Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00234391 Renewal 11/13/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.109(f)Alternate exits shall be used during fire drills. The home has two exits, but only the front door was used as the exit during all fire drills held from 10/05/2022 to 10/15/2023.Alternate exit routes shall be used during fire drills.The Life Sharing Provider was retrained on regulation 6500.105 on 11/30/23 and will begin using alternate exits during the next scheduled drill. There is one alternative exit (back door) which SD is able to evacuate from without any concerns. 11/30/2023 Implemented
6500.135(g)If a medication is prescribed to treat the symptoms of a diagnosed psychiatric illness, there shall be a review by a licensed practitioner at least every three months to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. The psychiatric medication reviews conducted on 11/03/2023, 7/21/2023 and 4/24/2023 for Individual #1 did not document the reason for prescribing the medications Carbamazepine and Risperdal. The psychiatric medication review conducted on 1/23/2023 did not document the reason for prescribing the medication Carbamazepine.If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review by a licensed physician at least every 3 months to document the r reason for prescribing the medication, the need to continue the medication and the necessary dosage.Individual #1 chooses to participate in tele-health visits with her psychiatrist every 3 months. Unfortunately, since she is not seen in the office, we do not have the opportunity to have our Dayspring form completed at each visit. We have tried to fax or drop off our forms in the office for completion after the tele-health visits; however, the physician has not been completing them, and instead the office is providing us with a printed out after visit summary. The after-visit summaries list the diagnoses and medications, but do not always specify exactly which diagnosis each medication is prescribed for. After this inspection, a Dayspring form was faxed to the office to be completed with no response. Another form along with a letter from the Director of Quality and Compliance explaining our regulations and the necessity of the medication diagnosis documentation was dropped off at the office. At the time of submitting this plan of correction, the office has not yet responded. The Director of Quality and Compliance sent an example of Individual #1¿s after visit summary to Licensing Supervisor on 12/8/23 and asked if the documentation was sufficient. Licensing Supervisor replied that he would accept the after-visit summary print out documentation. 02/29/2024 Implemented
SIN-00214378 Renewal 11/07/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.17(a)The self-assessment was not completed in within 3-6 months prior to the expiration date of the agency's certificate of compliance. The self-assessment was not completed until October 2022. The assessment was not completed in its entirety and there was not a full date of completion, the date listed October as the date of completion. (Repeat Violation 11/9/21)If an agency is the legal entity for the home, the agency shall complete a Self-Assessment of Homes the agency is licensed to operate within 3 to 6 months prior to the expiration date of the agency's certificate of compliance, to measure and record compliance with this chapter.The previous Compliance Manager was responsible for completing the self-assessments and failed to do so. The Director of Quality and Compliance was hired on 8/1/22 to take over the duties of the Compliance Manager, and effective 9/8/22 the Compliance Manager is no longer in her position. 01/30/2022 Implemented
6500.45(a)Life sharing provider #1 is not trained by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, and Heimlich techniques prior to an individual living in the home and annually thereafter.The primary caregiver shall be trained by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid and Heimlich techniques prior to an individual living in the home and annually thereafter.The previous LS Specialist was not ensuring that the LS Provider was attending and completing the required trainings. Additionally, this LS provider has been non-compliant and unresponsive when members of the Dayspring management team attempt to reach them for needs, such as signing up for trainings. Due to the LS Providers recent health decline, Dayspring has been in the process of switching the provider to the LS Provider¿s roommate. This change has not yet taken place because we are waiting for the new LS Provider to complete the required trainings. The prospective new LS Provider is currently working on the required trainings. Aside from training issues, the Dayspring management team has identified several concerns with this LS Provider recently. Due to these concerns, Dayspring has made the decision to give a 45-day notice to this provider. The Supports Coordinator is aware of this decision, Dayspring¿s CEO and Director of Operations are meeting with the Supports Coordinator on 11/28/22 to discuss Dayspring¿s concerns and the decision to terminate this LS Provider. The LS Provider will be issued the 45-day notice by 12/1/22 12/01/2022 Implemented
6500.45(b)Life sharing Provider (LSP) #1 is not trained and certified by an individual certified as a trainer by a hospital or other recognized health care organization in cardiopulmonary resuscitation, if indicated by the medical needs of the individual. (Repeat Violation 11/9/21)The primary caregiver shall be trained and certified by an individual certified as a trainer by a hospital or other recognized health care organization, in cardiopulmonary resuscitation, if indicated by the medical needs of the individual, prior to the individual living in the home and annually thereafter.The previous LS Specialist was not ensuring that the LS Provider was attending and completing the required trainings. Additionally, this LS provider has been non-compliant and unresponsive when members of the Dayspring management team attempt to reach them for needs, such as signing up for trainings. Due to the LS Providers recent health decline, Dayspring has been in the process of switching the provider to the LS Provider¿s roommate. This change has not yet taken place because we are waiting for the new LS Provider to complete the required trainings. The prospective new LS Provider is currently working on the required trainings. Aside from training issues, the Dayspring management team has identified several concerns with this LS Provider recently. Due to these concerns, Dayspring has made the decision to give a 45-day notice to this provider. The Supports Coordinator is aware of this decision, Dayspring¿s CEO and Director of Operations are meeting with the Supports Coordinator on 11/28/22 to discuss Dayspring¿s concerns and the decision to terminate this LS Provider. The LS Provider will be issued the 45-day notice by 12/1/22. 12/01/2022 Implemented
6500.48(a)Life Sharing Provider (LSP ) #1 did not complete 24 hours of training related to job skills and knowledge.The primary caregiver and the life sharing specialist shall complete 24 hours of training related to job skills and knowledge each year.The previous LS Specialist was not ensuring that the LS Provider was attending and completing the required trainings. Additionally, this LS provider has been non-compliant and unresponsive when members of the Dayspring management team attempt to reach them for needs, such as signing up for trainings. Due to the LS Providers recent health decline, Dayspring has been in the process of switching the provider to the LS Provider¿s roommate. This change has not yet taken place because we are waiting for the new LS Provider to complete the required trainings. The prospective new LS Provider is currently working on the required trainings. Aside from training issues, the Dayspring management team has identified several concerns with this LS Provider recently. Due to these concerns, Dayspring has made the decision to give a 45-day notice to this provider. The Supports Coordinator is aware of this decision, Dayspring¿s CEO and Director of Operations are meeting with the Supports Coordinator on 11/28/22 to discuss Dayspring¿s concerns and the decision to terminate this LS Provider. The LS Provider will be issued the 45-day notice by 12/1/22. 12/01/2022 Implemented
6500.48(b)(1)Life Sharing Provider #1 did not complete annual training hours that encompass the application of person-centered practices, rights, facilitating community integration, individual choice and supporting individuals to develop and maintain relationships.The annual training hours specified in subsection (a) must encompass the following areas: The application of person-centered practices, rights, facilitating community integration, individual choice and supporting individuals to develop and maintain relationships.The previous LS Specialist was not ensuring that the LS Provider was attending and completing the required trainings. Additionally, this LS provider has been non-compliant and unresponsive when members of the Dayspring management team attempt to reach them for needs, such as signing up for trainings. Due to the LS Providers recent health decline, Dayspring has been in the process of switching the provider to the LS Provider¿s roommate. This change has not yet taken place because we are waiting for the new LS Provider to complete the required trainings. The prospective new LS Provider is currently working on the required trainings. Aside from training issues, the Dayspring management team has identified several concerns with this LS Provider recently. Due to these concerns, Dayspring has made the decision to give a 45-day notice to this provider. The Supports Coordinator is aware of this decision, Dayspring¿s CEO and Director of Operations are meeting with the Supports Coordinator on 11/28/22 to discuss Dayspring¿s concerns and the decision to terminate this LS Provider. The LS Provider will be issued the 45-day notice by 12/1/22. 12/01/2022 Implemented
6500.48(b)(2)Life Sharing Provider #1 did not complete annual training hours that encompass the prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101 - 10225.5102), the Child Protective Services Law (23 Pa.C.S. §§ 6301 - 6386), the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.The annual training hours specified in subsection (a) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101 - 10225.5102), the Child Protective Services Law (23 Pa.C.S. §§ 6301 - 6386), the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.The previous LS Specialist was not ensuring that the LS Provider was attending and completing the required trainings. Additionally, this LS provider has been non-compliant and unresponsive when members of the Dayspring management team attempt to reach them for needs, such as signing up for trainings. Due to the LS Providers recent health decline, Dayspring has been in the process of switching the provider to the LS Provider¿s roommate. This change has not yet taken place because we are waiting for the new LS Provider to complete the required trainings. The prospective new LS Provider is currently working on the required trainings. Aside from training issues, the Dayspring management team has identified several concerns with this LS Provider recently. Due to these concerns, Dayspring has made the decision to give a 45-day notice to this provider. The Supports Coordinator is aware of this decision, Dayspring¿s CEO and Director of Operations are meeting with the Supports Coordinator on 11/28/22 to discuss Dayspring¿s concerns and the decision to terminate this LS Provider. The LS Provider will be issued the 45-day notice by 12/1/22. 12/01/2022 Implemented
6500.48(b)(3)Life Sharing Provider #1 did not complete annual training hours in Individual Rights.The annual training hours specified in subsection (a) must encompass the following areas: Individual rights.The previous LS Specialist was not ensuring that the LS Provider was attending and completing the required trainings. Additionally, this LS provider has been non-compliant and unresponsive when members of the Dayspring management team attempt to reach them for needs, such as signing up for trainings. Due to the LS Providers recent health decline, Dayspring has been in the process of switching the provider to the LS Provider's roommate. This change has not yet taken place because we are waiting for the new LS Provider to complete the required trainings. The prospective new LS Provider is currently working on the required trainings. Aside from training issues, the Dayspring management team has identified several concerns with this LS Provider recently. Due to these concerns, Dayspring has made the decision to give a 45-day notice to this provider. The Supports Coordinator is aware of this decision, Dayspring¿s CEO and Director of Operations are meeting with the Supports Coordinator on 11/28/22 to discuss Dayspring¿s concerns and the decision to terminate this LS Provider. The LS Provider will be issued the 45-day notice by 12/1/22. 12/01/2022 Implemented
6500.48(b)(4)Life Sharing Provider #1 did not complete annual training in recognizing and reporting incidents.The annual training hours specified in subsection (a) must encompass the following areas: Recognizing and reporting incidents.The previous LS Specialist was not ensuring that the LS Provider was attending and completing the required trainings. Additionally, this LS provider has been non-compliant and unresponsive when members of the Dayspring management team attempt to reach them for needs, such as signing up for trainings. Due to the LS Providers recent health decline, Dayspring has been in the process of switching the provider to the LS Provider's roommate. This change has not yet taken place because we are waiting for the new LS Provider to complete the required trainings. The prospective new LS Provider is currently working on the required trainings. Aside from training issues, the Dayspring management team has identified several concerns with this LS Provider recently. Due to these concerns, Dayspring has made the decision to give a 45-day notice to this provider. The Supports Coordinator is aware of this decision, Dayspring¿s CEO and Director of Operations are meeting with the Supports Coordinator on 11/28/22 to discuss Dayspring¿s concerns and the decision to terminate this LS Provider. The LS Provider will be issued the 45-day notice by 12/1/22. 12/01/2022 Implemented
6500.48(b)(5)Life Sharing Provider #1 did not complete annual training in the safe and appropriate use of behavior supports.The annual training hours specified in subsection (a) must encompass the following areas: The safe and appropriate use of behavior supports.The previous LS Specialist was not ensuring that the LS Provider was attending and completing the required trainings. Additionally, this LS provider has been non-compliant and unresponsive when members of the Dayspring management team attempt to reach them for needs, such as signing up for trainings. Due to the LS Providers recent health decline, Dayspring has been in the process of switching the provider to the LS Provider¿s roommate. This change has not yet taken place because we are waiting for the new LS Provider to complete the required trainings. The prospective new LS Provider is currently working on the required trainings. Aside from training issues, the Dayspring management team has identified several concerns with this LS Provider recently. Due to these concerns, Dayspring has made the decision to give a 45-day notice to this provider. The Supports Coordinator is aware of this decision, Dayspring¿s CEO and Director of Operations are meeting with the Supports Coordinator on 11/28/22 to discuss Dayspring¿s concerns and the decision to terminate this LS Provider. The LS Provider will be issued the 45-day notice by 12/1/22. 12/01/2022 Implemented
6500.48(b)(6)Life Sharing Provider #1 did not complete annual training that included the implementation of the individual plan.The annual training hours specified in subsection (a) must encompass the following areas: Implementation of the individual plan.The previous LS Specialist was not ensuring that the LS Provider was attending and completing the required trainings. Additionally, this LS provider has been non-compliant and unresponsive when members of the Dayspring management team attempt to reach them for needs, such as signing up for trainings. Due to the LS Providers recent health decline, Dayspring has been in the process of switching the provider to the LS Provider¿s roommate. This change has not yet taken place because we are waiting for the new LS Provider to complete the required trainings. The prospective new LS Provider is currently working on the required trainings. Aside from training issues, the Dayspring management team has identified several concerns with this LS Provider recently. Due to these concerns, Dayspring has made the decision to give a 45-day notice to this provider. The Supports Coordinator is aware of this decision, Dayspring¿s CEO and Director of Operations are meeting with the Supports Coordinator on 11/28/22 to discuss Dayspring¿s concerns and the decision to terminate this LS Provider. The LS Provider will be issued the 45-day notice by 12/1/22. 12/01/2022 Implemented
SIN-00196283 Renewal 11/08/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6500.23(a)Individual #2 started receiving services in the home on 7/7/21, and Staff #2 and Staff #3's Pennsylvania criminal history record checks were submitted on 11/5/21 which exceeds the required timeframe.An application for a Pennsylvania criminal history record check shall be submitted to the State Police for individuals 18 years of age or older who reside in the home, prior to an individual living or receiving respite care in the home.Since licensing, the provider has conducted an internal audit to address this citation; specifically reviewing each Life Sharing Provider¿s profile. The LS Specialist will ensure a LS Provider¿s profile is complete before services are provided. A shared tracker between LS Specialist and HR has been created to capture this information. The tracking tool will be used to record and track information the provider is required to obtain, review, update and maintain for each LS Provider and all household members. 01/31/2022 Implemented
6500.17(a)The self-assessment was completed on 11/07/2021, which was not within 3 to 6 months prior to the expiration date of the agency's certificate of compliance which was 8/06/2021.If an agency is the legal entity for the home, the agency shall complete a Self-Assessment of Homes the agency is licensed to operate within 3 to 6 months prior to the expiration date of the agency's certificate of compliance, to measure and record compliance with this chapter.The Life Sharing Specialist will develop and maintain a schedule for tracking when self- assessments are to be completed for all Life Sharing programs. The LS Specialist will then develop a process/system that ensures that the assessments are completed within the required timeframes. 01/31/2022 Implemented
6500.32(r)(1)Individual #2 did not have a lock on their bedroom door.An individual has the right to lock the individual's bedroom door. Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door.At the time of the inspection Individual #2 stated that she did not want a lock on her bedroom door. The LS Specialist was unsure if this information was included in SD¿s current ISP. Since this inspection, the LS specialist has reviewed the ISP and did not find the information included. The LS Specialist will email the SC and request that the information be included in SD¿s current ISP. 01/31/2022 Implemented
6500.45(a)Individual #2 moved into the home on 7/7/21 and Staff #2 has not been trained in First Aid and Heimlich techniques.The primary caregiver shall be trained by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid and Heimlich techniques prior to an individual living in the home and annually thereafter.The Life Sharing Provider had previously been training in First Aid and CPR, however the time lapsed. The Provider is in the process of working with the Life Sharing Provider on a resolution. At this time the LS Provider is experiencing several personal challenges. Individual #2 and the LS Provider have discussed this situation and have decided that it would be best to have Staff #3 become the primary LS Provider for Individual #2 to ensure that all regulatory requirements are sufficiently met. Individual #2 and her team will be scheduling a meeting to discuss the proposed change in the primary LS Provider. Individual #2 has lived with this family for 20+ years and it is her desire to continue to be part of this family. The LS Specialist will be responsible for ensuring that the new LS Provider profile is completed before transferring the role of primary LS Provider. 01/31/2022 Implemented
6500.45(b)Individual #2 moved into the home on 7/7/21 and Staff #2 has not been trained in cardiopulmonary resuscitation (CPR). Individual #2 is diagnosed with a seizure disorder. This indicates a medical need that may require the use of CPR.The primary caregiver shall be trained and certified by an individual certified as a trainer by a hospital or other recognized health care organization, in cardiopulmonary resuscitation, if indicated by the medical needs of the individual, prior to the individual living in the home and annually thereafter.The Life Sharing Provider had previously been training in First Aid and CPR, however the time lapsed. The Provider is in the process of working with the Life Sharing Provider on a resolution. At this time the LS Provider is experiencing several personal challenges. Individual #2 and the LS Provider have discussed this situation and have decided that it would be best to have Staff #3 become the primary LS Provider for Individual #2 to ensure that all regulatory requirements are sufficiently met. Individual #2 and her team will be scheduling a meeting to discuss the proposed change in the primary LS Provider. Individual #2 has lived with this family for 20+ years and it is her desire to continue to be part of this family. The LS Specialist will be responsible for ensuring that the new LS Provider profile is completed before transferring the role of primary LS Provider. 01/31/2022 Implemented
6500.47(a)Individual #2 moved into the home on 7/7/21, and Staff #2 did not complete an orientation.Prior to an individual living in the home, the primary caregiver and the life sharing specialist shall complete the orientation as described in subsection (b).The Life Sharing Specialist will ensure a Life Sharing Provider¿s profile is complete before services are provided. A shared tracker between the LS Specialist and HR has been created to capture this information. An Orientation packet will be developed that will be used to ensure all new LS Providers receive the necessary information and an orientation is completed as required by regulation. 01/31/2022 Implemented
6500.48(b)(1)Staff #4's annual trainings did not include person-centered practices, rights, individual choice and supporting individuals to develop and maintain relationships.The annual training hours specified in subsection (a) must encompass the following areas: The application of person-centered practices, rights, facilitating community integration, individual choice and supporting individuals to develop and maintain relationships.In response to citations received during last year¿s inspection, Dayspring management began the process of reviewing and revising our annual training curriculum and training process/program to ensure that all required annual training topics as listed in 6500.48 b3 are included in the annual training provided to all Life Sharing Providers. Due to unforeseen circumstances we were unable to accomplish this task in its entirety and the training curriculum and training process/program are still being revised. An annual training packet is being developed that will be provided to all LS providers at the beginning of the new training year. The training packet will include a list of all required annual trainings with instructions on how each training is to be completed- in person, on line etc., what documentation is needed to show the training was successfully completed- test after training, training summary etc. The packet will be an all-inclusive resource for LS providers to consult throughout the training year to ensure that all training requirements are met. 01/31/2022 Implemented
6500.48(b)(5)Staff #4's annual trainings did not include safe and appropriate use of behavior supports.The annual training hours specified in subsection (a) must encompass the following areas: The safe and appropriate use of behavior supports.n response to citations received during last year¿s inspection, Dayspring management began the process of reviewing and revising our annual training curriculum and training process/program to ensure that all required annual training topics as listed in 6500.48 b3 are included in the annual training provided to all Life Sharing Providers. Due to unforeseen circumstances we were unable to accomplish this task in its entirety and the training curriculum and training process/program are still being revised. An annual training packet is being developed that will be provided to all LS providers at the beginning of the new training year. The training packet will include a list of all required annual trainings with instructions on how each training is to be completed- in person, on line etc., what documentation is needed to show the training was successfully completed- test after training, training summary etc. The packet will be an all-inclusive resource for LS providers to consult throughout the training year to ensure that all training requirements are met. 01/31/2022 Implemented