| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(e)(3) | Individual #1 requires staff assistance to complete purchases due to physical limitations. On 3/17/2024, a purchase was made with the individual's funds in the amount of $23.91 at Domino's and a receipt was not obtained or retained.
NOTE: A handwritten petty cash receipt was written by an employee from the fiscal department two months later, on 5/16/2024, when the absence of a receipt was discovered. Without the original receipt, it is not possible to determine if the purchase was made for the individual or for the individual's benefit. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. | The Site Supervisor is responsible for maintaining the petty cash logs and ensuring all receipts are obtained. The previous Site Supervisor failed to attempt to get a duplicate receipt or have the staff member who made the purchase fill out a detailed petty cash slip.
The previous Site Supervisor is no longer employed by Dayspring Homes. The current Site Supervisor is aware of the requirements for obtaining proper receipts and to our knowledge, there have been no further issues. |
07/15/2024
| Implemented |
| 6400.112(e) | A fire drill shall be held at least every six months during sleeping hours. A fire drill during sleeping hours was held on 9/24/2023 at 4:45 AM, and the next drill during sleeping hours was held on 4/03/2024 at 12:00 AM. The time span between the two drills was seven months. | A fire drill shall be held during sleeping hours at least every 6 months. | The plan of correction listed below was put into place on 1/1/24, following Dayspring¿s licensing inspection on 12/22/23. When this plan of correction was put into place, the Director of Operations and Director of Quality and Compliance did not realize that the new fire drill schedule would cause the first asleep drills in 2024 to be slightly late in some of the programs. Currently, the asleep drills are in compliance. There was an asleep drill on 4/3/24 at 12:00am and the next asleep drill is scheduled for 10/1/24 at 2:00am.
PREVIOUS POC: The Director of Operations created a fire drill schedule for 2024 that went into effect on 1/1/24. The new schedule outlines a specific day and time that the fire drill must be conducted each month. After the drill is completed, the Site Supervisor is expected to review the fire drill documentation within 1 business day. If there are any issues with the fire drill, the Site Supervisor will assign staff to re-do the drill within 24 hours. Any issues with the fire drill will be immediately reported to the Program Manager and/or Director of Operations so the management team can evaluate the situation and address any potential safety concerns. All fire drill records will be sent to the office with the end of month paperwork each month for the Director of Operations or the Program Manager to complete a final review. This new schedule and review system will ensure that the drills are being completed within the correct timeframes, are documented accurately, and repeated promptly if there are any issues. |
01/01/2024
| Implemented |
| 6400.144 | The topical medication A & D Ointment is prescribed for Individual #1 to be administered as needed for skin sores, but the medication was not available in the home at the time of inspection. | 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.
| This individual has several daily and PRN creams/ointments to manage/prevent skin rashes and breakdown. Due to having orders for several other creams that have been working for him, the PRN A&D has not recently been needed. Following this inspection, the Site Supervisor contacted the individuals PCP to ask if the A&D should be discontinued or refilled. The PCP recommended keeping the PRN A&D and sent a new prescription to the pharmacy. The A&D was refilled on 6/20/24 and is now available at the home. |
06/20/2024
| Implemented |
| 6400.163(d) | Paradontax toothpaste, which is prescribed for Individual #1 to brush with three times per day for gum health, was being stored in the individual's bedroom at the time of the inspection and was not stored in a locked box or area with the individual's other prescribed medications. | 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 toothpaste and/or mouthwashes recommended by dentists could be used without being treated like a typical medication. Due to this misinformation, the Site Supervisor was not ensuring that the medication was remaining labeled, locked, signed for, etc.
The toothpaste was moved the individuals locked medication box on 6/12/24.
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 |