Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00245835 Renewal 06/12/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106Documentation indicates that cleaning of the homes furnace last occurred on 5/24/23. There was no documentation to indicate that an annual inspection had occurred for 2024 within regulated timeframes.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. The Office Manager is responsible for scheduling the annual furnace inspections. When the previous Office Manager resigned in October 2023, she left a memo for the current Office Manager that the furnace inspections were due by 6/30/24; therefore, the current Office Manager was under the impression that the inspections did not need to be completed until that date. While preparing for licensing, it was discovered that some of the furnace inspections were due prior to 6/30/24. The current Office Manager scheduled furnace inspections for each home on 6/3/24; however, when company went to the homes, they serviced the central air units and not the furnaces. The Office Manager contacted the company again, and the furnace inspections were completed on 6/13/24 and 6/14/24. 06/14/2024 Implemented
6400.181(a)Assessments for Individual #1 were dated as being completed on 6/2/22 then updated annually on 10/31/23, this extends beyond the annual timeframes. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential 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 residential home. The previous Program Manager had not been effectively tracking assessment due dates and ensuring that they were completed within the required timeframe. Due to this, the assessment was completed late. The previous Program Manager is no longer overseeing this home. A new Program Manager was hired in March 2024 and is now responsible for ensuring that the assessments are completed on time. 07/01/2024 Implemented
6400.46(d)Documents provided noted that Staff #1, with a hire date of 8/23/00, received CPR certification on 6/14/23. Documentation of previous training provided noted American Red Cross Bloodborne Pathogens training on 10/1/21 that was valid for one year as well as a certificate for CEU on 10/1/21 from the American Red Cross. The certificate does not indicate the nature of the CEU. Compliance with the required timeframe and course material could not be determined with the documents provided.Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation.At the time of this inspection, the staff members 2022-2023 training records were provided to the inspectors as requested. Since they were reviewing the 2022-2023 training records, the previous CPR certification from 2021 was not initially provided. The inspectors requested the 2021 CPR certification to ensure that the staff member was recertified within the required timeframe. The HR Generalist had to pull this documentation, along with a few other items and the inspectors stated that the 2021 CPR certification could be scanned to them by 12:00pm the following day. The HR Generalist scanned this documentation to the Director of Quality and Compliance; however, the Director of Quality and Compliance did not get it to the inspectors by 12:00pm the following day. Once the documentation was passed along to the inspectors, it was discovered that the HR Generalist had scanned this staff member¿s Blood Borne Pathogens certification, but not their CPR certification. At that point, this citation was issued as they were unable to verify the 2021 CPR certification date and the exit interview had already occurred. After the inspection, the Director of Quality and Compliance followed up with the HR Generalist to see if this staff member had her CPR certification in 2021, or if it was truly late. The HR Generalist reported that this staff member did complete CPR on 6/18/21 and she had scanned the wrong document. This certification was valid for two years; therefore, this staff member¿s CPR training was not out of compliance. The Director of Quality and Compliance obtained a record of the 2021 CPR certification on 6/26/24 to verify compliance. 06/26/2024 Implemented
6400.163(a)Individual #1 is prescribed Parodontax toothpaste to be used three times per day. At time of inspection the tube of Parodontax toothpaste in use was on the bathroom counter without the labeled packaging from the pharmacy. A new tube of Parodontax toothpaste was properly labeled and in the individual's medication box.Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy.The Site Supervisor of this home is aware that all medications need to be labeled; however, the Director of Quality and Compliance was under the impression that over-the-counter toothpastes and/or mouthwashes recommended by the dentist could be used without being treated like a typical medication. Due to this misinformation, the medication was written on the MAR as an FYI and the Site Supervisor was not ensuring that the medication was remaining labeled, locked, signed for, etc. The Site Supervisor was able to locate the labeled box and the toothpaste was returned to its original packaging on 6/12/24. All staff were educated on storing the toothpaste in the original labeled container. The Director of Quality and Compliance reached out to the Licensing Supervisor on 6/26/24 to clarify that over-the-counter toothpaste or mouthwash recommendations need to be labeled and treated as a medication. The Licensing Supervisor confirmed that this was the case. 06/12/2024 Implemented
6400.163(d)At time of inspection the prescribed Parodontax toothpaste in use for Individual #1 was located on the bathroom counter. The toothpaste was not properly locked when not in use. A new tube of Parodontax toothpaste was in the individuals locked medication box.Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked.The Site Supervisor of this home is aware that all medications need to be locked; however, the Director of Quality and Compliance was under the impression that over-the-counter toothpastes and/or mouthwashes recommended by the dentist could be used without being treated like a typical medication. Due to this misinformation, the medication was written on the MAR as an FYI and the Site Supervisor was not ensuring that the medication was remaining labeled, locked, signed for, etc. The toothpaste was moved to the individuals locked medication box on 6/12/24. All staff were educated on storing the toothpaste in the individuals locked medication box. The Director of Quality and Compliance reached out to the Licensing Supervisor on 6/26/24 to clarify that over-the-counter toothpaste or mouthwash recommendations need to be locked and treated as a medication. The Licensing Supervisor confirmed that this was the case. 06/12/2024 Implemented
6400.166(a)(10)The June 2024 Medication Administration Record (MAR) for Individual #1 contained an entry for "Paradontax Brush three times daily for oral hygiene." There were no administration times noted on the June 2024 MAR for Individual #1.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times.The Director of Quality and Compliance was under the impression that over-the-counter toothpastes and/or mouthwashes recommended by the dentist could be used without being treated like a typical medication. Due to this misinformation, the Site Supervisor was not adding the toothpaste to the MAR as a medication and it was listed as a reminder. The Site Supervisor corrected the MAR on 6/12/24. Administration times were added, and all staff were made aware that the toothpaste must now be signed for after each use. The Director of Quality and Compliance reached out to the Licensing Supervisor on 6/26/24 to clarify that over-the-counter toothpaste or mouthwash recommendations need to be labeled and treated as a medication. The Licensing Supervisor confirmed that this was the case. 06/12/2024 Implemented
6400.166(b)The June 2024 Medication Administration Records (MAR) for Individual #1 contained an entry for "Paradontax Brush three times daily for oral hygiene." Required items of the time of administration and the initial of the person administering were not recorded for any day on the June 2024 MAR for Individual #1.The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.The Director of Quality and Compliance was under the impression that over-the-counter toothpastes and/or mouthwashes recommended by the dentist could be used without being treated like a typical medication. Due to this misinformation, the Site Supervisor was not adding the toothpaste to the MAR as a medication and it was listed as a FYI; therefore, staff were not signing for it after each use. The Site Supervisor corrected the MAR on 6/12/24 and all staff were made aware that the toothpaste must now be signed for after each use. The Director of Quality and Compliance reached out to the Licensing Supervisor on 6/26/24 to clarify that over-the-counter toothpaste or mouthwash recommendations need to be labeled and treated as a medication. The Licensing Supervisor confirmed that this was the case. 06/12/2024 Implemented
6400.166(d)The June 2024 Medication Administration Records (MAR) for Individual #1 contained an entry for "Paradontax Brush three times daily for oral hygiene." There were no initials on the MAR to indicate that the toothpaste was used as directed. It could not be determined that the directions of the prescriber had been followed due to lack of documentation of administration.The directions of the prescriber shall be followed.The Director of Quality and Compliance was under the impression that over-the-counter toothpaste and/or mouthwashes recommended by dentists could be used without being treated like a typical medication. Due to this misinformation, the toothpaste was added to the MAR as an FYI for staff and was not being signed for after each use. On 6/12/24, the Site Supervisor alerted all staff that they must now sign for the toothpaste after each use. The Director of Quality and Compliance reached out to the Licensing Supervisor on 6/26/24 to clarify that over-the-counter toothpaste or mouthwash recommendations need to be labeled and treated as a medication. The Licensing Supervisor confirmed that this was the case. 06/12/2024 Implemented
SIN-00216001 Renewal 12/26/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(c)Poisons shall be stored in their original labeled containers. A bottle of what appeared to be liquid dish detergent was found at the kitchen sink without a label on the bottle.Poisonous materials shall be stored in their original, labeled containers. Due to it being more cost effective, refill size bottles of dish soap were being purchased to refill the dish soap container in the kitchen. Unfortunately, the label had come off the smaller dish soap container and it was not discarded. The unlabeled dish soap container was disposed of as soon as it was discovered by the inspector. 12/20/2022 Implemented
6400.144Health Services such as medical appointment are not being planned for or arranged. Individual #1's 10/12/22 GYN appointment recommended follow up her PCP for "RVQ adnominal pain, evaluate gallbladder. Patient reports 6--7-month history of RVQ pain." There was no documentation provided that this follows up occurred.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. Individual #1 has chronic constipation and will report abdominal pain to staff when she is having trouble going to the bathroom. Staff report that after they administer her PRN constipation medication, the pain resolves. Individual #1 saw her GI doctor on 9/21/22 and had no complaints of abdominal pain at that time. She had her annual physical on 11/17/22 and had no complaints of abdominal pain at that time either; however, due to the complaints Individual #1 made to the gynecologist on 10/12/22, the Site Supervisor did discuss this concern with the PCP during her annual physical exam. He was not concerned and did not recommend any further action at that time. The PCP did not make an additional note about the abdominal pain on her appointment paperwork but did check ¿normal¿ on the abdominal section of her physical exam form. Since no documentation of the abdominal pain being addressed was on file, a PCP appointment was scheduled on 12/22/22. The PCP assessed Individual #1 and no further intervention was recommended. 12/22/2022 Implemented
6400.46(b)Staff #1 and Staff #2 did not receive annual training in fire safety. Staff #1 completed fire safety training on 11/3/20 and did not complete it again until 3/9/22. Staff #2 completed fire safety training on 9/1/21 and then again did not complete it again until 9/12/22.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).The Dayspring team is well aware that training has been a deficiency of ours over the last few years for various reasons. The Human Resources Department has worked diligently on staff training over that last year and has made great progress with getting staff training back on track; however, there have still been some minor training issues as the team has worked on improving our staff training. At this time, the staff identified is current in fire safety training. 02/13/2023 Implemented
SIN-00197670 Renewal 12/13/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The agency did not complete a self assessment of the home. (repeat violation 1/12/21)The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. In response to the citation received in 2020, a self-assessment schedule was developed to track when assessments are to be completed for all programs. The Compliance Manager will review that schedule to ensure that the information is accurate and will make any needed corrections based on the current COC dates for all programs. The new schedule will then be used to track when all self ¿assessments are required to be completed. The Compliance Manager and Director of Operations will then develop an improved process/system that ensures the assessments are completed within the required timeframes. . 02/28/2022 Implemented
SIN-00181615 Renewal 01/11/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)There was not a self assessment of the home completed 3-6 months prior to the expiration of the agency's certificate of compliance.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. Dayspring Management staff will be retrained in the licensing requirements and expectations to maintain compliance with regulation 6400.15(a) by 3/12/21. Additionally, the Compliance Manager will develop a schedule to track when all self- assessments for Dayspring are to be completed. The current Certificate of Compliance for Dayspring 6400 programs is dated 9/23/20 - 9/23/21. The self- assessments for these programs will be completed between March 2021 and June 2021 to ensure compliance with this regulation. Director of Operations and the Compliance Manager will be responsible to ensure that the self- assessments are completed. The Compliance Manager will be responsible for continued monitoring to ensure ongoing compliance. 03/12/2021 Implemented
6400.73(a)The stairs leading out of the basement through bilco doors to the outside did not have a railing. Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. Dayspring will contract with a local contractor to have a railing installed on the basement staircase. Once we receive an estimate for the work and the work is scheduled, Dayspring will update the Regional office with a completion date for the work. The Director of Operations and the Compliance Manager will be responsible for ensuring that the work is completed and to ensure compliance with regulation 6400.73(a). 03/12/2021 Implemented
6400.110(a)At the time of inspection, the basement of the home did not have an operable automatic smoke detector. The home's smoke detectors were interconnected and all other smoke detectors were operable. The smoke detector in the basement has a strobe light on it that was operable at the time of inspection, the smoke detector did not have any sound. A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. Dayspring Management staff will be retrained in the licensing requirements and expectations to maintain compliance with regulation 6400.110(a) by 3/12/21. Additionally, at the time of the inspection the Compliance Manager purchased a new smoke detector and installed it in the basement of the home. A video of the working detector was sent to the licensing inspector at that time. Dayspring will schedule to have to the inoperable interconnected smoke detector inspected and repaired. The Program Specialist/ Supervisor will be responsible to ensure that the system is checked monthly as required and will ensure that any issues or concerns related to the system are reported and corrected immediately. The Director of Operations and the Compliance Manager will be responsible for ensuring ongoing compliance. 03/12/2021 Implemented
6400.141(c)(4)Individual #1's physical dated 7/8/20 did not include a hearing screening and one was not completed.The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. Dayspring Management staff will be retrained in the licensing requirements and expectations to maintain compliance with Chapter 6400 regulation 6400.141(c) (4) by 3/12/21. Individual # 1¿s Program Specialist/ Supervisor will be responsible for scheduling a hearing screening with her PCP as soon as possible. Documentation of that exam will be kept in the medical records at the home. The Program Specialist will be responsible to submit all individuals physical examination forms to the Director of Operations and the Compliance Manager for review within 5 days of the physical being completed. The Director of Operations and the Compliance Manager will be responsible for ensuring ongoing compliance. 03/12/2021 Implemented
6400.34(a)Individual #1's record contained a signed copy of individual rights signed on 1/21/20. The rights haven't been updated to reflect the current Chapter 6400 regulations including: The missing rights include: 6400.32. (e) An individual has the right to make choices and accept risks. (f) An individual has the right to refuse to participate in activities and services. (k) An individual has the right to participate in the development and implementation of the individual plan. (n) An individual has the right to unrestricted and private access to telecommunications. (p) An individual has the right to choose persons with whom to share a bedroom. (r) An individual has the right to lock the individual's bedroom door. (t) An individual has the right to access food at any time. (s) An individual has the right to have a key, access card, keypad code or other entry mechanism to lock and unlock an entrance door of the home.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.Dayspring policy 6.6 Program Participants Rights, Responsibilities and Resources will be updated and revised to include the updated regulatory rights as described in 6400.34 (a). The updated and revised policy will then be reviewed with all individuals and the documentation of that review will be kept in the records at the home. The policy will be reviewed with all individuals annually thereafter. The Compliance Manager and Director of HR will be responsible to ensure that Dayspring policy 6.6 Program Participants Rights, Responsibilities and Resources is updated and revised by 3/12/21. The Program Specialist and Director of Operations will be responsible to ensure that policy is then reviewed with all individuals and that the documentation is kept in the record at the home. The Program Specialist, Compliance Manager and Director of Operations will be responsible to ensure ongoing compliance. 03/12/2021 Implemented
6400.52(c)(1)Staff #1, date of hire 10/25/17, did not have the required annual training to encompass the following area: the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.The current Dayspring annual training curriculum will be reviewed and revised to ensure that all required annual training topics as listed in 6400.52 (c)(1) are included in the annual training provided to all employees. The Director of HR and the Compliance Manager will be responsible to ensure that the Dayspring annual training curriculum is updated and revised by 3/12/21. All current employees will receive training in the updated training curriculum during the current training year. The Director of HR will be responsible to ensure that the training occurs for all new employees initially. The Program Specialist and Director of Operations will be responsible to ensure training occurs annually thereafter. The Compliance Manager and Director of HR will be responsible to ensure ongoing compliance 03/12/2021 Implemented
6400.52(c)(2)Staff #1, date of hire 10/25/17, did not have the required annual training to encompass the following area: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.: The current Dayspring annual training curriculum will be reviewed and revised to ensure that all required annual training topics as listed in 6400.52 (c)(2) are included in the annual training provided to all employees. The Director of HR and the Compliance Manager will be responsible to ensure that the Dayspring annual training curriculum is updated and revised by 3/12/21. All current employees will receive training in the updated training curriculum during the current training year. The Director of HR will be responsible to ensure that the training occurs for all new employees initially. The Program Specialist and Director of Operations will be responsible to ensure training occurs annually thereafter. The Compliance Manager and Director of HR will be responsible to ensure ongoing compliance 03/12/2021 Implemented
6400.52(c)(3)Staff #1, date of hire 10/25/17, did not have the required annual training to include: Individual Rights.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.The current Dayspring annual training curriculum will be reviewed and revised to ensure that all required annual training topics as listed in 6400.52 (c)(3) are included in the annual training provided to all employees. The Director of HR and the Compliance Manager will be responsible to ensure that the Dayspring annual training curriculum is updated and revised by 3/12/21. All current employees will receive training in the updated training curriculum during the current training year. The Director of HR will be responsible to ensure that the training occurs for all new employees initially. The Program Specialist and Director of Operations will be responsible to ensure training occurs annually thereafter. The Compliance Manager and Director of HR will be responsible to ensure ongoing compliance 03/12/2021 Implemented
6400.52(c)(4)Staff #1, date of hire 10/25/17, did not have the required annual training to encompass the following area: Recognizing and reporting incidents.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.The current Dayspring annual training curriculum will be reviewed and revised to ensure that all required annual training topics as listed in 6400.52 (c)(4) are included in the annual training provided to all employees. The Director of HR and the Compliance Manager will be responsible to ensure that the Dayspring annual training curriculum is updated and revised by 3/12/21. All current employees will receive training in the updated training curriculum during the current training year. The Director of HR will be responsible to ensure that the training occurs for all new employees initially. The Program Specialist and Director of Operations will be responsible to ensure training occurs annually thereafter. The Compliance 03/12/2021 Implemented
6400.52(c)(5)Staff #1, date of hire 10/25/17, did not have the required annual training to encompass the area: The safe and appropriate use of behavior supports if the person works directly with an individual.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual.The current Dayspring annual training curriculum will be reviewed and revised to ensure that all required annual training topics as listed in 6400.52 (c)(5) are included in the annual training provided to all employees. The Director of HR and the Compliance Manager will be responsible to ensure that the Dayspring annual training curriculum is updated and revised by 3/12/21. All current employees will receive training in the updated training curriculum during the current training year. The Director of HR will be responsible to ensure that the training occurs for all new employees initially. The Program Specialist and Director of Operations will be responsible to ensure training occurs annually thereafter. The Compliance Manager and Director of HR will be responsible to ensure ongoing compliance 03/12/2021 Implemented
6400.165(g)Individual #1 had a medication review for medications prescribed for psychiatric illness on 12/29/20. The documentation from the review does not include the reason for prescribing the medication or the need to continue the medication.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Dayspring Management staff will be retrained in the licensing requirements and expectations to maintain compliance with regulation 6400.165 (g) by 3/12/21. The Program Specialist/Supervisor will contact Individual # 1 psychiatric provider to have the documentation from the 12/29/20 updated to include this information. The Program Specialist/Supervisor will ensure that all future appointment forms are completed accurately and completely. The Director of Operations and the Compliance Manager will be responsible to ensure ongoing compliance. 03/12/2021 Implemented
6400.169(a)Staff #1, date of hire, 10/25/17, was trained in medication administration on 11/16/17 and a renewal course on 12/23/19. Staff 1 has not completed the medication administration renewal annually as required.A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration).Dayspring Management staff will be retrained in the licensing requirements and expectations to maintain compliance with regulation 6400.169 (a) by 3/12/21. Staff #1 was out of work on medical leave at the time her annual practicum was due to be completed and will be completed by 3/12/21. At this time Dayspring has only one Medication Administration Trainer responsible for training and maintaining annual practicums. The current Director of Operations is completing the Train the Trainer Course and will be assisting to train staff and maintain annual practicums in the future. The Director of Operations, the Compliance Manager and Medication Administration Trainers, will be responsible to ensure ongoing compliance with this regulation. Annual Practicums will be divided among the trainers to ensure that all practicums are completed within the annual requirement. 03/12/2021 Implemented
SIN-00162985 Renewal 09/20/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.113(a)Individual #2's annual fire safety training was late. The current fire safety training occurred on 1/27/19 and the previous training was on 1/08/18. An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. Dayspring Management staff will be retrained in the licensing requirements and expectations to maintain compliance with regulation 6400.113 (a) by 11/29/19. The ongoing expectation is that all residents will participate in fire safety training twice a year. Supervisors of all programs will be expected to complete the Residential Book Review form on a quarterly basis. The Director of Operations will review those forms/ checklists as they are completed and will ensure that any issues identified are addressed and resolved or corrected. The Quality Manager will be responsible to review/ complete the Residential Book Review form for all programs on a quarterly basis as well. The Director of Operations and Quality Manager will be responsible for continued monitoring and ongoing compliance. 11/29/2019 Implemented
6400.141(c)(7)Individual #2's most recent annual gynecological examination was late. Individual#2's current examination occurred on 9/10/19, and the previous examination was on 6/27/18.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. : Dayspring Management staff will be retrained in the licensing requirements and expectations to maintain compliance with regulation 6400.141 (c) (7) by 11/29/19. Additionally, Supervisors of all programs will be expected to complete the Residential Book Review form on a quarterly basis. The Director of Operations will review those forms/ checklists as they are completed and will ensure that any issues identified are addressed and resolved or corrected. The Quality Manager will be responsible to review/ complete the Residential Book Review form for all programs on a quarterly basis as well. The Director of Operations and Quality Manager will be responsible for continued monitoring and ongoing compliance. 11/29/2019 Implemented
6400.141(c)(8)Individual #2's annual mammogram is overdue. The most recent mammogram occurred on 8/22/18.The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. : Dayspring Management staff will be retrained in the licensing requirements and expectations to maintain compliance with regulation 6400.141 (c) (8) by 11/29/19. Individual #2 had a mammogram completed on 9/23/19. Documentation of that appointment will be sent to OPD. Additionally, Supervisors of all programs will be expected to complete the Residential Book Review form on a quarterly basis. The Director of Operations will review those forms/ checklists as they are completed and will ensure that any issues identified are addressed and resolved or corrected. The Quality Manager will be responsible to review/ complete the Residential Book Review form for all programs on a quarterly basis as well. The Director of Operations and Quality Manager will be responsible for continued monitoring and ongoing compliance. 11/29/2019 Implemented
6400.144At an ophthalmology appointment on 7/15/19, the ophthalmologist determined that the eyeglasses being worn by Individual #2 were too strong, and that the prescription for the glasses did not match any previous prescription on file for the Individual. New glasses in the correct prescription were recommended but have not been obtained for the Individual.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. Dayspring Management staff will be retrained in the licensing requirements and expectations to maintain compliance with regulation 6400.144 by 11/29/19. Additionally, it was determined that Individual # 2 had worn the wrong glasses to her vision appointment on 7/15/19. At that appointment the doctor recommended new glasses based on a change in vision for Individual #2. Individual #2¿s father is the rep payee for her and the script for the new lenses was given to him. The father was resistant to paying for new lenses. Staff at the home failed to share this information with management. The Director of Operations will be responsible to ensure that the issue is resolved by working with the Supervisor and the father to ensure that the new lenses are ordered and received. 11/29/2019 Implemented
SIN-00140633 Renewal 08/29/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(7)Individual #1 should be getting pelvic ultrasounds per her doctor every two years. It was last done on 08-03-16 and did not yet occur this year.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. An appointment was held on 8/13/18 for Individual # 1 but the exam was able to be completed at that time and it was recommended that a pelvic ultrasound be scheduled. The doctor¿s office then called the individual¿s mother to schedule the appointment which caused a delay in the appointment being scheduled. Individual # 1 attended the pelvic ultrasound appointment on 9/25/18 at Dr. Consoil¿s office. Dayspring Management staff will be retrained in the requirements of regulation 6400.141 (c )(7) by 11/30/18. The Operations Manager will be responsible for retraining of staff. The agency Nurse will be responsible for ensuring the ongoing compliance with this regulation by monitoring all participant appointments on a monthly basis. 11/30/2018 Implemented
6400.141(c)(14)Information regarding Info pertinent to diagnosis and treatment in case of an emergency was left blank in Individual #1's file.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Individual #1¿s annual physical form will be updated to include the required information by 11/30/18. Additionally, the Operations Manager will be responsible for ensuring that all Management staff are retrained in the licensing requirements to ensure compliance with regulation 6400.141 (c ) (14) by 11/30/18. The agency Nurse will be responsible to ensure that staff are using the correct participant physical form which includes this information. The agency Nurse will be responsible to ensure continued monitoring to ensure compliance. 11/30/2018 Implemented
6400.143(a)There were refusals of medical appointments by Individual #1 in her file, but no desensitization plan or documentation of attempts to train her about the importance of attending medical appointments.If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. The agency Nurse will be responsible for developing a desensitization plan for Individual #1 to address the importance of attending and participating in medical appointments. The plan will be developed, approved and in the participant file by 11/30/18. The Operations Manager will be responsible to ensure that ongoing compliance with this regulation is maintained. 11/30/2018 Implemented
6400.181(e)(12)There were no recommendations found anywhere in Individual #1's assessment. Only her current status in various areas was listed.The assessment must include the following information: Recommendations for specific areas of training, programming and services. Dayspring Management staff will be retrained in the licensing requirements and expectations to maintain compliance with regulation 6400.181 (12) by 11/30/18. A change will be made to the Annual Assessment to include the following information: recommendations for specific areas of training, programming and services. The Operations Manager will be responsible for making the change to the Annual Assessment and for retraining of staff. The Program Manager will be responsible for ongoing monitoring to ensure compliance. 11/30/2018 Implemented
6400.181(f)Individual #1's assessment was not sent to the SC or team at least thirty days prior to the ISP meeting.(f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). Dayspring Management staff will be retrained in the licensing requirements and expectations to maintain compliance with regulation 6400.181(f) by 11/30/18. Additionally, the Operations Manager will develop a schedule for each home which will include the date each participants ISP is due as well as when the annual assessment is due to be completed. The Program Manager will be responsible to ensure that each Supervisor maintains ongoing compliance with this regulation by ensuring that they use the agency ISP checklist form when preparing for an upcoming ISP. The ISP checklist form includes the requirement that the annual assessment be completed one month prior to the ISP meeting and is to be sent to the team at that time. The Operations Manager and Program Managers will be responsible to ensure that Management staff are trained in this expectation and for continued monitoring to ensure compliance. 11/30/2018 Implemented
SIN-00124284 Renewal 10/31/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(f)Individual #3's ISP meeting was held on 12/15/2016. Her assessment was completed and sent to her team on 12/13/2016.(f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). Dayspring Management staff will be retrained in the licensing requirements and expectations to maintain compliance with Chapter 6400 regulation 6400.181(f) by 1/31/18. Additionally an ISP checklist form was developed and will be implemented as part of the retraining process. The ISP checklist will include 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 Specialists will be responsible to ensure that all Management staff are trained in the use of the ISP Checklist form by 1/31/18. 01/31/2018 Implemented
6400.186(b)Individual #3 did not sign her ISP Reviews dated 3/12/17, 6/12/17, and 9/12/17.The program specialist and individual shall sign and date the ISP review signature sheet upon review of the ISP. Dayspring Management staff will be retrained in the licensing requirements and expectations to maintain compliance with Chapter 6400 regulation 6400.186 (b) by 1/31/18. The Operations Manager and Program Specialists will be responsible to ensure ongoing compliance with this regulation. 01/31/2018 Implemented
SIN-00105291 Renewal 11/15/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(7)It was recommended by the OB/GYN that Individual #1 have a transabdominal ultrasound every 2 years. She had a transabdominal ultra sound on 6/17/2014. She didn't have another ultra sound until 8/3/2016, which exceeds the bi-annual recommendation from her doctor. 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. Dayspring Management staff will be retrained in the licensing requirements and expectations to maintain compliance with Chapter 6400 regulation 6400.163 (c) by 2/28/2017. Additionally, the Nurse Consultant has developed a system for tracking medical appointments for each individual and is completing monthly appointment reminder forms for each program. Dayspring Management staff will be trained in the purpose of this new tracking system and the ongoing expectations for the use of the system and forms. The CEO, Operations Manager, Program Specialist will be responsible for retraining of staff. The Nurse Consultant will be responsible for training in the medical appointment tracking system and the monthly appointment reminder forms. All retraining will be completed by 2/28/2017. 02/28/2017 Implemented
6400.186(c)(2)ISP areas such as health & safety are not being reviewed for Individual #1's ISP Reviews. The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. Dayspring Management staff will be retrained in the licensing requirements and expectations to maintain compliance with Chapter 6400 regulation 6400.168 (c) (2) by 2/28/2017. Additionally, changes have been made to the Quarterly Review Report to include a review of all sections of the ISP, as well as documentation of notification to the Support Coordinator for any changes noted. The CEO, Operations Manager and Program Specialist will be responsible for retraining of staff. The Program Specialist will be responsible to ensure that all Management staff are trained in the use of the new report format and begin using the form by 2/28/2017. 02/28/2017 Implemented
SIN-00086254 Renewal 10/21/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(d)The fire drill conducted on 8/31/2015 at 6:02pm had an evacuation time of 2 minutes and 57 seconds. Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. The fire drill completed on 8/31/2015 noted the time it took for all individuals to reach the meeting place (and not the time it took to evacuate the home). The Residential staff / Program Specialist have been re-trained (10/08/2015) in the regulatory requirement that fire drill evacuation times stop when all persons safely evacuate the residence (not total time to reach meeting place). Additionally, Dayspring Homes revised the Dayspring fire drill log to include directions relating to timing the evacuation times when completing a fire drill. 12/01/2015 Implemented
6400.112(e)Sleep fire drills were conducted on 10/15/14 and again 8 months later on 6/19/2015.A fire drill shall be held during sleeping hours at least every 6 months. Program Specialists will be retrained in this regulatory requirement `asleep fire drills¿ need to be conducted at least every 6 months. Attached is the Dayspring fire Drill log that notes fire drill times that rotate ¿ varying times drills are conducted, and that `Asleep drills¿ are to be conducted every three months. 12/01/2015 Implemented
6400.141(a)Individual #2 had a physical on 5/21/14 and not again until 7/9/15.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. The individual had her Physical examination completed on 7/09/2015. Dayspring Homes has developed a pre-admission checklist to ensure compliance of required medical regulatory requirements prior to admission into Residential Community Home services. 12/01/2015 Implemented
6400.181(a)Individual #2 has a date of admission of 6/19/15. Individual #2¿s initial assessment was completed on 10/16/2015. Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential 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 residential home. Dayspring Homes has developed a pre-admission checklist to ensure compliance of the required initial Skills Assessment regulatory requirement prior to admission into Residential Community Home services. 12/01/2015 Implemented
SIN-00235629 Renewal 12/19/2023 Compliant - Finalized
SIN-00122698 Renewal 10/31/2017 Compliant - Finalized