| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.21(l) | The provider did not hold conversations with Individual #1 relating to their preferred community participation and activities as required by ODP Announcement 24-061. | An individual has the right to make choices and accept risks. | The Supervisor of Day Services will meet monthly with participants, in the presence of another staff person or Program Lead, to develop and document a schedule of activities and preferred community participation opportunities, in alignment with ODP Announcement 24-061 and individual preferences.
The Supervisor will ensure that activities are reflective of each participant's assessed needs, preferences, and desired outcomes as outlined in the Individual Support Plan (ISP).
The Supervisor will communicate daily schedules and planned activities to assigned staff to ensure that services are delivered as intended and that each participant's needs and preferences are addressed in accordance with regulatory requirements. Documentation of scheduled activities will be maintained and made available for review. |
03/16/2026
| Implemented |
| 2380.39(c)(1) | Staff #1 did not have record of the following training during the last completed training year: Person-Centered Practices | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | The Director of Day Services will implement the use of Special Friends Foundation's Annual Training Plan, which is developed in accordance with 55 Pa. Code § 2380.39 and § 6100.143 (Annual Training Plan). The Annual Training Plan outlines all required training topics, minimum hour requirements, and approved training methods to ensure staff are trained to safely and effectively perform assigned duties.
All staff will complete required trainings within established timeframes, and documentation of training completion will be maintained to demonstrate compliance. The Director will ensure that all training requirements are met and that staff are not permitted to perform duties independently until required training has been completed, as applicable. |
03/16/2026
| Implemented |
| 2380.39(c)(2) | Staff #1 did not have record of the following training during the last completed training year: Recognizing and Reporting Abuse | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101 - 10225.5102), the child protective services law (23 Pa. C.S. §§ 6301 - 6386), the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations. | The Director of Day Services will implement the use of Special Friends Foundation's Annual Training Plan, which is developed in accordance with 55 Pa. Code § 2380.39 and § 6100.143 (Annual Training Plan). The Annual Training Plan outlines all required training topics, minimum hour requirements, and approved training methods to ensure that staff receive training relevant to their assigned duties and responsibilities and are able to safely and effectively perform their roles.
All staff will complete required trainings within established timeframes, and documentation of training completion will be maintained to demonstrate compliance. The Director will ensure that all training requirements are met and that staff are not permitted to perform assigned duties independently until required training has been completed, as applicable. |
03/16/2026
| Implemented |
| 2380.39(c)(3) | Staff #1 did not have record of the following training during the last completed training year: Individual Rights | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | The Director of Day Services will implement the use of Special Friends Foundation's Annual Training Plan, which is developed in accordance with 55 Pa. Code § 2380.39 and § 6100.143 (Annual Training Plan). The Annual Training Plan outlines all required training topics, minimum hour requirements, and approved training methods to ensure staff are trained to safely and effectively perform assigned duties.
All staff will complete required trainings within established timeframes, and documentation of training completion will be maintained to demonstrate compliance. The Director will ensure that all training requirements are met and that staff are not permitted to perform duties independently until required training has been completed, as applicable. |
03/16/2026
| Implemented |
| 2380.39(c)(4) | Staff #1 did not have record of the following training during the last completed training year: Incident Management | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents. | The Director of Day Services will implement the use of Special Friends Foundation's Annual Training Plan, which is developed in accordance with 55 Pa. Code § 2380.39 and § 6100.143 (Annual Training Plan). The Annual Training Plan outlines all required training topics, minimum hour requirements, and approved training methods to ensure staff are trained to safely and effectively perform assigned duties.
All staff will complete required trainings within established timeframes, and documentation of training completion will be maintained to demonstrate compliance. The Director will ensure that all training requirements are met and that staff are not permitted to perform duties independently until required training has been completed, as applicable. |
03/16/2026
| Implemented |