| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.144 | Individual #1 is prescribed Paradontax toothpaste to be used at bedtime. There is no record of this medication being submitted through the pharmacy or through insurance. Individual #1 purchased Perodontax toothpaste over the counter from Rite Aid on 4/11/2025 for $16.58 out of pocket. | 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.
| Parodontax was purchased for Individual #1 on 4/11/25.
This regulation is important because it protects individual health and safety by ensuring the provision of appropriate medical and psychological services.
This violation occurred because the staff who purchased it is a relatively new staff who took it upon himself to purchase it because it was available over the counter. The staff who made this purchase took that step without consulting with any other staff or the agency nurse.
As an immediate fix for this violation, Parodontax was filled from the pharmacy on 4/17/25 (Pharmacy Label as Attachment #1), and the cost for the purchase has been refunded into Individual #1s spending account on 4/30/2025 (April 2025 Financial Record as Attachment #2). |
05/01/2025
| Implemented |
| 6400.144 | Individual #1 has a Bowel Movement Protocol which states "if no bowel movement for 3 days, staff may administer Polyethylene Glycol as needed for constipation until bowel movement occurs." There are no additional instructions listed in the bowel movement protocol to administer the medication if any other symptoms as seen. As seen on their bowel movement tracking sheet, Individual #1 had a bowel movement on 3/14/2025 at 4:10pm. On 3/16/2025 at 7:54am, Polyethylene Glycol was administered with the reason "appeared strong to pass out." 3 days did not pass from the time that there was a bowel movement to the time that the medication was administered. There was an additional 10 times in March 2025 that Polyethylene Glycol was administered when the 3-day timeframe did not occur. | 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.
| This regulation is important because it protects individual health and safety by ensuring the provision of appropriate medical and psychological services.
The violation states that Individual #1 was administered Polyethylene Glycol daily whereas the Bowel Movement Protocol states that if the individual has no bowel movement for 3 days, staff may administer Polyethylene Glycol as needed for constipation until bowel movement occurs.
The instruction on the Miralax states, ¿Take 17 g by mouth once daily as needed for constipation¿ (Attachment #4). This gives the staff the prerogative to make a decision to administer Miralax daily, under the supervision of the agency nurse. The word ¿daily¿ also suggests every day, not just one day. If the presence of constipation can be established, staff may administer Miralax daily. Please note that all ISG staff took the Fatal Five training. All the same, they do not act independently in matters of commencing PRN medications. ISG nurses provide supervision and direction. Administering Miralax daily for many days was in order because the symptoms of constipation were still present.
However, ISG staff did not act independently. Individual #1 was taken to see a doctor on 2/26/25 due to Constipation. This is in line with the last bullet on the protocol that states that Individual #1¿s ¿PCP will be contacted if constipation is not resolved, and the doctor¿s order will be implemented.¿
The doctor gave the order that Individual #1 may continue using Miralax once daily to achieve a bowel movement. This is documented in both the Doctor¿s Progress Notes (page 5 of Attachment #5) and the After Visit Summary (Attachment #6). ISG folders are meticulously and neatly arranged, and all these documents were in Individual #1¿s Medical Folder, Tab #3 PCP, presented to the inspectors. The doctors order supersedes all previous orders.
Ideal Services Groups staff followed both the protocol, the doctors order, as well as the instruction for his Miralax to achieve regular bowel movement.
This should not have been a violation. |
05/01/2025
| Implemented |
| 6400.145(1) | Individual #1's emergency medical plan states "the hospital to be used: UPMC Community General Osteopathic Hospital." The emergency medical plan is not person specific as it does not say the home, the individual's name or that the hospital or source of health care was chosen based off the preferences of the Individual. | 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. | This regulation is important because it ensures that individual choice is protected during an emergency whenever possible; ensures that the needs of all individuals are met when staffing needs change as a result of an emergency.
As an immediate fix, the Emergency Medical Plan has been updated to make it person-specific (Attachment #8).
All Emergency Medical Plans for all ISG individuals have been reviewed for correctness. |
05/01/2025
| Implemented |
| 6400.211(b)(1) | Individual #1's alternate contact person to be contacted in case of an emergency does not list the relationship to the Individual. | Emergency information for each individual shall include the following: The name, address, telephone number and relationship of a designated person to be contacted in case of an emergency.
| This regulation is important because it ensures that critical health information is available in the event of a medical emergency. Important information will be easily accessible to all staff when it is needed.
The relationship of the designated person to be contacted in case of an emergency was not indicated in Individual #1s Emergency Information. This violation occurred because Individual #1 came in as an emancipated adult. He was under Children and Youth Custody after his parents voluntarily terminated their own parental rights two years prior to his moving into residential service.
To fix this violation, Individual #1¿s Emergency Information has been updated to include the relationship of the designated persons (Attachment #9).
The Emergency Information of all ISG individuals were reviewed for correctness; and they are all correct. |
05/01/2025
| Implemented |
| 6400.216(a) | At the time of the inspection, several records were unlocked and unattended. Individual #1's dental appointment sheet which includes their name, date of birth, and last 4 of social security number was found in the living room on the staff desk. Individual #1 and Individual #2's entire financial logs were found in an unlocked drawer in the kitchen. | An individual's records shall be kept locked when unattended.
| Regulation states that ¿an individual¿s records shall be kept locked when unattended.¿
This regulation is important because it protects individuals privacy.
A dental appointment record sheet for Individual #1 and the financial records were left unlocked in the home.
The violation occurred out of a disregard for HIPPA compliance requirement by staff in the Home.
All individuals¿ records are kept locked in ISG homes. However, the staff stated that he was in the home reviewing the dental record when the inspector showed up, so he placed a folder on top of the record as he went to answer the door. The appointment record was not locked, but it was not unattended.
Staff took responsibility for leaving the Financial Folders in an unlocked drawer after he finished reviewing the books that morning.
As an immediate fix, records in the home are well secured in a locked cabinet now. Any issue that could be gaps and deficiencies have been identified and addressed. |
05/01/2025
| Implemented |
| 6400.163(a) | Individual #1 is prescribed Paradontax toothpaste by dentist with the directions to be used at bedtime. The prescribed medication is not labeled with a label issued by the pharmacy as Ideal Services Group is purchasing this over the counter. | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | The benefit of this regulation is that it reduces the possibility of misplacing medications or administering the wrong medication to an individual.
Parodontax did not have the Pharmacy label on it at the time of inspection.
The violation occurred because a staff member took it upon himself to purchase it over the counter. The staff member is a relatively new staff and he took that step without consulting with any other staff or the nurse.
As an immediate fix for this violation, Parodontax was filled from the pharmacy on 4/17/25 (Pharmacy Label as Attachment #1). |
05/01/2025
| Implemented |
| 6400.181(f) | Individual #1's assessment dated 4/14/2025 was not sent to all the Individual team members. The assessment did not include the individual's parents. Individual's parents are listed as alternate contact persons, emergency medical treatment decision makers, as well as their contact information recorded in the Individual Service Plan. | 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 violation states that the assessment for Individual #1, dated 4/14/2025 was not sent to the Treatment Plan Team.
§ 6400.181(f) Assessment states that the program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.
Individual #1¿s ISP meeting was held on 1/29/2025. An Assessment was sent to the Treatment Plan Team on 11/21/2024 (email evidence as Attachment #13 - email and Meeting Sign-Up Sheet). This is in compliance with the regulation. Regulation does not specify that the Program Specialist must send a new update within two days of completing it. No ISP meeting is coming up at this point. It will ultimately be sent at some point, but it did not have to be sent by 4/16/2025.
This should not have been a violation as Ideal Services Groups Program Specialist is in compliance. |
05/01/2025
| Implemented |
| 6400.183(a)(2) | Individual #1's Individual Service Plan (ISP) meeting was held on 1/29/2025. The meeting did not include the persons designated by the individual (parents). Additionally, there is no record that the Individual's parents were invited to the ISP meeting on 1/29/2025. | The individual plan shall be developed by an interdisciplinary team, including the following: Persons designated by the individual. | The Regulation states that The individual plan shall be developed by an interdisciplinary team, including the following: persons designated by the individual.
The benefit of this regulation is that it ensures that the Individual Plan is person-centered, individual-driven, and fully understood by all of the individual¿s natural and formal supports.
The parents did not attend the meeting, even though they were informed and invited to the meeting. But since there is no evidence of that, a violation has occurred.
The parents were informed of the meeting, but they chose not to attend. They were not on the email list because they do not have an email address. Communication with Individual #1s parents is either verbal or through hand delivered notes. Individual #1¿s parents pick him up for visits to their home on the first Sunday of every month. On being picked up, they are handed a list of upcoming appointments for the month, in case they are interested. On the visit of 1/5/2025, they were handed the list of events for the month, including the ISP meeting notice. Obviously, they chose not to attend. Besides, Individual #1 did not overtly designate his parents as participants at the meeting. Again, the parents still do not have an email address for future correspondence.
To prevent a recurrence of this type of violation, all documents handed to the parents will be duplicated in Individual #1s records henceforth. |
05/01/2025
| Implemented |