Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00250586 Renewal 08/26/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.48(b)(1)Staff #3's Annual Training did not include "facilitating community integration" or "supporting individuals to develop and maintain relationships".The annual training hours specified in subsection (a) must encompass the following areas: The application of person-centered practices, rights, facilitating community integration, individual choice and supporting individuals to develop and maintain relationships.CR, HR Generalist, did remind Staff #3 that these trainings were coming due; however, they were still not completed by the due date. There are several factors that could have contributed to this. 1. It was discovered that there was an issue with Staff #3's email and their emails were being delivered to the spam folder. This caused them to miss important communications from the team. 2. Staff #3 also reported that they were completing trainings on MyODP; however, they were having trouble accessing the certificates. This was because Staff #3's MyODP account had been set up as a personal account, not professional. This has since been corrected. 09/30/2024 Implemented
SIN-00230554 Renewal 09/26/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.121(c)(14)Individual #1's annual physical dated 5/5/23 does not include info pertinent to diagnosis in case of emergency. The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency.This information was missing from the physical exam due to the Life Sharing Provider using an old version of the physical exam form on 5/5/23. On our current physical exam form, question #2 is "information pertinent to diagnosis and treatment in case of an injury or emergency". The updated form was faxed to the primary care physician on 9/29/23 to request they complete question #2. The physician completed question #2 and faxed the form back to Dayspring on 9/29/23. 10/31/2023 Implemented
6500.151(e)(7)Individual #1's assessment dated 5/25/23 does not address the individual's ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated.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.In section B (Environmental Awareness) of the assessment, it states that individual #1 is aware of heat sources and able to independently avoid heat sources; however, it did not specifically state that they have the knowledge of heat sources and are able to sense and quickly move away from them. The following question was added to the assessment on 10/6/23: Has knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° and are not insulated. Individual #1 is aware of the danger of heat sources, able to sense them and quickly move away independently. 10/31/2023 Implemented
6500.32(r)(1)Individual #1's individual rights dated 6/3/23 do not include that bedroom locking may be provided by a key; access card, keypad code or other entry mechanism accessible to the individual to permit the individual to permit the individual to lock and unlock the door.An individual has the right to lock the individual's bedroom door. Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door.The Director of Quality and Compliance will review regulation 6500.32 and draft needed updates to the Rights and Responsibilities Policy. The Executive Leadership Team (CEO, Dir. of Quality and Compliance, Dir. of HR and Dir. of Operations) will meet on 10/24/23 to review the revisions and finalize the policy. After this meeting, the policy will be sent to all programs to review the updates with the individuals and file in their records. 10/31/2023 Implemented
SIN-00212107 Renewal 10/03/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.74During this inspection, the steps leading to the upper deck were missing some of the nonskid strips on the steps.Interior stairs and outside steps that are accessible to individuals shall have a nonskid surface.The Life Sharing Provider is in the process of replacing the non-skid strips on the deck stairs. Several of the strips were already replaced; however, they ran out of materials to finish the project and it has not yet been completed. The Life Sharing Provider is aware of this citation and will be replacing the non-skid strips on the deck stairs by 10/31/22. The Director of Quality and Compliance will follow-up with the Life Sharing Provider to ensure this was completed. 10/31/2022 Implemented
6500.121(c)(7)Individual #1 had a gynecological exam on 8/4/21 and not again since, outside of the annual timeframe. 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 Life Sharing Provider reported that they did try to schedule the gynecological exam prior to the due date; however, they were told the first available appointment was 11/1/22. The gynecological exam is scheduled for 11/1/2022, the Director of Quality and Compliance will check with the Life Sharing Provider on this date to ensure it was completed. 11/01/2022 Implemented
6500.17(a)No self-assessment was completed for the home either 3-6 months prior to the license expiring or 3-6 months after the last annual inspection.If an agency is the legal entity for the home, the agency shall complete a Self-Assessment of Homes the agency is licensed to operate 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.The Compliance Manager was responsible for completing the self-assessment and failed to do so. The Director of Quality and Compliance was hired on 8/1/22 to take over the duties of the Compliance Manager, and effective 9/8/22 the Compliance Manager is no longer in their position. The self-assessment will be completed in January 2023, 3 months after this licensing inspection. 10/31/2022 Implemented
6500.48(a)For the training year from 7/1/21 to 6/30/22, Staff #3 only had 16.25 hours of training.The primary caregiver and the life sharing specialist shall complete 24 hours of training related to job skills and knowledge each year.The previous Compliance Manager was the Life Sharing Specialist for this home. They were responsible for ensuring that the Life Sharing Provider was completing the required trainings, and for turning in documentation of completed trainings to Human Resources. The Compliance Manager/Life Sharing Specialist was not ensuring that the Life Sharing Provider was completing the required trainings. Additionally, it was found that there were trainings that were indeed completed by the Life Sharing Provider; however, the paperwork was not forwarded to Human Resources to be added to the providers training record. The Director of Operations took over as Life Sharing Specialist on 7/25/22 and is overseeing life sharing until a new Life Sharing Specialist is in place. 10/31/2022 Implemented
6500.48(b)(2)For the training year from 7/1/21 to 6/30/22, Staff #3 did not have training on the Prevention, Detection, Reporting of Abuse.The annual training hours specified in subsection (a) 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 previous Compliance Manager was the Life Sharing Specialist for this home. They were responsible for ensuring that the Life Sharing Provider was completing the required trainings, and for turning in documentation of completed trainings to Human Resources. The Compliance Manager/Life Sharing Specialist was not ensuring that the Life Sharing Provider was completing the required trainings. Additionally, it was found that there were trainings that were indeed completed by the Life Sharing Provider; however, the paperwork was not forwarded to Human Resources to be added to the providers training record. The Director of Operations took over as Life Sharing Specialist on 7/25/22 and is overseeing life sharing until a new Life Sharing Specialist is in place. The Life Sharing Provider will complete this training and send a copy of the certificate of completion to the Operations Director by 10/31/22. 10/31/2022 Implemented
6500.48(b)(6)For the training year from 7/1/21 to 6/30/22, Staff #3 did not have training on Plan Implementation.The annual training hours specified in subsection (a) must encompass the following areas: Implementation of the individual plan.Training on the implementation of the individual plan was indeed completed by staff #3 on 6/30/22; however, it was listed as "Program Participant Training" on the staff's training record and the inspector was not aware that this included the individual ISP training. It was not discovered by the Quality and Compliance Manager until after the citations were submitted in CLS that we received this citation in error. A copy of the Program Participant Training verification form was submitted to the inspector on 10/11/22 and it was recommended that we explain the error in our plan of correction. 10/12/2022 Implemented
SIN-00196839 Renewal 11/29/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.24(d)(1)The home does not have an up-to-date property record for Individual #1 to include all possessions received, purchased, and obtained. The property record included entries up until 2013, then only two additional items for 2020; however, the property record is not a complete record of the individual's possessions. An up-to-date financial and property record shall be kept for each indivudal that includes the personal possessions and funds received by or deposited with the family or agency.The Life Sharing Specialist will work together with the LS Provider and Individual #1 to complete an updated inventory/property record that is an accurate reflection of the individuals personal possessions. Due to the extensive number of personal items Individual# 1 has in their possession, this will be a lengthy project which may need to be worked on over several months depending on the amount of time the Individual spends on it during each session. The Life Sharing Specialist will meet with the LS Provider and Individual #1 by 1/7/22, to discuss what needs to be done and develop a plan to accomplish the project. The target date for completion of the updated property record will be 2/28/22. The Life Sharing Specialist will be responsible for setting up the initial meeting and ensuring a plan is in place to accomplish this project. The LS Provider, Individual # 1 and the Life Sharing Specialist will be responsible for inventorying and documenting the possessions on the new record. 02/28/2022 Implemented
6500.109(h)The written fire drill record of the quarterly fire drills held in the home, do not document if all participants went to the meeting place during the drill. The form itself identifies the meeting place as the mailbox but does not state if participants met there.Individuals shall evacuate to a designated meeting place outside the home during each fire drill.The Fire Drill Log and Systems Check form currently being used will be revised to include the following statement: Did all Individuals evacuate to the designated meeting place? (circle one) YES or NO If No, please explain: _________________________________________________ The Life Sharing Specialist will be responsible for making the changes to the form by 1/14/22. The LS Specialist will be responsible for ensuring that all LS Providers have access to the new form by 1/31/22. 01/31/2022 Implemented
6500.110(d)The written record of the content of the fire safety training completed annually, on 6/26/20, 2/7/21, 6/8/21, and 10/15/21 was not kept. The fire safety training completed on 6/26/20, 2/7/21, and 10/15/21 did not document that the training included training on the use of fire extinguishers and smoke detectors and notification of the local fire department as soon as a fire is discovered. The fire safety training completed on 6/8/21 stated that the fire safety training was completed on 2/7/21. The content discussed on 6/8/21 is unclear. Family member #4 (identified as Staff person #4) has lived in the home since 2009. There are no records maintained that they received any training in the fire safety plan until 6/8/2021.A written record of fire safety training, including the content of the training and the individuals attending shall be kept.The form currently being used to document fire safety training for individuals lists the topics included in the training but does not included a detailed record of the content covered in each topic. The current form used to document Fire Safety training for Individuals will be revised to include a detailed record of the content included in the fire safety training as defined in 6500.110. The form currently being used to document training in the Fire Safety Training Plan for the Individual and all family members will be revised to include a detailed description of the content included in the training as defined in 6500.110. The LS Specialist is responsible for the error in dates on the plan dated 6/8/21, the date of 2/7/21 should have been 6/8/21- this will be corrected on the form - The new revised form will include clear documentation of the content included in the training. Family member # 4 has completed training in the fire safety plan annually since 2009. The records kept in the home include documentation of training in the fire safety plan for the current year and the prior year, all documentation of training for previous years has been purged from the record in the home and is kept in storage at the administrative office and can be provided if requested. The Life Sharing Specialist will be responsible for revising the Individual Fire Safety Training form and the Fire Safety Training Plan form by 1/14/22. 01/31/2022 Implemented
6500.121(c)(12)Individual #1's current, 4/27/2021 physical examination record did not include their physical limitations. This requirement was left unanswered on the examination record, thus not indicating if the individual's physical limitations were reviewed at the physical examination appointment. The physical examination shall include: Physical limitations of the individual.The current Participant Physical Examination form does include this information on page 2 in section #10. The physician is to circle anything that requires special needs, precautions etc. Section 10 of the form includes the following information: PLEASE CIRCLE ANY HEALTH MAINTENANCE NEEDS OR RESTRICTIONS AND EXPLAIN BELOW Diet Weight Control Exercise Physical Limitations Medical Treatments Hygiene Practices NONE Please explain any ¿circled¿ responses: On Individual #1's physical dated 4/27/21, the physician only circled weight control and included the explanation to continue weight control. Physical limitations was not circled which would indicate that the Individual does not have any physical limitations at this time. The physician reviews each section of the form during the exam and signs it to acknowledge that they have completed the exam with the individual which would indicate that the individual's physical limitations were reviewed at the appointment. The current Participant Physical Examination form will be revised to ensure that all requirements for the Individual physical examination as defined in 6500.121 are included and clearly documented on the form. Individual # 1's PCP will be contacted to obtain information and clear documentation regarding physical limitations. The new information/documentation will be added to or attached to her current physical. 02/28/2022 Implemented
6500.121(c)(15)Individual #1's current, 4/27/2021 physical examination record did not include their dietary needs or instructions. This information was missing from the record. The agency indicated of the self-assessment of the home, that this regulation wasn't applicable for Individual #1. However, all physical examination record requirements of 6500.121(a)-(c)(15) are required for the individual's physician to review, and document their review of each category, at the physical examination. The physical examination shall include: Special instructions for the individual's diet.The current Participant Physical Examination form does include this information on page 2 in section #10. The physician is to circle anything that requires special needs, precautions etc. Section 10 of the form includes the following information: PLEASE CIRCLE ANY HEALTH MAINTENANCE NEEDS OR RESTRICTIONS AND EXPLAIN BELOW Diet Weight Control Exercise Physical Limitations Medical Treatments Hygiene Practices NONE Please explain any ¿circled¿ responses: On Individual #1's physical dated 4/27/21, the physician only circled weight control and included the explanation to continue weight control. Diet was not circled which would indicate that the individual does not have any special dietary needs or instructions at this time. The physician reviews each section of the form during the exam and signs it to acknowledge that they have completed the exam with the individual which would indicate that the individual's dietary needs were reviewed at the appointment. The current Participant Physical Examination form will be revised to ensure that all requirements for the Individual physical examination as defined in 6500.121 are included and clearly documented on the form. Individual # 1's PCP will be contacted to obtain information and clear documentation regarding any dietary needs. The new information/documentation will be added to or attached to the current physical. 02/28/2022 Implemented
6500.124Per physical examination requirements of 6500.121(c)(8), Individual #1 required an annual mammogram or documentation of deferment from their physician. Individual #1 received a mammogram on 8/28/2020 and not again until 10/1/2021. There are no records maintain for when the family called to schedule Individual #1's annual mammogram examination, to ensure 10/1/2021 was the earliest appointment available. Individual #1 received a gynecological examination on 7/13/2020 and not again until 8/4/2021, outside the annual time frame requirement. Individual #1 saw their podiatrist on 1/13/2021 and was to return on 3/17/2021. The individual did not return until 3/31/2021, without records maintained of why the appointment was late. On 1/13/2021 Individual #1's podiatrist instructed the individual to go to urgent care for an evaluation to include cardiac and B/L LE arterial evaluation, along with COVID testing due to witnessing Individual #1 have blue toes during the 1/13/2021 visit. The home failed to obtain the podiatrist's 1/13/2021 appointment summary and recommendations until after 1/14/2021. The individual was not taken to urgent care until 1/14/21. Individual #1 had an Echocardiogram completed on 5/3/21. At the time of the 11/29/2021 inspection, there are no records maintained of the results of the test performed. On 2/5/2021 the individual's cardiologist instructed the individual to follow up with their primary care physician. The individual was not seen until 4/27/21 by their primary care physician. There are no records maintained for when the primary care physician was contacted to schedule an appointment, or that 4/27/21 was the appointment for the follow up to Individual #1's cardiologist visit recommendation. The individual's physician stated on 7/13/2020 and 8/4/2021 that the individual is to keep track of their periods and call if periods become excessively heavy or abnormal. There are no records that the individual, primary caregivers, or home/agency is tracking and monitoring Individual #1's periods.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.In response to the late mammogram, late GYN, late podiatry appointments and the delay in following up with the PCP after the cardiology appointment: To ensure that individuals are receiving all medical care as directed by their physicians, LS Providers will be required to keep accurate documentation of all communications with health care providers. A case record note will be completed and kept in the individual's records at the home to document occurrences of the following situations: - If the individual is to call to schedule a future appointment for a certain month and then when a call is made, the office for whatever reason, is not able to schedule an appointment within that month causing the appointment to be late or scheduled outside of the annual time frame requirements. - If a doctor's office calls to reschedule or cancel an appointment due to circumstances beyond the individuals, LS providers or provider agency's control which then causes the appointment to be late or scheduled outside of the annual time frame requirements. - A case record note may also be used to document any phone conversations that the individual and or LS Provider has with health care providers related to appointments, care, recommendations or well-being of the individual. The LS Specialist will be responsible for explaining the expectations, responsibilities and forms to be used to LS Providers. The LS Providers will be responsible for ensuring that accurate and timely documentation is kept in the record for each occurrence. The LS Specialist will be responsible for completing regular reviews of medical records kept in the home and for ongoing compliance. In response to results of the Echocardiogram not being maintained in the individual's records at the home: The LS Specialist will develop a process and form to be used to document and track when medical tests are scheduled and completed and when results are received and filed in the records at the home. The LS Specialist will be responsible for explaining the expectations, responsibilities and forms to be used to LS Providers. The LS Providers will be responsible for ensuring that accurate and timely documentation is kept in the record for each occurrence. The LS Specialist will be responsible for completing regular reviews of medical records kept in the home and for ongoing compliance. In response to the podiatry/urgent care situation: With all due respect, I do not agree with this citation. The LS Provider did ensure that the individual received treatment at an urgent care on the same day the instructions for the evaluation were given. The LS Provider did not clearly document the timeline of events or communications between providers at the time the situation occurred which has led to confusion as to what occurred on 1/13/21 and what occurred on 1/14/21. A detailed description of the timeline of events and communications to explain the situation was sent to the licensing inspector on 12/3/21. In response to this situation: To ensure that individuals are receiving all medical care as directed by their physicians, LS Providers will be required to keep accurate documentation of all communications with health care providers. A case record note will be completed and kept in the individual's records at the home to document occurrences of the following situations: - A case record note may also be used to document any phone conversations that the individual and or LS Provider has with health care providers related to appointments, care, recommendations or well-being of the individual. The LS Specialist will be responsible for explaining the expectations, responsibilities and forms to be used to LS Providers. The LS Providers will be responsible for ensuring that accurate and timely documentation is kept in the record for each occurrence. The LS Specialist will be responsible for completing regular reviews of medical records kept in the home and for ongoing compliance. In response to tracking of individual's periods: Individual #1 is very independent in their personal care needs and is aware of when the periods are occurring. The Individual may or may not document the information each month but the individual is aware of what would be normal for that month and what would be abnormal and is able to notify their LS Provider or their mother if there are any changes to the cycle or to the periods. The LS Specialist will meet with Individual # 1 to discuss the need for the Individual to keep track of the periods as recommended by the GYN doctor. The LS Specialist and Individual # 1 will determine what method of documentation will work best for the Individual to keep track of this information independently and also identify what type of changes may be needed to let others know about so the Individual can receive treatment if needed. 02/28/2022 Implemented
6500.45(a)Individual #1's primary caregiver, Staff person #1, received training by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid and Heimlich techniques on 12/7/2018 and not again until 7/20/2021.The primary caregiver shall be trained by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid and Heimlich techniques prior to an individual living in the home and annually thereafter.Staff person # 1 was due to attend a First Aid course in 7/2020 but did not attend until 7/2021. In July 2021, the provider was not holding in person training classes due to the Covid19 pandemic. The provider also did not have a certified CPR/First Aid trainer to instruct the course and was exploring alternative options for staff to obtain their certifications. The provider identified a member of management to attend the Red Cross training course to become a CRP/First Aid trainer. The trainer was certified in August 2020. The provider then needed to order and obtain the needed supplies to begin instructing the CPR/First Aid courses for staff. Due to the continued Covid19 pandemic concerns, CPR/First Aid courses were not offered until January 2021. Due to these circumstances, Staff person # 1 then attended and passed the course in July 2021. In response to citations received during last year's inspection, Dayspring management began the process of reviewing and revising our annual training curriculum and training process/program to ensure that all required annual training topics are included in the annual training provided to all Life Sharing Providers. 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 annual training packet is being developed that will be provided to all LS providers at the beginning of the new training year. The training packet will include a list of all required 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 packet will be an all-inclusive resource for LS providers to consult throughout the training year to ensure that all training requirements are met. 02/28/2022 Implemented
6500.45(b)Individual #1 had a diagnosis of Vasovagal syncope, history of passing out, and a history of other heart conditions. Individual #1's primary caregiver, Staff person #1, received training by an individual certified as a trainer by a hospital or other recognized health care organization, in cardiopulmonary resuscitation on 12/7/2018 and not again until 7/20/2021.The primary caregiver shall be trained and certified by an individual certified as a trainer by a hospital or other recognized health care organization, in cardiopulmonary resuscitation, if indicated by the medical needs of the individual, prior to the individual living in the home and annually thereafter.In response to citations received during last year's inspection, Dayspring management began the process of reviewing and revising our annual training curriculum and training process/program to ensure that all required annual training topics as listed in 6500.48 b1 are included in the annual training provided to all Life Sharing Providers. 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 annual training packet is being developed that will be provided to all LS providers at the beginning of the new training year. The training packet will include a list of all required 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 packet will be an all-inclusive resource for LS providers to consult throughout the training year to ensure that all training requirements are met. The Director of HR, the director of Operations and the Compliance Manager will be responsible for ensuring that the training packet is developed and that it includes all required information/ trainings to ensure compliance with annual training requirements. 02/28/2022 Implemented
6500.48(b)(1)Individual #1's primary caregiver, Staff person #1, and the life sharing specialist, Staff person #2, did not receive annual training in person-centered practices, rights, facilitating community integration, individual choice and support individuals to develop and maintain relationships.The annual training hours specified in subsection (a) must encompass the following areas: The application of person-centered practices, rights, facilitating 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 annual training curriculum and training process/program to ensure that all required annual training topics as listed in 6500.48 b1 are included in the annual training provided to all Life Sharing Providers. 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 annual training packet is being developed that will be provided to all LS providers at the beginning of the new training year. The training packet will include a list of all required 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 packet will be an all-inclusive resource for LS providers to consult throughout the training year to ensure that all training requirements are met. The Director of HR, the director of Operations and the Compliance Manager will be responsible for ensuring that the training packet is developed and that it includes all required information/ trainings to ensure compliance with annual training requirements. 02/28/2022 Implemented
6500.48(b)(2)Individual #1's primary caregiver, Staff person #1, and the life sharing specialist, Staff person #2, did not 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), the Child Protective Services Law (23 Pa.C.S. § § 6301---6386), the Adult Protective Services Act (35 P.S. § § 10210.101---10210.704) and applicable protective services regulations.The annual training hours specified in subsection (a) 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 last year's inspection, Dayspring management began the process of reviewing and revising our annual training curriculum and training process/program to ensure that all required annual training topics as listed in 6500.48 b2 are included in the annual training provided to all Life Sharing Providers. 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 annual training packet is being developed that will be provided to all LS providers at the beginning of the new training year. The training packet will include a list of all required 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 packet will be an all-inclusive resource for LS providers to consult throughout the training year to ensure that all training requirements are met. The Director of HR, the director of Operations and the Compliance Manager will be responsible for ensuring that the training packet is developed and that it includes all required information/ trainings to ensure compliance with annual training requirements. 02/28/2022 Implemented
6500.48(b)(3)Individual #1's primary caregiver, Staff person #1, and the life sharing specialist, Staff person #2, did not receive annual training in individual rights.The annual training hours specified in subsection (a) 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 annual training curriculum and training process/program to ensure that all required annual training topics as listed in 6500.48 b3 are included in the annual training provided to all Life Sharing Providers. 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 annual training packet is being developed that will be provided to all LS providers at the beginning of the new training year. The training packet will include a list of all required 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 packet will be an all-inclusive resource for LS providers to consult throughout the training year to ensure that all training requirements are met. The Director of HR, the director of Operations and the Compliance Manager will be responsible for ensuring that the training packet is developed and that it includes all required information/ trainings to ensure compliance with annual training requirements. 02/28/2022 Implemented
6500.48(b)(4)Individual #1's primary caregiver, Staff person #1, did not receive annual training in recognizing and reporting incidents.The annual training hours specified in subsection (a) 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 annual training curriculum and training process/program to ensure that all required annual training topics as listed in 6500.48 b4 are included in the annual training provided to all Life Sharing Providers. 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 annual training packet is being developed that will be provided to all LS providers at the beginning of the new training year. The training packet will include a list of all required 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 packet will be an all-inclusive resource for LS providers to consult throughout the training year to ensure that all training requirements are met. The Director of HR, the director of Operations and the Compliance Manager will be responsible for ensuring that the training packet is developed and that it includes all required information/ trainings to ensure compliance with annual training requirements. 02/28/2022 Implemented
6500.48(b)(5)Individual #1's primary caregiver, Staff person #1, and the life sharing specialist, Staff person #2, did not receive annual training in the safe and appropriate use of behavior supports.The annual training hours specified in subsection (a) must encompass the following areas: The safe and appropriate use of behavior supports.In response to citations received during last year's inspection, Dayspring management began the process of reviewing and revising our annual training curriculum and training process/program to ensure that all required annual training topics as listed in 6500.48 b5 are included in the annual training provided to all Life Sharing Providers. 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 annual training packet is being developed that will be provided to all LS providers at the beginning of the new training year. The training packet will include a list of all required 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 packet will be an all-inclusive resource for LS providers to consult throughout the training year to ensure that all training requirements are met. The Director of HR, the director of Operations and the Compliance Manager will be responsible for ensuring that the training packet is developed and that it includes all required information/ trainings to ensure compliance with annual training requirements. 02/28/2022 Implemented
6500.151(a)Individual #1's 5/21/2020 and 5/10/2021 annual assessments are verbatim. Therefore, an assessment of the individual's needs and skills over the previous 365 days was not completed as both assessments state the same information. Over the previous 365 days, the individual's life has looked different than that previous year due to the COVID-19 pandemic. Most of their daily routines and outings have changed and the assessment did not capture the individual's needs and skills at adapting to a new daily routine, or what the daily routine now consists of. Additionally, the individual has attended physician's visits and received new diagnoses, that were not captured within the assessment. The current assessment also failed to include an assessment of the individuals abilities (current level and progress) in the following sections: 1515(e)(7), 151(e)(9), 151(e)(10), 151(e)(13)(ii), 151(e)(13)(iii), 151(e)(13)(v), 151(e)(13)(vi), 151(e)(13)(vii), 151(e)(13)(viii), and 151(e)(13)(ix).Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the home.The Life Sharing Specialist will complete a new annual assessment for Individual #1 by 1/31/22. Once the updated/corrected assessment is completed, the Life Sharing Specialist will share it with the team so that accurate information can be updated and included in the ISP. The Life Sharing Specialist will be responsible to ensure that all annual assessments completed in the future are an accurate reflection of the individual's needs, skills, growth and progress for the past 365 days. The Director of Operations, the Compliance Manager and the LS Specialist will be responsible for ensuring ongoing compliance. The new assessment will include the following updated/corrected information: - assessment of the individual's needs and skills over the previous 365 days - individual's needs/skills at adapting to a new daily routine- what the daily routine is now - any new diagnoses that were not captured within the previous assessment - an assessment of the individual's abilities in the following sections (current level/progress) - Knowledge of heat sources - Disability, functional/ medical limitations, LTM History ¿- Motor & Communication skills - Activities of residential living - Socialization -Recreation - Financial independence - Managing personal property - Community integration 01/31/2022 Implemented
SIN-00180448 Renewal 12/10/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.34(a)The Department issued updated regulatory rights, effective 2/3/2020, stating that individuals have additional rights they need to be informed of. At the time of the 12/10/2020 annual inspection, Individual #1 was never informed of the individuals rights as described in 6500.32.Individual rights and the process to report a rights violation shall be explained to the individual, and persons designated by the individual prior to moving into 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 6500.32. The updated and revised policy will then be reviewed with Individual #1 and the documentation of that review will be kept in the records at the home. The policy will then be reviewed with Individual # 1 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 1/8/21. The Life Sharing Specialist will be responsible to ensure that policy is then reviewed with Individual # 1 by 1/15/21 and that the documentation is kept in the record at the home. The Life Sharing Specialist, Compliance Manager and Director of Operations will be responsible to ensure ongoing compliance with regulation 6500.34(a). 01/15/2021 Implemented
6500.48(a)Staff #3 completed 23.55 hours of annual job training and knowledge.The primary caregiver and the life sharing specialist shall complete 24 hours of training related to job skills and knowledge each year.: The Life Sharing Specialist and Director of HR will review the requirements for compliance with regulation 6500.48(a) to ensure that a training program is available to providers to meet the annual requirements. The Life Sharing Specialist will be responsible to monitor the training credit forms submitted by Staff # 3 on a quarterly basis to ensure that adequate documentation is submitted to the HR department for accurate tracking of training hours. The Life Sharing Specialist and Director of HR will review the requirements for compliance with regulation 6500.48(a) by 1/29/21 to ensure that a training program is available to providers to meet the annual requirements. The Life Sharing Specialist will be responsible for ongoing monitoring of Staff # 3s training hours. The Compliance Manager, Director of Operations and Director of HR will be responsible to ensure ongoing compliance with regulation 6500.48(a). 01/29/2021 Implemented
SIN-00145466 Renewal 11/27/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.43(d)(1)Individual #1 6/26/18 assessment indicated it was completed by Staff #1, the family living provider, on 5/26/18. The assessment then indicated it was coordinated by Staff #2, the family living specialist, on 6/26/18.The family living specialist shall be responsible for the following: Coordinating and completing assessments.The Assessment for Individual # 1 was completed on 12/28/18 by the Life Sharing Specialist. All future assessments will be coordinated and completed by the Life Sharing Specialist. The Life Sharing Specialist, Operations Manager and Quality Manager will be responsible to ensure ongoing compliance. 12/28/2018 Implemented
6500.64(a)A bar of soap in the upstairs bathroom was not in a covered, labeled containersClean conditions shall be maintained in all areas of the home.The soap was put into a labeled container on 11/27/18. The Operations Manager/ Quality Manager will be responsible for ensuring that the Life Sharing Provider is trained in the licensing requirements to ensure compliance with regulation 6500. 64 (a) by 1/31/19. The Life Sharing provider will be responsible to ensure ongoing compliance. 01/31/2019 Implemented
6500.66No exterior lights off of the sliding glass door egress to the back porch, missing middle light in bathroom.Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes, that are used by individuals shall be lighted to assure safety and to avoid accidents.The lightbulbs were replaced in these fixtures on 11/27/18. The Operations Manager will be responsible for ensuring that the Life Sharing Provider is trained in the licensing requirements to ensure compliance with regulation 6500. 66 by 1/31/19. The Life Sharing provider will be responsible to ensure ongoing compliance. 01/31/2019 Implemented
6500.121(c)(12)Individual #1 4/20/18 physical did not include physical limitations. There was a section for this on the physical exam but the physician left it blank. The physical examination shall include: Physical limitations of the individual.: Individual #1¿s annual physical form will be updated to include the required information by 1/31/19. Additionally, the Operations Manager will be responsible for ensuring that the Life Sharing Provider is trained in the licensing requirements to ensure compliance with regulation 6500. 121 (c) (12) by 1/31/19. 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. 01/31/2019 Implemented
6500.151(e)(1)Individual #1 assessment doesn't include individual's preferences.The assessment must include the following information: Functional strengths, needs and preferences of the individual.The assessment was revised to include the following information: Functional strengths, needs and preferences of the individual. A new assessment for Individual # 1 was completed by the Life Sharing Specialist on 12/28/18. All future assessments completed will include this information. The Life Sharing Specialist, Operations Manager and Quality Manager will be responsible to ensure ongoing compliance. 12/28/2018 Implemented
6500.151(e)(2)Individual #2 assessment doesn't include individual's interests.The assessment must include the following information: The likes, dislikes and interest of the individual.The assessment was revised to include the following information: The likes, dislikes and interest of the individual. A new assessment for Individual # 1 was completed by the Life Sharing Specialist on 12/28/18. All future assessments completed will include this information. The Life Sharing Specialist, Operations Manager and Quality Manager will be responsible to ensure ongoing compliance. 12/28/2018 Implemented
6500.151(e)(4)Individual #1 assessment doesn't include length of time Individual #1 could have unsupervised in the community and the specific stores Individual #1 can enter without staff present. The assessment only stated Individual #1 could have 24 hours of unsupervised time at home but didn't specify if that was per week, consecutively, etc.The assessment must include the following information: The individual's need for supervision.The assessment was revised to include the following information: The individual's need for supervision. A new assessment for Individual # 1 was completed by the Life Sharing Specialist on 12/28/18. All future assessments completed will include this information. The Life Sharing Specialist, Operations Manager and Quality Manager will be responsible to ensure ongoing compliance. 12/28/2018 Implemented
6500.151(f)Individual #1's assessment was not sent to the individual or any team member. Individual #1 assessment was signed and dated by Staff #2 on 6/26/18 and Individual #1 isp meeting was 6/26/18. Individual #1's team consisted of sc, mother, Staff #1, and day program. No documentation that any team member received the assessment.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 of the ISP, the 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).The updated assessment dated 12/28/18 was sent to team members on 1/4/19. 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 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. Documentation that the assessment was sent to the team will be kept in the record. The Life Sharing Specialist, Operations Manager and Quality Manager will be responsible to ensure ongoing compliance. 01/04/2019 Implemented
6500.153(3)Individual #1 outcome statement is to invite friends and/or family over for a meal Individual #1 has cooked with the duration of being at least once per week. However the description of the outcome indicated that after Individual #1 had independently mastered a meal Individual #1 will then invite friends and family over for the meal.The ISP, including annual updates and revisions under § 6500.156 (relating to ISP review and revision) must include the following: Current status in relation to an outcome and method of evaluation used to determine progress toward that expected outcome.Outcome # 21 for Individual # 1 was revised to be in compliance with regulation 6500.153 (3) on 1/2/19. Work will begin on this new outcome on 1/7/19. Progress will be documented by the provider and reported in the monthly report as well as future ISP reviews. The Life Sharing Specialist, Operations Manager and Quality Manager will be responsible to ensure ongoing compliance. 01/02/2019 Implemented
6500.153(4)Individual #1 isp doesn't indicate the length of time Individual #1 could have unsupervised in the community and the specific stores Individual #1 can enter without staff present. Isp only stated Individual #1 could have 24 hours of unsupervised time at home but didn't specify if that was per week, consecutively, etc. There wasn't a plan in place to increase Individual #1 unsupervised time.The ISP, including annual updates and revisions under § 6500.156 (relating to ISP review and revision) must include the following: A protocol and schedule outlining specified periods of time for the individual to be without direct supervision, if the individual's current assessment states the individual may be without direct supervision and if the individual's ISP includes an expected outcome which requires the achievement of a higher level of independence. The protocol must include the current level of independence and the method of evaluation used to determine progress toward the expected outcome to achieve the higher level of independence.: The Support Coordinator was emailed and the information will be updated and added to the ISP in HCSIS. The updated information was included in the most recent Quarterly ISP review dated 12/28/18 as well as in the updated annual assessment. The team will review this information on a quarterly basis. The Life Sharing Specialist, Operations Manager and Quality Manager will be responsible to ensure ongoing compliance 12/28/2018 Implemented
6500.153(7)(i)Individual #1 potential to advance in residential independence (i) community involvement (ii), vocational programming (iii), and competitive community-integration employment (iv) is not included in the isp. The ISP, including annual updates and revisions under § 6500.156 (relating to ISP review and revision) must include the following: Assessment of the individual's potential to advance in the following: Residential independence.The annual assessment was updated to include this information and was completed for Individual # 1 on 12/28/18. The Support Coordinator will be contacted and the following information will be added to the ISP. This information will be included in all future ISP updates and revisions: Assessment of the individual's potential to advance in the following: Residential independence. The Life Sharing Specialist, Operations Manager and Quality Manager will be responsible to ensure ongoing compliance. 12/28/2018 Implemented
6500.156(a)The program specialist, Staff #2, is not completing the isp reviews. The family living provider, Staff #1, is completing them. Individual #1 isp reviews weren't completed timely. Individual #1isp review covering the period from 6/26/18-9/28/18 was signed and dated by Staff #2 on 11/19/18. The isp review completed on 6/26/18 was reviewing the period 6/13/17-6/26/18 with no information included in the review that actually covered the previous 3 months. The 3/28/18 isp review did not include the last two days of the review period- it was covering 12/30/17-3/30/18. Isp review completed on 12/20/17 did not review the entire 3 months prior. It was supposed to review the period from 9/30/17 to 12/30/17.The family living specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the family living home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change, which impacts the services as specified in the current ISP.An ISP review was completed by the Life Sharing specialist dated 12/28/18. All future ISP reviews will be completed by the Life Sharing specialist every three months or more frequently if the individual's needs change, which impacts the services as specified in the current ISP. The Operations Manager and Life Sharing Specialist will utilize the Life Sharing ISP Review schedule form to ensure reviews are done in a timely manner. The Operations Manager and Quality Manager will be responsible to ensure ongoing compliance with this regulation. 12/28/2018 Implemented
6500.156(c)(1)Individual #1 11/19/18 isp review did not review outcome progress. Individual #1 is to cook and invite friends to diner once a week and there wasn't a mention of whether Individual #1 did this at least once a week. Individual #1 6/28/18, 3/28/18, and 12/20/17, isp reviews don't review participation and progress on Individual #1 color/mail affirmations monthly.The ISP review must include the following: A review of the monthly documentation of an individual's participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the family living home licensed under this chapter.An ISP review was completed by the Life Sharing specialist dated 12/28/18 which includes a review of outcomes. All future ISP reviews will include a review of the monthly documentation of an individual's participation and progress during the prior 3 months toward ISP outcomes. The Life Sharing Specialist, Operations Manager and Quality Manager will be responsible to ensure ongoing compliance with this regulation. 12/28/2018 Implemented
6500.156(c)(2)Individual #1 has 24 hours unsupervised time at home and some form of unsupervised time in the community and neither were reported on in Individual #1 isp reviews.The ISP review must include the following: A review of each section of the ISP specific to the family living home licensed under this chapter.An ISP review was completed by the Life Sharing specialist dated 12/28/18 which includes updated information regarding the supervision plan. All future ISP reviews will include a review of each section of the ISP specific to the family living home licensed under this chapter, specifically the supervision plan. The information was reviewed with the Support Coordinator and the information will be added to the ISP in HCSIS. The Life Sharing Specialist, Operations Manager and Quality Manager will be responsible to ensure ongoing compliance with this regulation. 12/28/2018 Implemented
6500.156(d)There's no documentation that any of Individual #1 team members or Individual #1 received a copy of Individual #1 isp reviews.The family living specialist shall provide the ISP review documentation, including recommendations if applicable, to the SC, as applicable, and plan team members within 30 calendar days after the ISP review meeting.The most recent Quarterly ISP review was emailed to the SC, the Life Sharing Provider and CPS provider on 1/3/19. A copy of the report was given to the individual and her mother and a copy is in the records at the home as well. All future Quarterly ISP reviews will be provided to the plan team members within 30 calendar days after the ISP review meeting. The Life Sharing Specialist, Operations Manager and Quality Manager will be responsible to ensure ongoing compliance with this regulation. 01/03/2019 Implemented
6500.156(e)None of Individual #1 team members were offered the option to decline Individual #1 isp reviews.The family living specialist shall notify the plan team members of the option to decline the ISP review documentation.An ISP review was completed by the Life Sharing specialist dated 12/28/18 which includes the option to decline reviews. All future ISP reviews will include the following statement: All team members have the option to decline the ISP review. If you choose to decline, please notify the Life Sharing Specialist at Dayspring Homes. The Life Sharing Specialist, Operations Manager and Quality Manager will be responsible to ensure ongoing compliance. 12/28/2018 Implemented
6500.182(b)Staff #2 explained to licensing during the inspection that Staff #2 added "information pertinent to diagnosis and treatment in case of an emergency: vasa vagal syncope" to the 2018 physical exam form but did not include the name or the date Staff #2 added this information.Entries in an individual's record must be legible, dated and signed by the person making the entry.Staff # 2 signed and dated the entry on the 2018 physical form using the date that the information was added (11/19/18). Dayspring Management staff and Life Sharing providers who have access to individual records, will be trained in the licensing requirements and expectations to maintain compliance with Chapter 6500 regulation 6500.182 (b) by 1/31/19. The Operations Manager and Quality Manager will be responsible for training of staff and providers and for ongoing monitoring to ensure compliance. 01/31/2019 Implemented
6500.182(c)(1)(iv)Individual #1 record did not include religious affiliation, it just listed Individual #1 attends church.Each individual's record must include the following information: Personal information, including: The religious affiliation.Individual #1 record was updated on 12/28/18 to include the needed information- Religious Affiliation: Christian. Copies are in the records at the home. To ensure on going compliance, the Operations Manager and Quality Manager will use the Participant Face Sheet Checklist when reviewing face sheets in preparation for licensing. The Operations Manager and Quality Manager will be responsible to ensure ongoing compliance. 12/28/2018 Implemented
6500.182(c)(10)Individual #1 physician indicated on the 4/20/18 physical form to continue carb diet of 45/45/60. There was no daily documented monitoring of dietary intake to follow Individual #1 physician's recommendations. Also, the agency indicated that Individual #1 no longer needs to follow this diet however there isn't any documentation from Individual #1 physician to indicate this is correct. Dietary restriction does not include physician order, diet was to continue, but was subsequently discontinued by program. Each individual's record must include the following information: Content discrepancy in the ISP, the annual updates or revisions under §  6500.156.: The provider called the PCP on 11/27/18 to discuss this issue. On 11/29/18, a letter was received from the PCP stating that Individual #1 is medically stable and only needs to maintain her weight and that all previous dietary restrictions and counts may be removed. This letter has been added to Individual #1¿s record to support the protocol being discontinued. In the future the Nurse Consultant will be responsible to ensure that accurate information and documentation is received from any medical professionals before discontinuing a protocol. The Operations Manager and Quality Manager will be responsible to ensure ongoing compliance. 12/28/2018 Implemented
SIN-00122527 Renewal 10/13/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.107(d)There were no monthly checks of the smoke dectors completed. A smoke detector shall be tested each month to determine if the detector is operative.Dayspring Homes Lifesharing Providers will be retrained in the licensing requirements and expectations to maintain compliance with Chapter 6500 regulation 6500.107 (d) by 12/31/2017. Additionally, a new form has been created and will be used to track the monthly testing of smoke detectors in the homes. The Operations Manager, Debbi Dougherty, will be responsible for the training of the providers and the ongoing monitoring to ensure compliance. 12/31/2017 Implemented
6500.151(c)Individual #1's current assessment dated 6/15/17 does not state what it is based on. The assessment shall be based on assessment instruments, interviews, progress notes and observations.Dayspring Homes Lifesharing Providers will be retrained in the licensing requirements and expectations to maintain compliance with Chapter 6500 regulation 6500.151 (c) by 12/31/2017. A change was made to the current Annual Assessment form to include the following statement: This assessment is based on assessment instruments, interviews, progress notes and observations. This statement had previously been included on the last page of the assessment , it is now on the front page of the assessment as well as the last page. The Operations Manager, Debbi Dougherty, will be responsible for the training of the providers and the ongoing monitoring to ensure compliance. 12/31/2017 Implemented
6500.151(e)(10)Individual #1's current assessment dated 6/15/17 did not include a lifetime medical history. The assessment must include the following information: A lifetime medical history.Dayspring Homes Lifesharing Providers will be retrained in the licensing requirements and expectations to maintain compliance with Chapter 6500 regulation 6500.151 (e) (10) by 12/31/2017. A change was made to the Annual Assessment form to include the following statement: A Lifetime Medical History is attached to this assessment. The Operations Manager, Debbi Dougherty, will be responsible for the training of the providers and the ongoing monitoring to ensure compliance. 12/31/2017 Implemented
6500.151(e)(13)(i)Individual #1's current assessment dated 6/15/17 did not contain progress over the last 365 calendar days and current level in 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.Dayspring Homes Lifesharing Providers will be retrained in the licensing requirements and expectations to maintain compliance with Chapter 6500 regulation 6500.151 (e) (13) (i) by 12/31/2017. A change was made to the Annual Assessment form to include the following section: Please note the individuals progress and growth over the last 365 days in the following area: Health. The Operations Manager, Debbi Dougherty, will be responsible for the training of the providers and the ongoing monitoring to ensure compliance. 12/31/2017 Implemented
6500.151(e)(13)(ii)Individual #1's current assessment dated 6/15/17 did not contain progress over the last 365 calendar days and current level in 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.Dayspring Homes Lifesharing Providers will be retrained in the licensing requirements and expectations to maintain compliance with Chapter 6500 regulation 6500.151 (e) (13) (ii) by 12/31/2017. A change was made to the Annual Assessment form to include the following section: Please note the individuals progress and growth over the last 365 days in the following area: Motor and Communication Skills. The Operations Manager, Debbi Dougherty, will be responsible for the training of the providers and the ongoing monitoring to ensure compliance. 12/31/2017 Implemented
6500.151(e)(13)(iii)Individual #1's current assessment dated 6/15/17 did not contain progress over the last 365 calendar days and current level in activities of residential living. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living.Dayspring Homes Lifesharing Providers will be retrained in the licensing requirements and expectations to maintain compliance with Chapter 6500 regulation 6500.151 (e) (13) (iii) by 12/31/2017. A change was made to the Annual Assessment form to include the following section: Please note the individuals progress and growth over the last 365 days in the following area: Activities of Residential Living. The Operations Manager, Debbi Dougherty, will be responsible for the training of the providers and the ongoing monitoring to ensure compliance. 12/31/2017 Implemented
6500.151(e)(13)(iv)Individual #1's current assessment dated 6/15/17 did not contain progress over the last 365 calendar days and current level in personal adjustment. 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.Dayspring Homes Lifesharing Providers will be retrained in the licensing requirements and expectations to maintain compliance with Chapter 6500 regulation 6500.151 (e) (13) (iv) by 12/31/2017. A change was made to the Annual Assessment form to include the following section: Please note the individuals progress and growth over the last 365 days in the following area: Personal Adjustment . The Operations Manager, Debbi Dougherty, will be responsible for the training of the providers and the ongoing monitoring to ensure compliance. 12/31/2017 Implemented
6500.151(e)(13)(v)Individual #1's current assessment dated 6/15/17 did not contain progress over the last 365 calendar days and current level in 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.Dayspring Homes Lifesharing Providers will be retrained in the licensing requirements and expectations to maintain compliance with Chapter 6500 regulation 6500.151 (e) (13) (v) by 12/31/2017. A change was made to the Annual Assessment form to include the following section: Please note the individuals progress and growth over the last 365 days in the following area: Socialization. The Operations Manager, Debbi Dougherty, will be responsible for the training of the providers and the ongoing monitoring to ensure compliance. 12/31/2017 Implemented
6500.151(e)(13)(vi)Individual #1's current assessment dated 6/15/17 did not contain progress over the last 365 calendar days and current level in 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.Dayspring Homes Lifesharing Providers will be retrained in the licensing requirements and expectations to maintain compliance with Chapter 6500 regulation 6500.151 (e) (13) (vi) by 12/31/2017. A change was made to the Annual Assessment form to include the following section: Please note the individuals progress and growth over the last 365 days in the following area: Recreation. The Operations Manager, Debbi Dougherty, will be responsible for the training of the providers and the ongoing monitoring to ensure compliance. 12/31/2017 Implemented
6500.151(e)(13)(vii)Individual #1's current assessment dated 6/15/17 did not contain progress over the last 365 calendar days and current level in financial independence. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.Dayspring Homes Lifesharing Providers will be retrained in the licensing requirements and expectations to maintain compliance with Chapter 6500 regulation 6500.151 (e) (13) (vii) by 12/31/2017. A change was made to the Annual Assessment form to include the following section: Please note the individuals progress and growth over the last 365 days in the following area: Financial Independence. The Operations Manager, Debbi Dougherty, will be responsible for the training of the providers and the ongoing monitoring to ensure compliance. 12/31/2017 Implemented
6500.151(e)(13)(viii)Individual #1's current assessment dated 6/15/17 did not contain progress over the last 365 calendar days and current level in managing personal property. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas : Managing personal property.Dayspring Homes Lifesharing Providers will be retrained in the licensing requirements and expectations to maintain compliance with Chapter 6500 regulation 6500.151 (e) (13) (viii) by 12/31/2017. A change was made to the Annual Assessment form to include the following section: Please note the individuals progress and growth over the last 365 days in the following area: Managing Personal Property. The Operations Manager, Debbi Dougherty, will be responsible for the training of the providers and the ongoing monitoring to ensure compliance. 12/31/2017 Implemented
6500.151(e)(13)(ix)Individual #1's current assessment dated 6/15/17 did not contain progress over the last 365 calendar days and current level in community intrgration. 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.Dayspring Homes Lifesharing Providers will be retrained in the licensing requirements and expectations to maintain compliance with Chapter 6500 regulation 6500.151 (e) (13) (ix) by 12/31/2017. A change was made to the Annual Assessment form to include the following section: Please note the individuals progress and growth over the last 365 days in the following area: Community Integration. The Operations Manager, Debbi Dougherty, will be responsible for the training of the providers and the ongoing monitoring to ensure compliance. 12/31/2017 Implemented
6500.155(b)Individual #1's ISP last updated 8/7/17 is not implemented as written. The ISP meeting was held 6/15/17 and the annual review update date is 9/11/17. The ISP outcome states a self directions/ reflection outcome. It states individual #1 requires someone to help sort out her feelings at times. This outcome is to encourage the discussion of feelings. The actual outcome that the individual is currently working on is maintaining friendships by conecting by mailing a colored page to a friend or a family member. The ISP shall be implemented as written.Dayspring Homes Lifesharing Providers will be retrained in the licensing requirements and expectations to maintain compliance with Chapter 6500 regulation 6500.155 (b) by 12/31/2017. Lifesharing providers will be trained in the use of the quarterly review report format which includes a review of each section of the ISP, notably, Services and Support which includes Individual Outcome Summary and Outcome Action Plan. If a discrepancy is noted, an email will be sent to the Support Coordinator to alert them to the change that needs to be made to the ISP. Documentation of this correspondence will be kept with the ISP in the individuals record. The Operations Manager, Debbi Dougherty, will be responsible for the training of the providers and the ongoing monitoring to ensure compliance. 12/31/2017 Implemented
SIN-00165775 Renewal 11/22/2019 Compliant - Finalized
SIN-00101798 Initial review 10/07/2016 Compliant - Finalized