual #1's physical exam was left blank.The physical examination shall include: Physical limitations of the individual.The physical exam dated 8/5/21, has been returned to the PCP office for corrections. Information regarding Individual #1¿s physical limitations must be completed and documented in section 11 of the form. The corrected form will then be maintained in his files at the CPS program and in his home. 07/29/2022 Implemented
2380.111(c)(11)Individual #1's physical exam dated 8/5/21 did not include special instructions for an individual's diet. This section of Individual #1's physical exam was left blank.The physical examination shall include: Special instructions for an individual's diet.The physical exam dated 8/5/21, has been returned to the PCP office for corrections. Information regarding special instructions for diet for Individual #1 must be completed and documented in section 11 of the form. The corrected form will then be maintained in his files at the CPS program and in his home. 07/29/2022 Implemented
SIN-00155310 Renewal 05/08/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.89(e)Fire drills conducted during the months of April 2018 through April 2019 all utilized the front door as the exit route.Alternate exit routes shall be used during fire drills.All Crosswalk staff will be retrained in the licensing requirements to maintain compliance with Chapter 55 PA Code 2380.89(e) by 7/31/19. Additionally, the Program Specialist has developed a chart to list the exit to be used during each monthly drill to ensure that alternate exits are being used regularly. The Operations Manager and Program Specialist will be responsible for ongoing programmatic monitoring to ensure compliance. The Quality Manager will also monitor records to ensure compliance 07/31/2019 Implemented
2380.111(c)(10)The annual physical examination dated 6/15/18 for Individual #1 did not include medical information pertinent to diagnosis and treatment in case of emergency. The annual physical examination dated 5/07/18 for Individual #2 did not include medical information pertinent to diagnosis and treatment in case of emergency. The annual physical examination dated 5/03/19 for Individual #3 did not include medical information pertinent to diagnosis and treatment in case of emergency. The annual physical examination dated 3/27/19 for Individual #4 did not include medical information pertinent to diagnosis and treatment in case of emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.The physical form for Individual # 1 dated 6/15/18, for Individual # 2 dated 5/7/18, for Individual # 3 dated 5/3/19 and for Individual # 4 dated 3/27/19 will be updated to include the following information: medical information pertinent to diagnosis and treatment in case of emergency by 7/31/19. In the future, the agency Nurse will be responsible to ensure that all physicals for participants that are residents of Dayspring Homes are completed on the appropriate physical form which includes a section for Medical information pertinent to diagnosis and treatment in case of an emergency. The agency Nurse will also be responsible for reviewing all physical forms for participants who live with other providers or with family to ensure that all required information is on the form. The agency Nurse and Operations Manager and Program Specialist will be responsible for ongoing programmatic monitoring to ensure compliance. The Quality Manager will also monitor records to ensure compliance 07/31/2019 Implemented
2380.181(e)(13)(i)The assessment dated 10/11/18 for Individual #3 did not document progress over the last 365 days in the area of health.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.The Annual Assessment for Individual # 3 was completed on the wrong form. The Annual Assessment form was revised in 2018 but was not being used by all programs consistently. The form is now available to all Managers and all Managers have been trained in the use of the new form and how to access it on the Google drive. The assessment for Individual # 3 will be updated to include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health. The Operations Manager will be responsible to ensure that the assessment is updated by 7/31/19. All future assessments completed will include this information. The Operations Manager will be responsible to ensure that Management staff are trained in this expectation. The Operations Manager and Program Specialist will be responsible for ongoing programmatic monitoring to ensure compliance. The Quality Manager will also monitor records to ensure compliance. 07/31/2019 Implemented
2380.181(e)(13)(ii)The assessment dated 1/02/19 for Individual #2 did not document progress over the last 365 days in the area of motor and communication skills. The assessment dated 10/11/18 for Individual #3 did not document progress over the last 365 days in the area of motor and communication skills.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas:  Motor and communication skills.The Annual Assessment for Individual # 2 was completed on the wrong form. The Annual Assessment form was revised in 2018 but was not being used by all programs consistently. The form is now available to all Managers and all Managers have been trained in the use of the new form and how to access it on the Google drive. The assessment for Individual # 2 will be updated to include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. The Operations Manager will be responsible to ensure that the assessment is updated by 7/31/19. All future assessments completed will include this information. The Operations Manager will be responsible to ensure that Management staff are trained in this expectation. The Operations Manager and Program Specialist will be responsible for ongoing programmatic monitoring to ensure compliance. The Quality Manager will also monitor records to ensure compliance. 07/31/2019 Implemented
2380.181(e)(13)(iii)The assessment dated 1/02/19 for Individual #2 did not document progress over the last 365 days in the area of personal adjustment.. The assessment dated 10/11/18 for Individual #3 did not document progress over the last 365 days in the area of personal adhustment.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Personal adjustment.The Annual Assessment for Individual # 2 was completed on the wrong form. The Annual Assessment form was revised in 2018 but was not being used by all programs consistently. The form is now available to all Managers and all Managers have been trained in the use of the new form and how to access it on the Google drive. The assessment for Individual # 2 will be updated to include the following information: progress over the last 365 days in the area of personal adjustment. The Operations Manager will be responsible to ensure that the assessment is updated by 7/31/19. All future assessments completed will include this information. The Operations Manager will be responsible to ensure that Management staff are trained in this expectation. The Operations Manager and Program Specialist will be responsible for ongoing programmatic monitoring to ensure compliance. The Quality Manager will also monitor records to ensure compliance. 07/31/2019 Implemented
2380.181(e)(13)(iv)The assessment dated 1/02/19 for Individual #2 did not document progress over the last 365 days in the area of socialization. The assessment dated 10/11/18 for Individual #3 did not document progress over the last 365 days in the area of socialization.The assessment must include the following information: The individual¿s progress over the last 365 calendar days and current level in the following areas: Socialization.The Annual Assessment for Individual # 2 was completed on the wrong form. The Annual Assessment form was revised in 2018 but was not being used by all programs consistently. The form is now available to all Managers and all Managers have been trained in the use of the new form and how to access it on the Google drive. The assessment for Individual # 2 will be updated to include the following information: progress over the last 365 days in the area of socialization. The Operations Manager will be responsible to ensure that the assessment is updated by 7/31/19. All future assessments completed will include this information. The Operations Manager will be responsible to ensure that Management staff are trained in this expectation. The Operations Manager and Program Specialist will be responsible for ongoing programmatic monitoring to ensure compliance. The Quality Manager will also monitor records to ensure compliance. 07/31/2019 Implemented
2380.181(e)(13)(v)The assessment dated 1/02/19 for Individual #2 did not document progress over the last 365 days in the area of recreation. The assessment dated 10/11/18 for Individual #3 did not document progress over the last 365 days in the area of recreation.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation.The Annual Assessment for Individual # 2 was completed on the wrong form. The Annual Assessment form was revised in 2018 but was not being used by all programs consistently. The form is now available to all Managers and all Managers have been trained in the use of the new form and how to access it on the Google drive. The assessment for Individual # 2 will be updated to include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. The Operations Manager will be responsible to ensure that the assessment is updated by 7/31/19. All future assessments completed will include this information. The Operations Manager will be responsible to ensure that Management staff are trained in this expectation. The Operations Manager and Program Specialist will be responsible for ongoing programmatic monitoring to ensure compliance. The Quality Manager will also monitor records to ensure compliance. 07/31/2019 Implemented
2380.181(e)(13)(vi)The assessment dated 1/02/19 for Individual #2 did not document progress over the last 365 days in the area of community integration. The assessment dated 10/11/18 for Individual #3 did not document progress over the last 365 days in the area of community integration.The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community integration.The Annual Assessment for Individual # 2 was completed on the wrong form. The Annual Assessment form was revised in 2018 but was not being used by all programs consistently. The form is now available to all Managers and all Managers have been trained in the use of the new form and how to access it on the Google drive. The assessment for Individual # 2 will be updated to include the following information: progress over the last 365 days in the area of community integration. The Operations Manager will be responsible to ensure that the assessment is updated by 7/31/19. All future assessments completed will include this information. The Operations Manager will be responsible to ensure that Management staff are trained in this expectation. The Operations Manager and Program Specialist will be responsible for ongoing programmatic monitoring to ensure compliance. The Quality Manager will also monitor records to ensure compliance. 07/31/2019 Implemented
2380.181(f)The assessment dated 1/02/19 for Individual #1 was not sent to the SC and team members at least 30 calendar days prior to the ISP meeting. The assessment dated 9/11/18 for Individual #2 was not sent to the SC and team members at least 30 calendar days prior to the ISP meeting. The assessment dated 10/11/18 for Individual #3 was not sent to the SC and team members at least 30 calendar days prior to the ISP meeting. The assessment dated 12/20/18 for Individual #4 was not sent to the SC and team members at least 30 calendar days prior to the ISP meeting.The program specialist shall provide the assessment to the SC or plan lead, 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 Chapter 2380.181 (f) by 7/31/19. Additionally, the Annual Assessment for has been updated to include the following statement ¿This assessment was shared with the team at least one month prior to the ISP meeting and documentation of how that was shared is attached: YES / NO¿. This statement will serve as a prompt to the manager completing the assessment to ensure this requirement is met. As part of the training that management staff will receive, they will be educated in practices to be used to ensure that the assessment is completed within the correct timeframe and what methods should be used to share the assessment with the team as well as what type of documentation is needed to show that it was shared. The practices to be used will include completing the Annual Assessment at the time of the third quarterly ISP review to ensure that there is adequate time to complete it properly and to share it with the team. The Operations Manager will be responsible to ensure that Management staff are trained in this expectation. The Operations Manager and Program Specialist will be responsible for ongoing programmatic monitoring to ensure compliance. The Quality Manager will also monitor records to ensure compliance. ((The date the assessment was sent to the team will be kept -CH 7/18/19)) 07/31/2019 Implemented
SIN-00134637 Renewal 05/08/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.53(a)Two bottles of hand sanitizer with labels stating contact ''Poison Control Center if ingested'' were found unlocked and accessible in the main program area near the copy machine.Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use.: Dayspring Management staff will be retrained in the licensing requirements and expectations to maintain compliance with Chapter 2380. 53 (a) by 7/31/18. Retraining will consist of a review of what materials are considered to be poisonous and how to determine if an item is considered to be a poisonous material. The Operations Manager and Program Specialist will be responsible to ensure that all Management staff are trained in this expectation and for continued monitoring for compliance. ((hand sanitizer was removed from the program area during the inspection - CH 6/27/18)) 07/31/2018 Implemented
2380.173(1)(ii)The record for Individual #3 did not documentif the individual has any identifying marks.Each individual's record must include the following information: Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks.: Dayspring Management staff will be retrained in the licensing requirements and expectations to maintain compliance with Chapter 2380.173 (1) (ii) by 7/31/18. Additionally, the Participant Face Sheet checklist will be completed for each participant. It will be expected that all participant records be reviewed for accuracy and any corrections will be made and completed by 7/31/18. The Operations Manager and Program Specialist will be responsible to ensure that all Management staff are trained in this expectation and for continued monitoring for compliance. 07/31/2018 Implemented
2380.181(a)Individual #3's Initial assessment dated 1/24/18 was not completed within 60 days of the individual's admission date of 9/11/17.Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter.Dayspring Management staff will be retrained in the licensing requirements and expectations to maintain compliance with Chapter 2380.181 (a) by 7/31/18. Use of the Pre- admission Into Services checklist will be reviewed. The Operations Manager and Program Specialist will be responsible to ensure that all Management staff are trained in this expectation and for continued monitoring for compliance. 07/31/2018 Implemented
2380.181(e)(5)The current annual assessment dated 12/11/17 for Individual # 1 did not document the individual's ability to self-administer medication. The current annual assessment dated 12/13/17 for Individual #2 did not document the individual's ability to self-administer medication. The current annual assessment dated 1/24/18 for Individual #3 did not document the individual's ability to self-administer medication.The assessment must include the following information: The individual's ability to self-administer medications.: Dayspring Management staff will be retrained in the licensing requirements and expectations to maintain compliance with Chapter 2380.181 (e) (5) by 7/31/18. Retraining will consist of a review of each section of the assessment and the expectations for completing each section accurately. The Operations Manager and Program Specialist will be responsible to ensure that all Management staff are trained in this expectation and for continued monitoring for compliance. ((All assessments will be reviewed by the Program Specialist and updated with the required information -CH 6/27/18)) 07/31/2018 Implemented
2380.181(e)(6)The annual assessment dated 12/11/17 for Individual #1 did not document the individual's ability to safely use or avoid poisons.The assessment must include the following information: The individual's ability to safely use or avoid poisonous materials, when in the presence of poisonous materials.Dayspring Management staff will be retrained in the licensing requirements and expectations to maintain compliance with Chapter 2380.181 (e) (6) by 7/31/18. Retraining will consist of a review of each section of the assessment and the expectations for completing each section accurately. The Operations Manager and Program Specialist will be responsible to ensure that all Management staff are trained in this expectation and for continued monitoring for compliance. ((All assessments will be reviewed by the Program Specialist and updated with the required information -CH 6/27/18)) 07/31/2018 Implemented
2380.181(e)(7)The current annual assessment dated 12/13/17 for Individual #2 did not document the individual's knowledge of heat sources.The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated.: Dayspring Management staff will be retrained in the licensing requirements and expectations to maintain compliance with Chapter 2380.181 (e) (7) by 7/31/18. Retraining will consist of a review of each section of the assessment and the expectations for completing each section accurately. The Operations Manager and Program Specialist will be responsible to ensure that all Management staff are trained in this expectation and for continued monitoring for compliance. ((All assessments will be reviewed by the Program Specialist and updated with the required information -CH 6/27/18)) 07/31/2018 Implemented
2380.181(e)(14)The annual assessment dated 12/13/17 for Individual #2 did not document the individual's knowledge of water safety and ability to swim.The assessment must include the following information: The individual's knowledge of water safety and ability to swim.: Dayspring Management staff will be retrained in the licensing requirements and expectations to maintain compliance with Chapter 2380.181 (e) (14) by 7/31/18. Retraining will consist of a review of each section of the assessment and the expectations for completing each section accurately. The Operations Manager and Program Specialist will be responsible to ensure that all Management staff are trained in this expectation and for continued monitoring for compliance. ((All assessments will be reviewed by the Program Specialist and updated with the required information -CH 6/27/18)) 07/31/2018 Implemented
2380.181(f)The annual assessment dated 12/13/17 for Individual #2 was not provided to the SC or plan lead and team at least 30 calendar days prior to the ISP meeting which was held on 12/18/17.The program specialist shall provide the assessment to the SC or plan lead, 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 Chapter 2380.181 (f) by 7/31/18. Additionally, an ISP checklist form will used to prepare for each ISP. The ISP checklist form includes the requirement that the annual assessment is to be completed one month prior to the ISP meeting and is to be sent to the Support Coordinator at that time. The Operations Manager and Program Specialist will be responsible to ensure that all Management staff are trained in this expectation and for continued monitoring for compliance. 07/31/2018 Implemented
SIN-00115628 Renewal 05/23/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.84The annual fire safety inspection was done on 4/19/2016. It was done again until 5/9/2017, which exceeds the annual requirement.The facility shall have an annual onsite firesafety inspection by a firesafety expert. Documentation of the date, source and results of the firesafety inspection shall be kept.The Program Manager will be responsible for contacting the fire safety expert in a timely manner to ensure that the annual inspection occurs with the specified timeframe. The Operations Manager will ensure that the Program Manager meets all requirements to maintain compliance with this regulation. All staff will be retrained in the fire safety regulation 55 PA Code Chapter 2380.84. 08/31/2017 Implemented
2380.89(d)On 3/16/2017, the total evacuation time was 2 minutes & 55 seconds, which exceeds the requirement by 25 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 firesafety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a firesafety expert. A fire safe area is an area that is accessible from the facility by two different routes and that is separated from other areas of the building by a minimum of 1-hour rated wall and door assemblies. Two fire safe areas in different directions of travel from the facility are acceptable. The firesafety expert may not be an employe of the facility or of the legal entity of the facility.The fire drill on 3/16/17 exceeded the evacuation time by 25 seconds due to participant EW not wanting to evacuate the building. After the drill EW was educated about the importance of fire safety and the need to exit the building in a timely manner. A repeat fire drill was held on 3/20/17. The evacuation time for that drill was 58 seconds and EW participated in that drill. All staff and participants of CrossWalk will be retrained in the fire safety regulation 55 PA Code Chapter 2380.89 (d). 08/31/2017 Implemented
2380.128(a)Staff #2 was rehired on 10/12/2016, after a 6-7 year absence. In his file was his initial medication administration training from 10/24/2004 and a medication administration practicum dated 1/5/2017. Staff #2 would be required to re-take the initial medication administrating training course due to the amount of time which lapsed from the date of his last training and the date of this last practicum.A staff person who has completed and passed the Department¿s Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications.Staff #2 will not administer medications until he successfully completes the Medication Administration Course. Staff #2 will complete the course by 8/31/17 and documentation will be kept in his personnel file. Dayspring Homes Medication trainers and the HR Manager will be responsible for ensuring that all new or rehired staff receive the appropriate training and will maintain accurate documentation of training in the personnel files. 08/31/2017 Implemented
2380.128(d)Staff #1 had her Med Practicum on 9/9/2015. She did not have another Med Practicum until 11/22/2016, which exceeds the annual requirement.A staff person who administers prescription medications or insulin injections to individuals shall complete 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 1 additional Medication Administration Trainer trained by the end of 2017. Training has begun for the new trainer and she is scheduled to complete the Face to Face portion of the training on 8/9/17. The Operations Manager will be responsible to ensure that all training requirements are met for this new trainer. Medication Administration Course Practicums will then become a shared responsibility between the two trainers. Dayspring Homes Medication Administration trainers will be responsible for ensuring that all initial and annual training requirements are met for all employees. 08/31/2017 Implemented
SIN-00080830 Renewal 03/11/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
2380.51 Dayspring Homes, Inc. Crosswalks Day Program is located on the second floor of a church. The front entrance has 25 steps and an elevator to the second floor and the rear entrance has 37 steps to the program area. There are fire safe areas on the second floor in the front and rear both with a one hour rating. There is also a rescue sled that can be used to transport an individual with a physical disability. Individual #1 is wheelchair bound and is limited to using the elevator to access the Day Program on the second floor. In the event of a fire she would not be able to use the elevator and could only rely on others to evacuate her from the building. This facility does not provide the necessary accommodations to ensure her safety and reasonable accessibility for entrance to and exit from the building. A facility serving one or more individuals with a physical disability, blindness, a visual impairment, deafness or a hearing impairment shall have accommodations to ensure the safety and reasonable accessibility for entrance to, movement within and exit from the facility based upon each individual's needs.The provider obtains annual inspections by the Laureldale Fire Company (the last being 2/04/2015. These annual inspections are completed by the Fire Chief (David Feltenberger)of the Laureldale Fire Department. The Fire Chief has designated two 'fire safe areas' which are located immediately outside of each doorway exit of the licensed programming area. Additionally, CrossWalk staff receive annual training in the use of 'life sliders' which are located in each fire safe area. Sandra Margaro, Program Manager is responsible to ensure this annual re-training of CrossWalk staff in the usage of the 'life slider' which could be used in an emergency situation. And the provider will file for a request for a waiver on regulation 2380.51 by 7/31/2015, as the provider has received annual Fire Department inspections, has safely utilized fire safe areas with in the building, has life slider sleds at each fire safe area, and has provided annual re-training for Crosswalk staff in the safe usage of the life slider sleds. 07/31/2015 Implemented
SIN-00115627 Renewal 05/09/2018 Compliant - Finalized
SIN-00060264 Initial review 02/07/2014 Compliant - Finalized