Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00235627 Renewal 12/19/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)Clean and sanitary conditions shall be maintained in the home. The faucet, hot and cold faucet handles, and bathroom sink drain located in the basement bathroom all had multiple areas that were covered in an unidentifiable white substance. The white substance resembled toothpaste residue or calcium buildup.Clean and sanitary conditions shall be maintained in the home. Staff attempted to clean the sink with basic cleaning products but were not able to remove all the build-up. Maintenance was made aware and was able to thoroughly clean the faucet/sink and remove all the build-up. This job was completed on 1/18/24. All Site Supervisors and the Program Manager were shown photos of the sink/faucet and trained on this regulation on 1/15/24. 01/18/2024 Implemented
6400.67(a)Floors, walls, ceilings, and other surfaces shall be in good repair. There were 2 sections on the bottom left of on the bathroom door located in the basement that the stained wood was missing and exposing the untreated wood on the door. 1 section of the door was approximated 4 inches long by 12 inched high and the second section was approximately 3 inches long and 5 inches high. There was an extra dresser located in the basement for storage and one of the drawers was missing the front wooden piece of the drawer.Floors, walls, ceilings and other surfaces shall be in good repair. Maintenance was made aware that the bathroom door would need to be repaired or replaced and that the dresser in the basement would need to be repaired or removed. Maintenance was able to sand and paint the bathroom door, this was completed on 1/9/24. The missing dresser drawer was located and returned to the dresser and the broken drawer was fully repaired by 1/16/24. The Site Supervisors and Program Manager were trained on these citations during the monthly site supervisor meeting on 1/15/24. 01/16/2024 Implemented
6400.32(r)Individual #1's bedroom door lock is a "privacy lock"/pin key lock. This type of lock can be opened with a tool or device that is not specific to the particular door or lock, such as, a screwdriver or pin. These types of locks do not provide the level of privacy and security of person and possessions as expected by this regulation.An individual has the right to lock the individual's bedroom door.This individual has declined a lock on her bedroom door. This is stated in her ISP and the team agreed with her decision. Maintenance was made aware, and the knob will be replaced by 2/1/24. We will be providing her with a knob with a keypad locking feature; however, the keypad will not be activated unless she asks for a lock in the future. The Supports Coordinator was made aware so that her ISP can be updated. All Site Supervisors and the Program Manger were retrained of bedroom door lock requirements on 1/15/24. 02/01/2024 Implemented
6400.32(s)(1)Assistive technology shall be provided as needed to allow the individual to lock and unlock the door without assistance. Individual #2's Individual Support Plan (ISP) states that Individual #2's residential team discussed a bedroom lock for privacy and agreed that since Individual #2 cannot use a key to open a lock, she would not be able to use one on her bedroom door.Assistive technology shall be provided as needed to allow the individual to lock and unlock the door without assistance.MC¿s 2022 ISP stated the following: MC'S RESIDENTIAL TEAM DISCUSSED A BEDROOM LOCK FOR PRIVACY AND AGREED THAT SINCE MC CANNOT USE A KEY TO OPEN A LOCK, SHE WOULD NOT BE ABLE TO USE ONE ON HER BEDROOM DOOR. MC¿s current ISP updated in 2023 states the following: DURING TEAM MEETING ON 8/1/23, LEGAL GUARDIAN, CC, DECLINED A DOOR LOCK FOR MC'S BEDROOM DUE TO HEALTH AND SAFETY AS MC HAS A SEIZURE DIAGNOSIS AND A DOOR LOCK WOULD PREVENT STAFF ENTERING THE BEDROOM DURING A SEIZURE. MC has not expressed any desire to have a lock and the team agrees with her father that a lock could be a health and safety risk in the event of a seizure. Due to this, adaptive locks will not be pursued. If MC expresses the desire to have a lock in the future, we will reevaluate this decision. All Site Supervisors and the Program Manger were retrained of bedroom door lock requirements on 1/15/24. 12/19/2023 Implemented
SIN-00201813 Unannounced Monitoring 03/02/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(b)Staff #1, Staff #2 and Staff #7 are not current in fire safety training. Staff #1 and Staff #7 last received fire safety training on 1/5/21, and Staff #2 on 1/19/21.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).In response to citations received during our 2020 and 2021 inspections, Dayspring HR department and management team began the process of reviewing and revising our training curriculums as well as the training process/program to ensure that all required training topics as listed in chapters 6100 and 6400 regulations are included in the training provided to all staff. The new training packets have been completed and the revised training program has now been implemented. The Annual Employee Development Training Packet encompasses all required annual training areas to ensure compliance with 6100 and 6400 regulations. The training packet includes a list of all required annual trainings with instructions on how each training is to be completed- instructor led/blended, on demand etc., what documentation is needed to show the training was successfully completed- test after training, training summary or certificate etc. The packet is an all-inclusive resource for staff to utilize to complete their trainings and ensure that all training requirements are met. A thorough review of all employee annual training records was conducted to identify areas of non-compliance. The Employee Development/HR department contacted employees whose records showed they did not meet all annual training requirements. The HR department explained the new training process and program that has been implemented and provided each employee with an Annual Employee Development Training Packet. The expectations for completing all outstanding trainings and submitting documentation of completed trainings to HR by the specified deadline was reviewed and explained to each employee. The Employee Development/ HR departments have been receiving documentation of completed trainings from employees and are tracking the progress for each employee to ensure that all employee records meet the regulatory requirements and are in compliance within 30 days. Dayspring received the POC from ODP on 3/18/22 and has implemented a plan to ensure all annual training requirements are met and all employee records are in compliance by 4/15/22. The employees from the sample reviewed during the inspection on 3/2/22 have completed the following annual trainings Staff # 7 completed this training on 3/15/22 Staff # 1 and # 2 need to completed this training by 4/15/22 04/15/2022 Implemented
6400.46(d)Staff #2's CPR /First Aid training date is documented as 8/11/21. Previous training date documented is 6/27/19. This does not meet the annual requirement.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.In response to citations received during our 2020 and 2021 inspections, Dayspring HR department and management team began the process of reviewing and revising our training curriculums as well as the training process/program to ensure that all required training topics as listed in chapters 6100 and 6400 regulations are included in the training provided to all staff. The new training packets have been completed and the revised training program has now been implemented. The Annual Employee Development Training Packet encompasses all required annual training areas to ensure compliance with 6100 and 6400 regulations. The training packet includes a list of all required annual trainings with instructions on how each training is to be completed- instructor led/blended, on demand etc., what documentation is needed to show the training was successfully completed- test after training, training summary or certificate etc. The packet is an all-inclusive resource for staff to utilize to complete their trainings and ensure that all training requirements are met. A thorough review of all employee annual training records was conducted to identify areas of non-compliance. The Employee Development/HR department contacted employees whose records showed they did not meet all annual training requirements. The HR department explained the new training process and program that has been implemented and provided each employee with an Annual Employee Development Training Packet. The expectations for completing all outstanding trainings and submitting documentation of completed trainings to HR by the specified deadline was reviewed and explained to each employee. The Employee Development/ HR departments have been receiving documentation of completed trainings from employees and are tracking the progress for each employee to ensure that all employee records meet the regulatory requirements and are in compliance within 30 days. Dayspring received the POC from ODP on 3/18/22 and has implemented a plan to ensure all annual training requirements are met and all employee records are in compliance by 4/15/22. The employees from the sample reviewed during the inspection on 3/2/22 have completed the following annual trainings Staff # 2 completed this training on 8/11/21 and will need to complete certification prior to 8/11/23 The new training packets along with the HRMS being implemented along with additional oversite and tracking for compliance staff training will be expected to be completed prior to current certifications expiration dates. 04/15/2022 Implemented
6400.52(c)(1)Staff #1, Staff #2 and Staff #7 did not receive annual training in person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. (Repeat Violation 1/11/21)The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.In response to citations received during our 2020 and 2021 inspections, Dayspring HR department and management team began the process of reviewing and revising our training curriculums as well as the training process/program to ensure that all required training topics as listed in chapters 6100 and 6400 regulations are included in the training provided to all staff. The new training packets have been completed and the revised training program has now been implemented. The Annual Employee Development Training Packet encompasses all required annual training areas to ensure compliance with 6100 and 6400 regulations. The training packet includes a list of all required annual trainings with instructions on how each training is to be completed- instructor led/blended, on demand etc., what documentation is needed to show the training was successfully completed- test after training, training summary or certificate etc. The packet is an all-inclusive resource for staff to utilize to complete their trainings and ensure that all training requirements are met. A thorough review of all employee annual training records was conducted to identify areas of non-compliance. The Employee Development/HR department contacted employees whose records showed they did not meet all annual training requirements. The HR department explained the new training process and program that has been implemented and provided each employee with an Annual Employee Development Training Packet. The expectations for completing all outstanding trainings and submitting documentation of completed trainings to HR by the specified deadline was reviewed and explained to each employee. The Employee Development/ HR departments have been receiving documentation of completed trainings from employees and are tracking the progress for each employee to ensure that all employee records meet the regulatory requirements and are in compliance within 30 days. Dayspring received the POC from ODP on 3/18/22 and has implemented a plan to ensure all annual training requirements are met and all employee records are in compliance by 4/15/22. The employees from the sample reviewed during the inspection on 3/2/22 have completed the following annual trainings Staff # 1 completed this training 3/22/22 -3/26/22 Staff # 2 completed this training 3/23/22 -3/26/22 Staff # 7 completed this training on 3/24/22 04/15/2022 Implemented
6400.52(c)(2)The annual abuse training for Staff #1 and Staff #2 is documented as being conducted on 2/6/21. Training conducted was based upon Texas State Sexual abuse training and intended to fulfill insurance requirements. The training only includes child protective services law. Staff #7 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. (Repeat Violation 1/11/21)The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.In response to citations received during our 2020 and 2021 inspections, Dayspring HR department and management team began the process of reviewing and revising our training curriculums as well as the training process/program to ensure that all required training topics as listed in chapters 6100 and 6400 regulations are included in the training provided to all staff. The new training packets have been completed and the revised training program has now been implemented. The Annual Employee Development Training Packet encompasses all required annual training areas to ensure compliance with 6100 and 6400 regulations. The training packet includes a list of all required annual trainings with instructions on how each training is to be completed- instructor led/blended, on demand etc., what documentation is needed to show the training was successfully completed- test after training, training summary or certificate etc. The packet is an all-inclusive resource for staff to utilize to complete their trainings and ensure that all training requirements are met. A thorough review of all employee annual training records was conducted to identify areas of non-compliance. The Employee Development/HR department contacted employees whose records showed they did not meet all annual training requirements. The HR department explained the new training process and program that has been implemented and provided each employee with an Annual Employee Development Training Packet. The expectations for completing all outstanding trainings and submitting documentation of completed trainings to HR by the specified deadline was reviewed and explained to each employee. The Employee Development/ HR departments have been receiving documentation of completed trainings from employees and are tracking the progress for each employee to ensure that all employee records meet the regulatory requirements and are in compliance within 30 days. Dayspring received the POC from ODP on 3/18/22 and has implemented a plan to ensure all annual training requirements are met and all employee records are in compliance by 4/15/22. The employees from the sample reviewed during the inspection on 3/2/22 have completed the following annual trainings Staff # 1 completed this training on 3/24/22 Staff # 2 completed this training on 3/24/22 04/15/2022 Implemented
6400.52(c)(3)Staff #1, Staff #2 and Staff #7 did not receive annual training in individual rights. Repeat Violation 1/11/21 and 12/13/21.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.In response to citations received during our 2020 and 2021 inspections, Dayspring HR department and management team began the process of reviewing and revising our training curriculums as well as the training process/program to ensure that all required training topics as listed in chapters 6100 and 6400 regulations are included in the training provided to all staff. The new training packets have been completed and the revised training program has now been implemented. The Annual Employee Development Training Packet encompasses all required annual training areas to ensure compliance with 6100 and 6400 regulations. The training packet includes a list of all required annual trainings with instructions on how each training is to be completed- instructor led/blended, on demand etc., what documentation is needed to show the training was successfully completed- test after training, training summary or certificate etc. The packet is an all-inclusive resource for staff to utilize to complete their trainings and ensure that all training requirements are met. A thorough review of all employee annual training records was conducted to identify areas of non-compliance. The Employee Development/HR department contacted employees whose records showed they did not meet all annual training requirements. The HR department explained the new training process and program that has been implemented and provided each employee with an Annual Employee Development Training Packet. The expectations for completing all outstanding trainings and submitting documentation of completed trainings to HR by the specified deadline was reviewed and explained to each employee. The Employee Development/ HR departments have been receiving documentation of completed trainings from employees and are tracking the progress for each employee to ensure that all employee records meet the regulatory requirements and are in compliance within 30 days. Dayspring received the POC from ODP on 3/18/22 and has implemented a plan to ensure all annual training requirements are met and all employee records are in compliance by 4/15/22. The employees from the sample reviewed during the inspection on 3/2/22 have completed the following annual trainings Staff # 1 completed this training on 3/24/22 Staff # 2 completed this training on 3/14/22 Staff # 7 completed this training on 3/14/22 04/15/2022 Implemented
6400.52(c)(4)Staff #7 did not receive annual training in recognizing and reporting incidents. Repeat Violation 1/11/21.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.In response to citations received during our 2020 and 2021 inspections, Dayspring HR department and management team began the process of reviewing and revising our training curriculums as well as the training process/program to ensure that all required training topics as listed in chapters 6100 and 6400 regulations are included in the training provided to all staff. The new training packets have been completed and the revised training program has now been implemented. The Annual Employee Development Training Packet encompasses all required annual training areas to ensure compliance with 6100 and 6400 regulations. The training packet includes a list of all required annual trainings with instructions on how each training is to be completed- instructor led/blended, on demand etc., what documentation is needed to show the training was successfully completed- test after training, training summary or certificate etc. The packet is an all-inclusive resource for staff to utilize to complete their trainings and ensure that all training requirements are met. A thorough review of all employee annual training records was conducted to identify areas of non-compliance. The Employee Development/HR department contacted employees whose records showed they did not meet all annual training requirements. The HR department explained the new training process and program that has been implemented and provided each employee with an Annual Employee Development Training Packet. The expectations for completing all outstanding trainings and submitting documentation of completed trainings to HR by the specified deadline was reviewed and explained to each employee. The Employee Development/ HR departments have been receiving documentation of completed trainings from employees and are tracking the progress for each employee to ensure that all employee records meet the regulatory requirements and are in compliance within 30 days. Dayspring received the POC from ODP on 3/18/22 and has implemented a plan to ensure all annual training requirements are met and all employee records are in compliance by 4/15/22. The employees from the sample reviewed during the inspection on 3/2/22 have completed the following annual trainings Staff # 7 completed this training on 3/20/22 04/15/2022 Implemented
6400.52(c)(5)Staff #7 did not receive annual training in the safe and appropriate use of behavior supports if the staff works with an individual. Repeat Violation 1/11/21.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual.In response to citations received during our 2020 and 2021 inspections, Dayspring HR department and management team began the process of reviewing and revising our training curriculums as well as the training process/program to ensure that all required training topics as listed in chapters 6100 and 6400 regulations are included in the training provided to all staff. The new training packets have been completed and the revised training program has now been implemented. The Annual Employee Development Training Packet encompasses all required annual training areas to ensure compliance with 6100 and 6400 regulations. The training packet includes a list of all required annual trainings with instructions on how each training is to be completed- instructor led/blended, on demand etc., what documentation is needed to show the training was successfully completed- test after training, training summary or certificate etc. The packet is an all-inclusive resource for staff to utilize to complete their trainings and ensure that all training requirements are met. A thorough review of all employee annual training records was conducted to identify areas of non-compliance. The Employee Development/HR department contacted employees whose records showed they did not meet all annual training requirements. The HR department explained the new training process and program that has been implemented and provided each employee with an Annual Employee Development Training Packet. The expectations for completing all outstanding trainings and submitting documentation of completed trainings to HR by the specified deadline was reviewed and explained to each employee. The Employee Development/ HR departments have been receiving documentation of completed trainings from employees and are tracking the progress for each employee to ensure that all employee records meet the regulatory requirements and are in compliance within 30 days. Dayspring received the POC from ODP on 3/18/22 and has implemented a plan to ensure all annual training requirements are met and all employee records are in compliance by 4/15/22. The employees from the sample reviewed during the inspection on 3/2/22 have completed the following annual trainings Staff # 7 will need to completed this training by 4/15/22 04/15/2022 Implemented
6400.52(c)(6)Staff #7 did not receive annual training in Implementation of the individual plan if the person works directly with an individual.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual.In response to citations received during our 2020 and 2021 inspections, Dayspring HR department and management team began the process of reviewing and revising our training curriculums as well as the training process/program to ensure that all required training topics as listed in chapters 6100 and 6400 regulations are included in the training provided to all staff. The new training packets have been completed and the revised training program has now been implemented. The Annual Employee Development Training Packet encompasses all required annual training areas to ensure compliance with 6100 and 6400 regulations. The training packet includes a list of all required annual trainings with instructions on how each training is to be completed- instructor led/blended, on demand etc., what documentation is needed to show the training was successfully completed- test after training, training summary or certificate etc. The packet is an all-inclusive resource for staff to utilize to complete their trainings and ensure that all training requirements are met. A thorough review of all employee annual training records was conducted to identify areas of non-compliance. The Employee Development/HR department contacted employees whose records showed they did not meet all annual training requirements. The HR department explained the new training process and program that has been implemented and provided each employee with an Annual Employee Development Training Packet. The expectations for completing all outstanding trainings and submitting documentation of completed trainings to HR by the specified deadline was reviewed and explained to each employee. The Employee Development/ HR departments have been receiving documentation of completed trainings from employees and are tracking the progress for each employee to ensure that all employee records meet the regulatory requirements and are in compliance within 30 days. Dayspring received the POC from ODP on 3/18/22 and has implemented a plan to ensure all annual training requirements are met and all employee records are in compliance by 4/15/22. The employees from the sample reviewed during the inspection on 3/2/22 have completed the following annual trainings Staff # 7 completed this training on 3/29/21 and the training is due again by 3/29/2is currently in the process of completing it to maintain compliance 04/15/2022 Implemented
6400.169(a)Staff #1 did not complete the annual course renewal requirements for medication administration. Previous training dates are recorded as 1/20/20 and 2/18/21. Staff #7 did not complete the annual course renewal requirements for medication administration. Previous training dates are recorded as 2/17/21. (Repeat Violation 1/11/21)A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration).In response to citations received during our 2020 and 2021 inspections, Dayspring HR department and management team began the process of reviewing and revising our training curriculums as well as the training process/program to ensure that all required training topics as listed in chapters 6100 and 6400 regulations are included in the training provided to all staff. The new training packets have been completed and the revised training program has now been implemented. The Annual Employee Development Training Packet encompasses all required annual training areas to ensure compliance with 6100 and 6400 regulations. The training packet includes a list of all required annual trainings with instructions on how each training is to be completed- instructor led/blended, on demand etc., what documentation is needed to show the training was successfully completed- test after training, training summary or certificate etc. The packet is an all-inclusive resource for staff to utilize to complete their trainings and ensure that all training requirements are met. A thorough review of all employee annual training records was conducted to identify areas of non-compliance. The Employee Development/HR department contacted employees whose records showed they did not meet all annual training requirements. The HR department explained the new training process and program that has been implemented and provided each employee with an Annual Employee Development Training Packet. The expectations for completing all outstanding trainings and submitting documentation of completed trainings to HR by the specified deadline was reviewed and explained to each employee. The Employee Development/ HR departments have been receiving documentation of completed trainings from employees and are tracking the progress for each employee to ensure that all employee records meet the regulatory requirements and are in compliance within 30 days. Dayspring received the POC from ODP on 3/18/22 and has implemented a plan to ensure all annual training requirements are met and all employee records are in compliance by 4/15/22. The employees from the sample reviewed during the inspection on 3/2/22 have completed the following annual trainings Staff #7 will need to complete this training by 4/15/22 04/15/2022 Implemented
SIN-00197668 Renewal 12/13/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)There was no record of the agency completing a self-assessment. (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-00181613 Renewal 01/12/2021 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
6400.34(a)Individual #1's record contained a signed copy of individual rights signed on 1/27/20. 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, hired on 6/9/15, 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, hired on 6/9/15, 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 ServicesThe 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 6/9/15, 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 6/9/15, 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 Manager and Director of HR will be responsible to ensure ongoing compliance. 03/12/2021 Implemented
6400.52(c)(5)Staff #1, date of hire 6/9/15, 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(c)Individual #1 is prescribed Abilify 2mg tabs. Take 1 and ½ tableted by mouth once daily at 5PM. The Medication Administration Record indicates that the medication is being given at 5AM.A prescription medication shall be administered as prescribed.Dayspring Management staff will be retrained in the licensing requirements and expectations to maintain compliance with regulation 6400.165(c) by 3/12/21. Management staff will receive training in the following sections of Dayspring policy 3.3 Medication Administration Policy & Procedures- Section II- Medication Administration- Administration Procedures, Documentation, 5 Rights of Medication Administration. Additionally, the Medication Administration Record(MAR) for Individual # 1 has been corrected and the medication is being administered at the correct time of 5 PM. The Program Specialist will be responsible to monitor the MARs on a monthly basis. The Director of Operations, the Compliance Manager will be responsible to ensure ongoing compliance. 03/12/2021 Implemented
SIN-00162983 Renewal 09/20/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(b)There was no scissors in the first aid kit. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. Dayspring Management staff will be retrained in the licensing requirements and expectations to maintain compliance with regulation 6400.77 (b) by 11/29/19. Additionally, the scissors were located and returned to the kit at the time of the inspection. At that time, the Quality Manager spoke to the resident who had removed them and explained why the scissors needed to stay with the kit. To ensure ongoing compliance, the Supervisors of all programs will be expected to complete the Residential Site Review form on a quarterly basis. The Program Managers will be responsible to complete the Program Manager Checklist on a monthly basis. The Director of Operations will review those forms/ checklists as they are completed and will ensure that any issues identified are addressed and resolved or corrected. The Quality Manager will be responsible to review/ complete the Residential Site Review form for all programs on a quarterly basis as well. 11/29/2019 Implemented
6400.52(a)(1)Staff #2, who is a direct service worker, completed 15.5 hours of training in the most recent complete training year.The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers.Dayspring Management staff will be retrained in the licensing requirements and expectations to maintain compliance with regulation 6400.52 (a) (1) by 11/29/19. Additionally, staff have been provided with information on how to obtain the required 24 hours of training. They have been given information on how to access training courses that are available through the ODP website as well as trainings provided by Dayspring on an annual basis. The Director of Human Resources will be responsible for monitoring and tracking all completed training hours for staff and will send out a 6 month update to all staff. Dayspring is also in the process of contracting with Paylocity. Once Paylocity is activated all staff will have an account which tracks all training and will send alerts to both the staff and HR when training is due. The Director of Human Resources, Director of Operations and the Quality Manager will be responsible to ensure ongoing compliance. 11/29/2019 Implemented
SIN-00124282 Renewal 10/31/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.168(d)Staff #1 had her Med Practicum on 5/4/2016. She did not have her Med Practicum again until 10/11/2017, which exceeds the annual requirement.A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually. Dayspring Management staff will be retrained in the licensing requirements and expectations to maintain compliance with Chapter 6400 regulation 6400.168 (d) by 1/31/18. Dayspring Homes had only one Medication Administration Trainer in 2017 that was responsible for training and maintain annual practicums. As of August 2017 an additional trainer was added. The Nurse Consultant and Operations Manager, as 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. 01/31/2018 Implemented
SIN-00105289 Renewal 11/15/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.68(b)The water temperature in the downstairs bathroom read 126.8 degrees. The water temperature reading in the upstairs bathroom read 127.0 degrees. Both reading exceed the 120 degree requirement. Hot water temperatures in bathtubs and showers may not exceed 120°F. Dayspring Management staff will be retrained in the licensing requirements and expectations to maintain compliance with Chapter 6400 regulation 6400.68(b) by 2/28/2017. Additionally, the Dayspring Homes Fire Drill Log will be updated to include the location of where the water temperature is being tested each month to ensure that the water temperature of each sink is being tested on a regular basis. All Dayspring Management staff will be trained in this expectation. The CEO, Operations Manager, Program Specialist will be responsible for retraining of staff. All retraining will be completed by 2/28/2017. 02/28/2017 Implemented
6400.163(c)Individual #4 had 3 month psychiatric medication reviews 1/7/2016, 4/7/2016, 7/20/2016, and 10/20/2016. The time frame between 4/7-7/20/2016 exceeds the 3 month requirement. If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Dayspring Management staff will be retrained in the licensing requirements and expectations to maintain compliance with Chapter 6400 regulation 6400.163 (c) by 2/28/2017. Additionally, the Nurse Consultant has developed a system for tracking medical appointments for each individual and is completing monthly appointment reminder forms for each program. Dayspring Management staff will be trained in the purpose of this new tracking system and the ongoing expectations for the use of the system and forms. The CEO, Operations Manager, Program Specialist will be responsible for retraining of staff. The Nurse Consultant will be responsible for training in the medical appointment tracking system and the monthly appointment reminder forms. All retraining will be completed by 2/28/2017. 02/28/2017 Implemented
6400.186(c)(2)ISP areas such as health & safety are not being reviewed for Individual #4'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-00215999 Renewal 12/19/2022 Compliant - Finalized
SIN-00140631 Renewal 08/29/2018 Compliant - Finalized
SIN-00122696 Renewal 10/31/2017 Compliant - Finalized
SIN-00086252 Renewal 10/21/2015 Compliant - Finalized