Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00264618 Unannounced Monitoring 04/14/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.151(a)Staff #2 had a physical exam on 1/30/2023, then not again until 3/14/2025, exceeding the 2-year regulation. A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. This policy ensures that staff have taken the necessary medical precautions to avoid the spread of communicable diseases. This violation occurred because ISG staff took the literal interpretation of the regulation outlined in § 6400.151.a - Staff Physical Examination. This was obviously a misinterpretation of what was required for regulatory compliance. Staff #2 has just switched to an office position a few months back; therefore, he had assumed that he was not required to do the physical examination again, since he was not working directly with the individuals; he has been a DSP Supervisor since September 2024. As an immediate fix for the problem, the physical examination was already done on 3/14/25. All agency staff records were also reviewed for compliance. 05/01/2025 Implemented
6400.169(a)Staff #2 completed initial medication administration training on 4/29/2019. Since 2019 there is no record of completing the "student annual practicum form", but there are records of completing MAR reviews and observations.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).The benefit of this regulation is that it ensures that medications are administered properly by trained personnel to avoid medication errors. The Student Annual Practicum Certificate for Staff #2 was presented. However, it was recorded on an old form. This violation occurred because Ideal Services Groups Med Admin Trainer used an outdated form. The Agency Med Trainer accepts responsibility for this oversight. The Agency Nurse followed the Annual Requirements for Two (2) Medication administration observations (1 every 6 months), and Two (2) Medication record reviews (1 every 6 months). These were duly recorded on the forms provided for those purposes. However, the Med Admin Trainer was not aware of the fact that the Practicum form has changed. To fix the immediate problem, the Agency Nurse/Med Admin Trainer has transferred the Annual Practicum information for Staff #2 on to the new form (included as Attachment #22). In addition, all ISG staffs practicum information has been transferred to the new form. 05/01/2025 Implemented
6400.169(a)There is no documentation of Staff #4's initial medication administration training. Additionally, there is no record of completing the "student annual practicum form," but there are records of completing MAR review and observations.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).The benefit of this regulation is that it ensures that medications are administered properly by trained personnel to avoid medication errors. Staff #4 had her Initial Medications Administration Training completed on 3/17/2023. She did a re-certification, which was not required, on 3/21/2025. In addition, she completed her Practicum Observer Training on 9/12/2024. All these certificates were placed in her Medications Administration folder (Certificates included as Attachment #23). The Agency Nurse compiled all the medication administration folders for all staff, and they are housed in a separate cabinet. These files are periodically reviewed by the Program Specialist. After Ideal Services Group received the staff selection for this inspection, all relevant folders were pulled out by the Agency Nurse and checked for completeness by the Staff Compliance Office, and then by the Program Specialist. The CEO finally examined the same documents, and they were presented for inspection. All these steps of oversight are to remove any margin of error on ISG¿s part. At the conclusion of the inspection, when ISG staff removed all the folders presented, all the certificates were still intact in Staff #2¿s folder. The ISG team was not briefed about any missing certificate prior to the conclusion of the inspection or even at the Exit Interview; otherwise, we would have assisted the inspection team in pointing them to a thorough look at the folder presented. ISG has been compliant with regards to this preliminary citation. This should not have been a violation. The Student Annual Practicum Certificate for Staff #4 was presented. However, it was recorded on an old form. This violation occurred because Ideal Services Group¿s Med Admin Trainer used an outdated form. The Agency Nurse and Program Specialist accept responsibility for this oversight. The Agency Nurse followed the Annual Requirements for Two (2) Medication administration observations (1 every 6 months), and Two (2) Medication record reviews (1 every 6 months). These were duly recorded on the forms provided for those purposes. However, the Med Admin Trainer was not aware of the fact that the Practicum form has changed. To fix the immediate problem, the Agency Nurse/Med Admin Trainer has transferred the Annual Practicum information for Staff #2 on to the new form (included as Attachment 24). In addition, all ISG staff¿s practicum information has been transferred to the new form. The new forms have been properly filed away in each staff¿s Med Admin folder. 05/01/2025 Implemented
SIN-00250254 Renewal 08/26/2024 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.43(b)(1)The agency has a progressive discipline policy which reads "Upon evidence of deficient or unsatisfactory performance or unacceptable job-related conduct by an employee, a supervisor may choose to issue a dissatisfaction notice. A written dissatisfaction notice must be reviewed with the employee within five working days of the date of the notice." Staff # 5 supervised Staff # 6 and reported during licensing discussions, that the progressive discipline policy was not enacted as written when deficiencies with Staff # 6's performance were identified.The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. § 6400.43.(b)(1) Chief Executive Officer (b) The chief executive officer shall be responsible for the administration and general management of the home, including the following: (1) Implementation of policies and procedures. The error occurred because this is actually an administrative issue, not strictly a home issue per se. Ultimately, the CEO is responsible for the overall tone of the agency¿s administration, but it was not brought to his attention. The agency¿s policy states that ¿upon evidence of unsatisfactory performance ¿, a supervisor may choose to issue a satisfaction notice ¿.¿ Staff #5 chose not to issue a dissatisfaction notice because the issue just came up at the beginning of the licensing inspection week when a document was missing. It had been just three days, (Monday ¿ Wednesday) when the deficiency was noticed. Staff #5 still expected Staff # 6 to show up at work, at least on inspection day. There was no time to write a dissatisfaction notice while Staff #5 was trying to get documents together for inspection. Neither was there time to report to the CEO while the inspection was going on. Staff #6 is no longer employed by ISG, given her dereliction of duty. 10/01/2024 Not Implemented
6400.101There is no handle on the basement door, instead there is just a deadbolt lock with the turn handle in the hallway.Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. § 6400.101. Unobstructed egress. Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed. At the time of the inspection, the door leading to the basement in Butler did not have a functional handle. To Fix the Immediate Problem: On the inspection date ¿ 8/28/24, as soon as the obstruction was pointed out, ISG maintenance staff went over and fixed the problem ¿ a picture of the corrected door latch is attached as Attachment #8. The Program Supervisor, the Program Specialist, and the CEO have gone to the home to check that the repair worked, and that the door is no longer an obstructed egress. All ISG homes were inspected to ensure that all physical sights are in compliance. As a matter of fact, Licensing officials inspected all ISG homes within the two days of inspection. There is no obstructed egress in any ISG homes any longer. All door latches are in place, and they are functioning as expected. 10/01/2024 Implemented
6400.214(b)The current assessment for Individual # 3 was not in the home during the physical site walk through on 08/28/24. The most recent assessment was dated 08/24/22. The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home. § 6400.214.(b) Record Location states that the most current copies of record information required shall be kept at the residential home. At the time of the inspection, the current Annual Assessments for Individual #3 was not in the home. The Program Specialist is responsible for writing the assessments and correcting this problem. The Program Specialist shall provide the current assessments for all the individuals concerned, as an immediate corrective measure for the error that had arisen. The Program Specialist has provided the assessment, attached as Attachment #7. All individuals in the agency currently have all their assessments placed in their folders in their respective homes. The current Annual Assessment for Individual #3 has been attached as Attachment #7. 10/01/2024 Not Implemented
6400.52(c)(2)Staff # 1 did not have Abuse training during the July 23-June 24 training year.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.§ 6400.52.(c)(2) Annual Training (c) The annual training hours specified in subsections (a) and (b) must encompass the following areas: (2) The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services ¿. At the time of the inspection, the ¿Abuse¿ training certificate for Staff #1 was not found. The error occurred probably due to a problem of filing by the Training Director. It was probably misplaced. It was available during the 2023 Licensing exercise. So, obviously, it was misplaced. As an immediate way of fixing the problem, ODP was contacted to ask for help in retrieving the certificate, as those certificates have been archived. ODP responded with the resolution ¿ e-mail attached as Attachment #10. The Training Director is the custodian for all staff¿s certificates. At the time of the inspection, the Training Director was neither at work, nor were we able to contact her by phone. She has since ceased to be a staff member of ISG. ISG is in the process of hiring another Training Director. According to the agency¿s organogram, the Training Director reports to the Director of Operations (DOO). So, the DOO is taking charge of training processes right now. 10/01/2024 Not Implemented
SIN-00208901 Renewal 08/08/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Staff #4's start date is noted as 11/3/20. Her criminal record check was completed on 9/18/2021.An application for a Pennsylvania criminal history record check shall be submitted to the State Police for prospective employes of the home who will have direct contact with individuals, including part-time and temporary staff persons who will have direct contact with individuals, within 5 working days after the person's date of hire. ISG has taken steps to ensure that all new staff are thoroughly onboarded in a timely manner. ISG has revamped its new staff onboarding processes and has debriefed all administrative staff on the updated protocols going forward. In addition, all current staff clearances and records have been reviewed to ensure quality assurance. 08/15/2022 Implemented
6400.141(c)(7)Individual #1's 10/26/21 annual physical exam does state individual #1 did not have a PAP completed. It is noted that she is not sexually active; however, there is no formal documentation from a physician that individual #1 does not require a PAP exam and why it is waived.The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. A PAP smear screening was scheduled for the individual on 9/7/22. The Outpatient Visit Summary, as well as the e-Message documenting the result interpretation from the visit, is attached (Attachment #4). Supervisors and administrative staff have been debriefed and retrained to be cognizant of the need for the PAP smear and to ensure they are scheduled on an ongoing basis. The agencys Nurse is in charge of reviewing each individuals record for needed labs and diagnostic tests. In addition to this, the nurse will schedule all tests in a timely fashion. 09/07/2022 Implemented
6400.141(c)(13)Individual #1 is prescribed Cetirizine 10mg for allergies; however, the current physical states she has no known allergies.The physical examination shall include: Allergies or contraindicated medications.ISG returned the individuals Physical Examination Form to the physician in order to update the physical report to reflect the individuals seasonal/environmental allergies. The physical has now been updated. The nurse on staff has reviewed all of ISGs individuals medical paperwork to ensure compliance. All Supervisors have been debriefed and trained to be cognizant of the correction made to the individual's physical and the relevant rationale for the correction. The amended physical for the individual to include that she has seasonal/environmental allergies is included as Attachment #3 for verification. 09/15/2022 Implemented
SIN-00193024 Renewal 09/21/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(b)At the time of the inspection, first aid kit did not contain antiseptic. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. (b) A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors VIOLATION: At the time of the inspection, the First Aid kit did not contain antiseptic. WHY THE REGULATION IS IMPORTANT: This regulation is important because it ensures that homes have all the equipment needed to provide first aid in the event of an injury. WHY THE VIOLATION OCCURRED: The violation occurred because a staff had taken out all the antiseptic and did not report that it needed to be replaced. Secondly, supervision for the maintenance of the First Aid kit was lacking. IMMEDIATE SOLUTION: A new First Aid box was bought in replacement for the incomplete one immediately. Supervisors were briefed on the importance of ensuring that their First Aid boxes have all the needed supplies. 10/14/2021 Implemented
SIN-00177770 Renewal 10/13/2020 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.104There was a notification to the fire department on 7/26/2020 but the individual's admission date was 6/26/2020.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. This regulation is important because it provides advance knowledge of the layout of the home and the needs of the individuals to help first responders evacuate individuals quickly in the event of an emergency. The notification to the Fire Department was sent late. The Program Director did not quite understand the time-sensitivity involved in complying with this regulation. This error cannot be fixed in retrospect. But the importance of sending it on time is learned. The Licensing Representative had explained the importance of registering an advanced notice. To prevent this error in the future, all notifications will be sent before the individuals move in. The Program Specialist shall send this notice in advance of the individuals move into the home. The CEO will supervise the Program Specialist to ensure compliance with this safety regulation. 11/06/2020 Implemented
6400.165(f)Individual #1 is diagnosed with situational anxiety and depressive disorder for which she is prescribed Citalopram for anxiety, and at the time of the inspection, her most recent ISP (Individual Plan) dated 9/18/2020 did not contain a SEEN plan. Also, under section "social/emotional information" it states that Individual #1 is taking Lexapro, which is not the correct medication. It also states that she does not have a mental health diagnosis, which is also inaccurate information and needs to be updated.If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness.If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness. This regulation is important because the written protocol (SEEN Plan) includes historical data regarding the individual¿s diagnosis and general techniques staff can utilize to assist this individual if symptoms are displayed. It is important that this plan is in place so it can assist staff to respond appropriately when the symptoms of their psychiatric illness manifests. The SEEN Plan was not sent to the Supports Coordinator (SC). Consequently, it was not incorporated into the individuals ISP. The Program Specialist failed to send the SEEN Plan to the SC. To correct this immediately, the SEEN Plan has been sent to the SC (e-mail cover letter attached as Attachment #1). To prevent this in the future, the Program Specialist will send this type of protocol to the SC on time, and implement it in the home immediately. The CEO will provide more oversight for the Program Specialist to ensure compliance with this regulation. 11/07/2020 Implemented
6400.165(g)Individual #1 is diagnosed with situational anxiety and Depressive Disorder for which she is prescribed citalopram. Individual #1 was due for a psychotropic medication check up by 9/26/2020. The provider stated they had a tele-visit on 9/11/2020 with the Individual's PCP, however the chart did not contain supporting documentation to verify the appointment occurred nor was there current documentation that indicated the reason for prescribing the medication, the need to continue the medication and the need to continue the medication at the necessary dosage currently being taken.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.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 documentation of the reason for prescribing the medication, the need to continue the medication and the necessary dosage. This regulation is important because many psychotropic medications have sedating side effects; and adhering to this regulation prevents maintenance medications from being used or interpreted as a form of chemical restraint. This medication monitoring serves to confirm that the individual is complying with their medication regimen, while also ensuring they are avoiding potentially dangerous drug interactions and other complications. The review also helps the psychiatrist review/assess the effectiveness of the medication and the need to continue its use. Overall, the review guarantees an optimal medication therapy and improves therapeutic outcomes for the individual. The individual had a medication check with her PCP, who follows her psychiatrically, on 09/11/2020. The needed documentation was not in the individuals record at the time of the inspection. The visit was a tele-health visit due to measures imposed by the Medical Center as a result of the coronavirus lockdown. The doctor, however, did not send the needed documentation, following the visit. Despite numerous efforts on the part of the Program Specialist, the doctor would not respond. To correct this immediately, the Program Specialist was eventually able to obtain a completed form from the doctor. Unfortunately, the documentation was done on a wrong form (attached as Attachment #2). The Program Specialist has scheduled another appointment for 10/5/2020 so we can have the doctor complete another form, but he cancelled the appointment. The Program Specialist will continue to make the effort to see him so he can fill out the correct form. A copy of the correct form is attached as attached as Attachment #3). To prevent this from happening in the future, the staff has established service for the individual with a psychiatrist. An evaluation was done by remote visit on 10/29/2020. The agencys nurse will take over facilitating these visits. She will be supervised by the Program Specialist. 11/07/2020 Implemented
6400.166(a)(3)The Electronic Medication Administration Record had a spot to list the individual's allergies, however on individual #1's MAR it was left blank. If the individual does not have any drug allergies, it should be listed as no known allergies, or NKA, or NA, etc.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Drug allergies.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: (3) Drug allergies. This regulation is important because consistent and comprehensive recording of drug allergy status is important to ensure that all patients with confirmed or suspected drug allergy have a full and accurate record of this in their electronic medical record. Accurate recording of drug allergy status will prevent the prescription and administration of drugs inducing allergic reactions and will improve patient safety. Providing this information could help avoid patients with known allergies wrongly receiving drugs that could endanger their health. The individual's drug allergy status was not documented in her electronic medical record. This error occurred because the MAR was not reviewed by the agency's Nursing Staff. After the IT Staff had input the basic information, the Clinical staff members did not review it. To correct this immediately, all MARs have been updated to include all necessary information, including Drug Allergies (Attachment #4 - Individual's current MAR. This was reviewed with all staff at the post-inspection briefing. All certified medication administration staff have been asked to look out for this information in all MARs. To prevent this from happening in the future, a multi-level system of verification has been put in place: After IT has input all the medications information in the electronic system, it will be reviewed by: 1. The Nursing Supervisor 2. The Director of Nursing Services This way, all possible errors will be captured and corrected immediately. The Program Specialist shall be responsible for providing oversight in this area. 11/07/2020 Implemented
6400.167(a)(1)The MAR for individual #1 indicates that medication: Zyrtec (Cetirizine) 10mg was not given on 9/30/2020 at 7:30am for reason, "has not arrived from pharmacy". There was no documentation indicating when the medication arrived or if it had been given later that day. There were no incident reports indicating that the medication was missed in HCSIS and there was documentation in the individual's file, at the time of the inspection, that stated "There has been no unusual incidents in the period under review".Medication errors include the following: Failure to administer a medication.Medication errors include the following: (1) Failure to administer a medication. This regulation is important because medication errors have the potential to cause harm to the individual. Sometimes, the harm can be life-threatening. The individuals medication, Zyrtec (Cetirizine), was not documented as administered. The medication did not arrive in the home along with the usual monthly batch. The staff on duty administered the morning medications with the exception of Zyrtec. The Pharmacist supplied the medication right after Sarah left her home for her Program. Staff took the medication to administer to her immediately, but did not go back to document the administration. All med admin trained staff have been informed that this kind of errors must be reported immediately, so that the supervisory staff can report it in EIM. To prevent this type of error in the future, the Nursing Supervisor will review the documentation on a daily basis. Staff who make errors will be offered re-trainings. Re-trainings will include a root cause analysis of the medication error, so that specific actions will be taken to prevent recurrence. The Director of Nursing will supervise the Nursing Supervisor to ensure error-free med administration, and thereby improve outcomes and increase safety for the individuals. 11/07/2020 Implemented
6400.181(f)At the time of the inspection, there was no documentation to support that the PS sent individual #1's assessment to the SC and team 30 days prior to the ISP meeting scheduled for 10/06/2020.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. The importance of this regulation cannot be overstated. Assessments are essential to maximizing personal growth and development, the persons ability to self-direct through choice and control over decisions affecting them directly while protecting the health and safety of the individual. Assessments are the foundation for many of the requirements of the residential program. Regulation requires that assessments are completed in a timely fashion and that notification of assessment results are provided to individual plan team member at least 30 calendar days prior to an individual plan meeting. This is important because the assessment would have reflected all changes in the past year which would be relevant to the annual individual plan review. The individuals assessment was not sent to the plan team members at least 30 calendar days prior to the individual plan meeting of 10/6/2020. The invitation for the meeting was not sent by the Supports Coordinator on time. The invitation was sent on 9/21/2020 for a 10/6/2020 meeting. This was only 15 days in advance. That did not allow 30 days for the Program Specialist to fulfil the regulation. This error cannot be rectified retroactively. To prevent this type of error in the future, the Program Specialist (PS) shall do the following: The PS will send the Assessments as soon as they are completed, even when a meeting has not been scheduled. The PS will not consent to a meeting that does not allow enough time to send the Assessment in a timely fashion. The PS will re-send the Assessment when a meeting invitation is received. 11/07/2020 Implemented
6400.182(c)Individual #1's current ISP dated 9/18/2020 has not been revised to reflect the individual's needs that have changed since moving in with Ideal Services Group. The Assessment has been updated to reflect these changes, however the ISP still states that the individual's mother is responsible for items such as the individual's health and safety.The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.The individual plan shall be initially developed, revised annually and revised when an individuals needs change based upon a current assessment. The development and implementation of high-quality Individual Plans is crucial for individuals to live an everyday life. Individual plans must be revised in response to any change identified by an assessment that requires an alteration of the Individual Plan. The Program Specialist ensures that the individual plan is up to date and accurately reflects the individuals needs. The individual plan was not reviewed by the Program Specialist. The newly reviewed ISP did not update in HCSIS as of 9/18/2020. In the first place, the ISP Review meeting did not hold until 10/6/2020. It is doubtful that the ISP in question is the reviewed one. The Program Specialist reviewed the approved ISP and all the information in it is correct as of the time of entering the POCs in LIS (please refer to HCSIS). To prevent this type of error in the future, the Program Specialist (PS) shall review the ISP immediately. The CEO will supervise the PS, to ensure compliance. 11/07/2020 Implemented
SIN-00259689 Unannounced Monitoring 02/03/2025 Compliant - Finalized
SIN-00227743 Unannounced Monitoring 07/11/2023 Compliant - Finalized