Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00235626 Renewal 12/19/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(a)An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Individual #1 had a physical examination on 7/18/22 and has not had one since. This exceeds the requirement.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. The Site Supervisor had called to schedule this physical exam well in advance; however, the office did not have any appointments until January 2024. The office stated they would put the individual on the cancellation list and call us if an appointment became available sooner. We discussed taking the individual to urgent care for the exam but their sister, who is the representative payee, did not want to pay for the urgent care fees out of pocket and requested that we wait until they could see their PCP. The office did have a cancellation sooner than the original appointment in January and the physical was able to be completed on 12/29/24. The Site Supervisors and Program Manger were retrained on the physical exam requirements on 1/15/24. 12/29/2023 Implemented
6400.143(a)Individual #1 had retinal surgery on 2/2/23 and Individual #1 refused a follow up appointment. There is no record or documentation on an attempt to train the individual.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 Site Supervisor reported that she did make several attempts to discuss the appointment with the individual and train him on the importance/necessity of the visit; however, she was not aware that she needed to document these conversations. The Site Supervisor was trained on this expectation on 12/21/23. All Site Supervisors and the Program Manager were trained on this expectation on 1/15/24. 01/15/2024 Implemented
6400.144Individual #1 had a vision appointment in 9/14/23 and the form noted a follow up appointment for 9/28/23. There was no record or documentation of the 9/28/23 follow up appointment. Individual #1 attended a vision appointment/lazer appointment on 10/13/23. The provider agency failed to provide health services as planned.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. The appointment on 9/28/23 was for a laser procedure which the individual refused to go to. The Site Supervisor reported that she did talk with the individual about the procedure and educated him on why it was important; however, he still refused to go. The Site Supervisor rescheduled the appointment but forgot to document what happened on a case note form. The procedure was rescheduled and completed on 10/13/23. This citation was reviewed with the Site Supervisor on 12/21/23. All Site Supervisors and the Program Manager were trained on this expectation on 1/15/24. 01/15/2024 Implemented
6400.52(c)(1)Staff #1 did not have documentation or record that they received annual training in the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships in the training year 7/1/22-6/30/23.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.It was discovered that the previous Employee Development Manager had not been accurately maintaining the annual training trackers, nor did she have an effective system for ensuring that the documentation of completed training courses was being received and filed. As of 10/3/23, the previous Employee Development Manager is no longer with Dayspring Homes and a new Employee Development Manager started on 10/9/23. The new Employee Development Manager immediately began conducting a full audit of all staff training files and working with staff to complete any training courses that were out of compliance. Unfortunately, there was nothing that could be done about trainings that were missed in the previous fiscal year. 03/01/2024 Implemented
6400.52(c)(3)Staff #1 did not have documentation or record that they received annual training in Individual rights in the training year 7/1/22-6/30/23.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.It was discovered that the previous Employee Development Manager had not been accurately maintaining the annual training trackers, nor did she have an effective system for ensuring that the documentation of completed training courses was being received and filed. As of 10/3/23, the previous Employee Development Manager is no longer with Dayspring Homes and a new Employee Development Manager started on 10/9/23. The new Employee Development Manager immediately began conducting a full audit of all staff training files and working with staff to complete any training courses that were out of compliance. Unfortunately, there was nothing that could be done about trainings that were missed in the previous fiscal year. 03/01/2024 Implemented
6400.52(c)(4)Staff #1 did not have documentation or record that they received annual training in recognizing and reporting incidents in the training year 7/1/22-6/30/23.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.It was discovered that the previous Employee Development Manager had not been accurately maintaining the annual training trackers, nor did she have an effective system for ensuring that the documentation of completed training courses was being received and filed. As of 10/3/23, the previous Employee Development Manager is no longer with Dayspring Homes and a new Employee Development Manager started on 10/9/23. The new Employee Development Manager immediately began conducting a full audit of all staff training files and working with staff to complete any trainings that were out of compliance. Unfortunately, there was nothing that could be done about trainings that were missed in the previous fiscal year. 03/01/2024 Implemented
6400.169(a)Staff #1 had an initial Medication Administration course test in their file dated 1/6/21, then a Medication practicum completed 12/31/21, and then the next documented medication practicum was dated 12/11/23. Staff #1 did not have a medication administration practicum completed in 2022.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).It was discovered that the previous Employee Development Manager had not been accurately maintaining the annual training trackers, nor did she have an effective system for ensuring that the documentation of completed training courses was being received and filed. When it came to Medication Administration, we learned that she was indeed completing the annual practicums; however, she was not always completing and/or filing the paperwork. This led to us having several staff members who did indeed complete practicums, but no record was maintained in their file. As of 10/3/23, the previous Employee Development Manager is no longer with Dayspring Homes and a new Employee Development Manager started on 10/9/23. The new Employee Development Manager has not yet been certified to teach the medication administration course so the Director of Quality and Compliance, who was the back-up medication administration trainer, took over monitoring and managing the initial course as well as annual practicums. This staff member completed their annual practicum requirements and was back in compliance as of 12/11/23. 12/11/2023 Implemented
SIN-00215998 Renewal 12/26/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71Emergency telephone numbers were not posted on or near the landline telephone located in the front sitting room at the time of the inspection. Staff did correct this by posting emergency numbers while the licensing inspector was present in the home.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. The day of licensing this home was hosting a Christmas dinner for the individuals and their families. Staff rearranged the front room (where the landline is located) to accommodate a table and chairs. While rearranging, the phone was moved to another location so when the inspector came to the home, the emergency numbers were not posted by the phone and were unable to be located. The Site Supervisor printed new emergency numbers while the inspector was at the home and posted them immediately. When staff cleaned up after the dinner, the original emergency numbers were found near the table where the phone had been prior to rearranging. 12/20/2022 Implemented
6400.112(c)The fire drill record for a drill conducted on 4/29/2022 did not record the evacuation time.A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. The staff that completed the fire drill on 4/29/2022 did not fill out the fire drill form entirely and left the evacuation time blank. While we are unsure exactly what the evacuation time was on that particular day, the individuals at this home have never had any issues evacuating in 2.5 minutes. The Site Supervisor did not get a report that there were any issues with the fire drill that particular day, we believe the staff just missed that section when completing the form. Due to the amount of time it has been since this drill was conducted, we were unable to correct this fire drill form. 12/27/2022 Implemented
SIN-00201802 Unannounced Monitoring 03/02/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(a)Staff #3 was hired on 2/14/22. Fire safety training was not completed.Program specialists and direct service workers shall be trained before working with individuals 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, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered.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 # 3 will need to complete this training by 4/15/22 04/15/2022 Implemented
6400.46(c)Staff #8 was not trained in first aid techniques before working with individuals.Program specialists and direct service workers and at least one person in a vehicle while individuals are being transported by the home shall be trained before working with individuals in first aid techniques.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 # 8 completed this training on 3/22/22 04/15/2022 Implemented
6400.51(b)(1)Staff #5 was hired on 4/5/21. There is no training on the application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships was conducted. (Repeat Violation 1/11/21).The orientation 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 New Employee Development Training Packet encompasses all required orientation training areas to ensure compliance with 6100 and 6400 regulations. The training packet includes a list of all required orientation 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 orientation 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 orientation training requirements. The HR department explained the new training process and program that has been implemented and provided each employee with a New 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 orientation 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 orientation trainings Staff # 5 completed this training on 3/27/22 04/15/2022 Implemented
6400.51(b)(2)Staff #5 was hired on 4/5/21. There is documentation of training on abuse on 7/28/21 and 4/8/21. The training conducted only included child protective services law. (Repeat Violation 1/11/21)The orientation 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 New Employee Development Training Packet encompasses all required orientation training areas to ensure compliance with 6100 and 6400 regulations. The training packet includes a list of all required orientation 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 orientation 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 orientation training requirements. The HR department explained the new training process and program that has been implemented and provided each employee with a New 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 orientation 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 orientation trainings Staff # 5 completed this training on 3/28/22 04/15/2022 Implemented
6400.51(b)(3)Staff #5 was hired on 4/5/21. There is no training on Individual Rights . (Repeat violation 1/11/21)The orientation 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 New Employee Development Training Packet encompasses all required orientation training areas to ensure compliance with 6100 and 6400 regulations. The training packet includes a list of all required orientation 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 orientation 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 orientation training requirements. The HR department explained the new training process and program that has been implemented and provided each employee with a New 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 orientation 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 orientation trainings Staff # 5 completed this training on 3/14/22 04/15/2022 Implemented
6400.51(b)(4)Staff #5 was hired on 4/5/21. Documentation shows that training on Recognizing and reporting incidents was conducted on 6/22/21. Training on recognizing and reporting incidents is required within 30 days after hire. (Repeat violation 1/11/21)The orientation 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 New Employee Development Training Packet encompasses all required orientation training areas to ensure compliance with 6100 and 6400 regulations. The training packet includes a list of all required orientation 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 orientation 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 orientation training requirements. The HR department explained the new training process and program that has been implemented and provided each employee with a New 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 orientation 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 orientation trainings Staff # 5 completed this training on 3/14/22 04/15/2022 Implemented
SIN-00197667 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
6400.141(c)(3)Individual #2 Tetanus/Diphtheria was given 5/11/11 and they didn't receive it again until 12/13/21 which exceeds the requirement for the immunization to be administered every 10 years.The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. A new process for reviewing physical exam forms for all individuals will be developed. The process will include a system to track when physical exams are due as well as when all immunizations, tests, procedures or other required information is due. 02/28/2022 Implemented
6400.51(b)(1)Staff #4's date of hire is 9/8/21 and her orientation did not include application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. (repeat violation 1/12/21)The orientation 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 last year¿s inspection, Dayspring management began the process of reviewing and revising our orientation and annual training curriculums as well as the training process/program to ensure that all required orientation/annual training topics as listed in chapter 6400 regulations are included in the training provided to all staff. Due to unforeseen circumstances we were unable to accomplish this task in its entirety and the training curriculum and training process/program are still being revised. An orientation training packet and an annual training packet are being developed that will be provided to all staff at the time of hire and annually thereafter. The training packets will include a list of all required orientation/annual trainings with instructions on how each training is to be completed- in person, on line etc., what documentation is needed to show the training was successfully completed- test after training, training summary etc. The packets will be an all-inclusive resource for staff to consult throughout the training year to ensure that all training requirements are met. 02/28/2022 Implemented
6400.51(b)(3)Staff #4's date of hire is 9/8/21 and her orientation did not include individual rights. (repeat violation 1/12/21)The orientation must encompass the following areas: Individual rights.In response to citations received during last year¿s inspection, Dayspring management began the process of reviewing and revising our orientation and annual training curriculums as well as the training process/program to ensure that all required orientation/annual training topics as listed in chapter 6400 regulations are included in the training provided to all staff. Due to unforeseen circumstances we were unable to accomplish this task in its entirety and the training curriculum and training process/program are still being revised. An orientation training packet and an annual training packet are being developed that will be provided to all staff at the time of hire and annually thereafter. The training packets will include a list of all required orientation/annual trainings with instructions on how each training is to be completed- in person, on line etc., what documentation is needed to show the training was successfully completed- test after training, training summary etc. The packets will be an all-inclusive resource for staff to consult throughout the training year to ensure that all training requirements are met. 02/28/2022 Implemented
6400.166(a)(11)Individual #2's December Medication Administration Record (MAR) did not include the diagnosis or purpose for their medication Clotrimazole-betamethasone.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.Individual #2¿s January 2022 MARs have been reviewed to ensure that the diagnosis is now included for this medication and all other medications listed on the MAR. A new process will be developed to ensure that MARs for all individuals include a diagnosis or purpose for each medication listed on the MAR. 02/28/2022 Implemented
SIN-00181611 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
6400.141(c)(9)Individual #1 had a physical exam completed on 11/9/20 that recommended that a prostate exam be completed. The prostate exam has not been completed or scheduled.The physical examination shall include: A prostate examination for men 40 years of age or older. Dayspring Management staff will be retrained in the licensing requirements and expectations to maintain compliance with Chapter 6400 regulation 6400.141(c) (9) by 3/12/21. Individual # 1¿s Program Specialist/ Supervisor will be responsible for scheduling a prostate exam with his 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 dated 3/2/20. The rights haven't been updated to reflect the current Chapter 6400 regulations including: Chapter 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
6400.51(b)(1)Staff #1, hired on 3/19/20, did not complete the required orientation trainings to encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.The orientation 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 orientation training curriculum will be reviewed and revised to ensure that all required orientation training topics as listed in 6400.51 (b)(1) are included in the orientation training provided to all employees. The Director of HR and the Compliance Manager will be responsible to ensure that the Dayspring orientation training curriculum is updated and revised by 3/12/21. Staff #1 will receive training in the updated orientation training curriculum. The Director of HR will be responsible to ensure that the training occurs for all new employees initially. The Compliance Manager and Director of HR will be responsible to ensure ongoing compliance. 03/12/2021 Implemented
6400.51(b)(2)Staff #1, hired on 3/19/20, did not complete the required orientation trainings to 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 Adult Protective Services Act (35 P.S.§§ 10210.101-10210.704) and applicable protective services regulations. Staff 1did complete training on the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Child Protective Services Law (23 PA.C.S. §§6301-638 on 4/13/20.The orientation 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 orientation training curriculum will be reviewed and revised to ensure that all required orientation training topics as listed in 6400.51 (b)(2) are included in the orientation training provided to all employees. The Director of HR and the Compliance Manager will be responsible to ensure that the Dayspring orientation training curriculum is updated and revised by 3/12/21. Staff #1 will receive training in the updated orientation training curriculum. The Director of HR will be responsible to ensure that the training occurs for all new employees initially. The Compliance Manager and Director of HR will be responsible to ensure ongoing compliance. 03/12/2021 Implemented
6400.51(b)(3)Staff #1, hired on 3/19/20, did not complete the required orientation trainings to encompass the following areas: Individual Rights.The orientation must encompass the following areas: Individual rights.The current Dayspring orientation training curriculum will be reviewed and revised to ensure that all required orientation training topics as listed in 6400.51 (b)(3) are included in the orientation training provided to all employees. The Director of HR and the Compliance Manager will be responsible to ensure that the Dayspring orientation training curriculum is updated and revised by 3/12/21. Staff #1 will receive training in the updated orientation training curriculum. The Director of HR will be responsible to ensure that the training occurs for all new employees initially. The Compliance Manager and Director of HR will be responsible to ensure ongoing compliance. 03/12/2021 Implemented
6400.51(b)(4)Staff #1, hired on 3/19/20, did not complete the required orientation trainings to encompass the following areas: recognizing and reporting incidents.The orientation must encompass the following areas: recognizing and reporting incidents.The current Dayspring orientation training curriculum will be reviewed and revised to ensure that all required orientation training topics as listed in 6400.51 (b)(4) are included in the orientation training provided to all employees. The Director of HR and the Compliance Manager will be responsible to ensure that the Dayspring orientation training curriculum is updated and revised by 3/12/21. Staff #1 will receive training in the updated orientation training curriculum. The Director of HR will be responsible to ensure that the training occurs for all new employees initially. The Compliance Manager and Director of HR will be responsible to ensure ongoing compliance. 03/12/2021 Implemented
6400.165(g)Individual #1 is prescribed medication for a psychiatric illness. Individual #1 had reviews of medications for his psychiatric illness and medications on 3/17/20, 4/16/20, and 6/3/20. He has not attended a review for medications to treat his psychiatric illness since 6/3/20. Individual #1 did not have three-month review of his medications by a licensed physician.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. Individual # 1 did attend a psychiatric medication review appointment on 1/11/21. The Program Specialist/ Supervisor will ensure that regular appointments are scheduled and attended every 3 months as required. The Director of Operations and the Compliance Manager will be responsible to ensure ongoing compliance. 03/12/2021 Implemented
SIN-00178358 Unannounced Monitoring 10/06/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.144Individual #1 has a diabetes protocol/plan that indicates what steps should be taken when measuring his blood glucose and providing diabetes medication. The plan indicates steps that should be taken for low and high glucose readings. On 9/15/20, Individual #1 was administered 22 units of Novolog instead of 22 units of Levemir as prescribed. At approximately 11:30PM, Staff #3 checked Individual #1's glucose level and found it to be 101. A glucose level of 101 is considered low according to Individual #1's diabetes plan. According to the diabetes plan, Individual #1 should have been given a soda and hand glucose levels checked in 15 minutes. If the glucose level was not above 120 after this 15 minute check, Individual #1 should be administered 2 sugar pills and have glucose levels rechecked in 15 minutes. If the glucose level was not above 120 after this check then 2 sugar pills should be administered and these steps should continue every 15 minutes until glucose levels are above 120. Staff #3 failed to follow this diabetes plan. Staff #3 did not give Individual #1 a soda and recheck glucose levels in 15 minutes. At approximately 12:20AM, Staff #3 found Individual #1 to be unresponsive in bed with a glucose level of 21.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. All staff at the program will be retrained in the licensing requirements and expectations to maintain compliance with regulation 6400.144 by 11/30/20. Additionally, all staff were trained in Individual # 1¿s updated Diabetes Protocol dated 10/14/20 on 10/19/20. The Diabetes Protocol for Individual #1 was updated on 11/11/20 to include additional information regarding the sliding/ correction scale for Novolog. All staff will be trained in the protocol dated 11/11/20 by 11/30/20 and will be trained annually in all medical protocols. Encompass Nursing is providing additional diabetes related training and support in the home for all staff. Staff will receive initial training and then quarterly training for a period of 1 year. Staff # 1 received Encompass training on 10/19; staff JK received training on 10/22. All staff in the home will receive initial training through Encompass by 12/16/20. Staff #1¿s employment with Dayspring ended on 11/5/20. The Director of Operations and Program Manager will be responsible to ensure that all staff are trained in the Diabetes Protocol dated 11/11/20 by 11/30/20. The Director of Operations and Program Manager will be responsible to ensure that all staff receives initial training in the home through Encompass Nursing by 12/16/20. The Director of Operations will ensure that quarterly training in scheduled through Encompass Nursing for the period of 1 year. The Director of HR will track all training for staff. The Director of Operations, Director of HR and the Compliance Manager will be responsible for continued monitoring and ongoing compliance. 11/30/2020 Implemented
6400.145(1)The home emergency plan for drug overdose is to contact 911 immediately. On 9/15/20, upon discovering that Individual #1 had been administered Novolog 22 units instead of Levemir 22 units Staff #1 neglected to contact 911 for a drug overdose. The largest dosage of Novolog that would be administered to Individual #1 is 8 units if glucose level was 300. Individual #1 was administered almost 3 times the largest dose of Novolog that should be administered to Individual #1. Staff #1 notified Dayspring Homes' on call staff of the overdose. On call staff did not contact 911 or instruct Staff #1 to contact 911 as per agency policy. Staff #3 was informed of the overdose at change of shift and did not call 911 as per agency policy. Though all required information per this regulation was included in the emergency medical plan, the staff failed to follow this plan.The home shall have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency. : All staff at the residence as well as all on-call Management staff will be retrained in the licensing requirements and expectations to maintain compliance with regulation 6400.145(1) by 11/30/20. All staff at the residence as well as all on-call Management staff will be retrained in Dayspring policies 3.1 Emergency Medical Procedures and 3.2 Act 169 Substitute Decision Making, Emergency 911 Procedures and Dayspring Fall Protocol by 11/30/20. The Director of Operations and the Compliance Manager will be responsible to ensure that all training occurs by 11/30/20. 11/30/2020 Implemented
6400.32(c)Individual #1 is prescribed Levemir 22 units at bedtime. On September 15, 2020 at 9:45PM,the wrong diabetes medication was administered to Individual #1. Individual #1 was administered Novolog 22 units instead of Levemir. Novolog is prescribed during daytime hours and before meals with dosing amounts dependent upon Individual #1's glucose readings. The highest dosage of Novolog that Individual #1 should receive would be 8 units if glucose level was 300. Staff #1 administered 22 units of Novolog. Staff #1 noticed the mistake at 10:30pm and checked Individual #1's glucose level which was 168. Staff #1 then gave Individual #1 a can of soda. Staff #1 contacted the agency on call to report the medication error. According to Dayspring Homes' Emergency Policy, 911 should be called for a drug overdose. 911 was not contacted at this time. Staff #1 communicated the medication error to Staff #3 at 11PM during shift change. Staff #3 checked Individual #1's glucose level at 11:30PM. The glucose level was 101. Individual #1's diabetes plan states that if his glucose level is less than 120, staff should give Individual #1 a can of soda and recheck the glucose level in 15 minutes. If the glucose level is not above 120 after this 15 minute check, staff should administer two sugar pills and continue to recheck glucose levels every 15 minutes and administer two sugar pills after each check until glucose level is above 120. Staff #3 did not follow the diabetes plan. Staff #3 sent Individual #1 back to bed after checking the glucose at 11:30PM and did not give Individual #1 a can of soda, recheck glucose levels, or administer sugar pills. Staff #3 continued to monitor Individual #1. At 12:20AM, Staff #3 found Individual #1 in bed and unresponsive. Staff #3 checked Individual #1's glucose level which was 21. Staff #3 administered emergency glucagon and called 911. Individual #1 was neglected as 911 was not contacted by Staff #1, Staff #3 or the agency on call staff for a drug overdose as per Dayspring Homes' Emergency Policy after discovering 22 units of Novolog were administered to Individual #1 and by the failure of Staff #3 to follow Individual #1's diabetes plan after glucose levels were discovered to be 101.An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment.: All staff at the residence as well as all on-call Management staff will be retrained in the licensing requirements and expectations to maintain compliance with regulation 6400.32(c) by 11/30/20. Additionally, Staff # 1 received training on 9/19/20 which consisted of Medication Error retraining, new storage procedures for AM Insulin medications, Dayspring Policies- 2.2 Reportable Incidents- section 13- Neglect; 6.6 Program Participant Rights ¿section 17- Medication error and 3.3 Medication Policy & Procedures. Staff # 1 also received training in diabetes from Encompass Health on 10/19/20. Staff #1¿s employment with Dayspring ended on 11/5/20. Staff # 3 will receive training in the Individual #1¿s Diabetes Protocol dated 11/11/20 by 11/30/20. All staff in the program received training in Incident Management /Reporting and Medication Error Reporting on 10/19/20. All Management and Leadership staff received training Incident Management/Reporting and Medication Error Reporting on 10/8/20. All agency staff will have completed this training by 11/15/20. All staff at the residence as well as all on-call Management staff will be retrained in Dayspring policies 3.1 Emergency Medical Procedures and 3.2 Act 169 Substitute Decision Making, Emergency 911 Procedures and Dayspring Fall Protocol by 11/30/20. The Director of Operations and the Compliance Manager will be responsible to ensure that all training occurs by 11/30/20. The Compliance Manager will be responsible to ensure that all agency staff are trained in Incident Management/ Reporting and Medication Error Reporting by 11/15/20. The Director of Operations will be responsible to ensure that Staff # 3 is trained in the Diabetes Protocol dated 11/11/20 by 11/30/20. 11/30/2020 Implemented
6400.165(c)Individual #1 was given the wrong diabetes medication on 9/15/20. Individual #1 was given 22 units of Novolog at bedtime when he should have been given 22 units of Levemir. On 9/8/20 at 5PM; 9/11 at 12PM; 9/18 at 12 PM; 9/20 at 12PM; 9/24 at 5PM; 9/25 at 12PM; 9/26 at 12PM; 9/27 at 7AM and 12PM; 9/29 at 7AM; 10/5 at 12PM; 10/6 at 7AM and 12PM; 10/8 at 5PM; 10/9 at 7AM and 10/13 at 7AM, medication administration records indicate in one area that Novolog was held (H) and that it was given in a second area as indicated by staff signatures. There were no physician orders to hold the medication and it is unknown if medication was administered. On 9/8 at 7AM and 9/11 at 12PM it is indicated that the amount of Novolog that was given was double what should have been given based on a glucose reading below 100. Individual #1's diabetes plan indicates if a reading is below 60, it should be treated as a low and Individual #1 should be given soda and 4 peanut butter cups or peppermint patties and glucose should be rechecked in 15 minutes. If not over 120 after the 15 minute check, Individual #1 should be given 2 sugar pills and staff should continue to check Individual #1's glucose levels and administer two sugar pills until glucose is 120. On 9/25/20 at 7AM, Individual #1's glucose reading was 50. Individual 1's low was not treated as a low and his plan was not followed. Medication administration records indicate that Novolog was held in one area but then signed out with Staff #2 indicating that they reduced the insulin dose by half as per Individual #1's sliding scale. On 9/29/20 at 7AM, Individual #1's glucose reading was 55. Individual #1's low was not treated as a low and his plan was not followed. Medication administration records indicate that Novolog was held in one area but then signed out with Staff #2 indicating that they reduced the Novolog dose by half as per Individual #1's sliding scale. On 10/6/20 at 7AM, Individual 1's glucose reading was 53. Individual #1's low was not treated as a low and his plan was not followed. Medication administration records indicate that Novolog was held in one area but then signed out with Staff #2 indicating that they reduced the Novolog dose by half as per Individual #1's sliding scale. Individual #1 receives Novolog 100u/ml 3 units SQ before breakfast, 4 units SQ before lunch and 6 units SQ before dinner with reductions or additions to units based on glucose readings. On 9/8/20 at 5PM, Individual #1's glucose reading was 70. Based on this reading, Individual #1's Novolog should have been reduced by 50% and he should have been given 3 units. Medication administration records indicate that Individual #1's Novolog was held but also that he was given +3 units which would mean that he was administered 9 units of Novolog instead of 3. On 9/11/20 at 12PM, Individual #1's glucose reading was 78. Based on this reading, Individual #1's Novolog should have been reduced by 50% and he should have been given 2 units. Medication administration records indicate that Individual #1's Novolog was held but also that he was given +2 units which would mean that he was administered 6 units of Novolog instead of 2. Individual #1 did not receive Aspirin Chew 81 mg as prescribed at 8am on 9/24/20. Individual #1 did not receive Levothyroxine 150mcg as prescribed on 10/22/20.A prescription medication shall be administered as prescribed.All staff at the program will be retrained in the licensing requirements and expectations to maintain compliance with regulation 6400.165(c) by 11/30/20. All program 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 ; Section III- Administration Errors, Documentation Errors, Reporting, Tracking and Documenting Errors. Additionally, the Medication Administration Record(MAR) for Individual # 1 will be revised to allow for clear documentation of the administration of Insulin and the use of the Sliding/Correction Scales as listed in the Diabetes Protocol dated 11/11/20. The Director of Operations, the Compliance Manager and the Medication Administration Trainer will be responsible to ensure that all training occurs by 11/30/20. The Medication Administration Trainer will be responsible to ensure that the MAR¿s for Individual #1 are revised by 11/30/20. 11/30/2020 Implemented
6400.167(b)Individual 1 did not receive Aspirin Chew 81 mg as prescribed at 8am on 9/24/20. Individual 1 did not receive Levothyroxine 150mcg as prescribed on 10/22/20. There is no documentation of these medication errors.Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record.Upon looking into this citation we discovered that the medications were in fact given which is why the med errors were not reported or entered into EIM. If these were in fact med errors we have been notified and proper reporting would have occurred. It does appear that these errors where in fact documentation errors. We were unable to locate the empty blister packs to show that staff did administer the medications. Programs are required to keep the empty blister packs for two months. Due to this incident we are now requiring all programs to scan the empty blister packs and they will be stored in the Google drive. Since the documentation could not be found we will enter the following corrective action: All staff at the program will be retrained in the licensing requirements and expectations to maintain compliance with regulation 6400.167(b) by 11/30/20. All program 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 ; Section III- Administration Errors, Documentation Errors, Reporting, Tracking and Documenting Errors. The Director of Operations, the Compliance Manager and the Medication Administration Trainer will be responsible to ensure that all training occurs by 11/30/20. The medication errors will be entered into EIM and documentation of the errors will be kept in Individual # 1¿s record. The Compliance Manager will be responsible to ensure that the errors are entered into EIM and that documentation is in Individual #1¿s record by 11/30/20. 11/30/2020 Implemented
6400.167(c)Individual #1 did not receive Aspirin Chew 81 mg as prescribed at 8am on 9/24/20. Individual #1 did not receive Levothyroxine 150mcg as prescribed on 10/22/20. These medication errors were not reported.A medication error shall be reported as an incident as specified in § 6400.18(b) (relating to incident report and investigation).: Upon looking into this citation we discovered that the medications were in fact given which is why the med errors were not reported or entered into EIM. If these were in fact med errors we have been notified and proper reporting would have occurred. It does appear that these errors where in fact documentation errors. We were unable to locate the empty blister packs to show that staff did administer the medications. Programs are required to keep the empty blister packs for two months. Due to this incident we are now requiring all programs to scan the empty blister packs and they will be stored in the Google drive. All staff at the program will be retrained in the licensing requirements and expectations to maintain compliance with regulation 6400.167(c) by 11/30/20. All program 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 ; Section III- Administration Errors, Documentation Errors, Reporting, Tracking and Documenting Errors. The Director of Operations, the Compliance Manager and the Medication Administration Trainer will be responsible to ensure that all training occurs by 11/30/20. The medication errors will be entered into EIM and documentation of the errors will be kept in Individual # 1¿s record. The Compliance Manager will be responsible to ensure that the errors are entered into EIM and that documentation is in Individual #1¿s record by 11/30/20. 11/30/2020 Implemented
SIN-00162981 Renewal 09/20/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.52(a)(1)Staff #1 completed only 12 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
6400.181(f)The annual assessment completed on 2/06/19 for Individual #1 was not sent to the individual plan team members at least 30 calendar days prior to the individual plan meeting held on 3/07/19.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.Dayspring Management staff will be retrained in the licensing requirements and expectations to maintain compliance with regulation 6400.181(f) by 11/29/2019. Additionally, the Director of Operations has developed a master schedule for all residential participants that tracks ISP and quarterly due dates as well as Assessment due dates. The annual assessments will now be completed at the time the third quarterly report is done which will ensure that the assessment is sent to the entire team at least 30 calendar days prior to the ISP meeting. Documentation that the assessment has been sent to the team will be attached and filed with the assessment. 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
SIN-00140629 Renewal 08/29/2018 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.151(c)(3)The section pertaining to communicable diseases on Staff #1's physical form was left blank. The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. Staff # 1 physical form was faxed to the doctor¿s office to have to required information updated on 9/28/18. When the form is returned it will be updated in the staff file. The Human Resources Manager will be responsible to ensure that form is returned and filed by 11/30/18. The Human Resources Manager will ensure that all requirements regarding staff physicals are current, complete and accurate. These requirements will be reviewed with the Human Resources Manager by 11/30/18. The Human Resources Manager and the CEO will be responsible to ensure this expectation is met for ongoing compliance. 11/30/2018 Implemented
SIN-00124280 Renewal 10/31/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.181(f)Individual #2's ISP meeting was held on 3/28/2017. His assessment was completed & sent to his team on 3/10/2017.(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
6400.213(1)(i)Identifying marks are not listed in Individual #2's record.Each individual's record must include the following information: Personal information including: (i) The name, sex, admission date, birthdate and social security number. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (ii) The race, height, weight, color of hair, color of eyes and identifying marks.(iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph.Dayspring Management staff will be retrained in the licensing requirements and expectations to maintain compliance with Chapter 6400 regulation 6400.213 (1) by 1/31/18. It will be expected that records for all participants will be reviewed for accuracy and any corrections will be made and completed by 1/31/18. The Operations Manager and Program Specialists will be responsible to ensure that all Management staff are trained and all corrections are completed by 1/31/18. 01/31/2018 Implemented
SIN-00105287 Renewal 11/15/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.168(d)Staff #3 was medication administration certified in 2012. He had his annual practicum on 6/17/2015. He did not have another practicum until 10/26/2016, 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 Homes currently has one Medications Administration Trainer responsible for maintaining all staff medication administration training requirements. Dayspring Homes will have 2 additional Medication Administration Trainers trained by the end of 2017. Training will begin for the new trainers by 1/31/2017. The online portion of the training is to be completed by 2/28/2017. The face to face portion of the training will be scheduled to be completed as soon as possible according to the dates set by the Medication Administration Train the Trainer program. (We have not yet received the dates for the trainings scheduled for 2017). The Operations Manager will be responsible to ensure that all online training is completed by 2/28/2017 ; and that the face to face portion of the training is scheduled as soon as the dates are received from the Medication Train the Trainer Course program. 02/28/2017 Implemented
6400.186(c)(2)ISP areas such as health & safety are not being reviewed in Individual #3'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-00056596 Unannounced Monitoring 11/08/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.80(b)An outside porch light to the left of the front door was broken off from the house and hanging by an approximately 12 inch metal cord.(b) The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. Plan of Correction on file. Fully Implemented CH 12/2/13 Implemented
6400.162(a)Individual #1 is prescribed Novolog 100/ml. The label reads that 4 units should be administered at breakfast, 5 units should be administered at lunch, 7 units should be administered at dinner, and 2 units should be administered at bedtime. The 2 unit dosage at bedtime was discontinued in 11/2013. The prescription label is incorrect.(a) The original container for prescription medications shall be labeled with a pharmaceutical label that includes the individual's name, the name of the medication, the date the prescription was issued, the prescribed dose and the name of the prescribing physician. Plan of Correction on File. Partially Implemented, Adequate Progress CH 12/2/13 Implemented
SIN-00122694 Renewal 10/31/2017 Compliant - Finalized
SIN-00086250 Renewal 10/21/2015 Compliant - Finalized