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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.144 | Per Individual #1's dental hygiene plan updated 4/5/25, Individual #1 is to receive 1mg of Lorazepam 30 minutes prior to dental visits for anxiety. Individual #1 had a dental exam on 10/30/25. No Lorazepam was administered 30 minutes prior. Individual #1 had a bowel protocol developed 4/7/25 documenting that if Individual #1 went 72 hours with no bowel movement they were to receive a Bisacodyl suppository. They went 72 hours with no bowel movements twice. (11/23-11/25 and 12/18-12/20). They were administered a Bisacodyl suppository on 10/14 and 10/20. However, the bowel tracking did not support the need for this. | 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 regulation states that:
§ 6400.144. Health Services
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.
Per Individual #1's dental hygiene plan updated 4/5/25, Individual #1 is to receive 1mg of Lorazepam 30 minutes prior to dental visits for anxiety. Individual #1 had a dental exam on 10/30/25. No Lorazepam was administered 30 minutes prior. Individual #1 had a bowel protocol developed 4/7/25 documenting that if Individual #1 went 72 hours with no bowel movement they were to receive a Bisacodyl suppository. They went 72 hours with no bowel movements twice. (11/23-11/25 and 12/18-12/20). They were administered a Bisacodyl suppository on 10/14 and 10/20. However, the bowel tracking did not support the need for this.
WHY THIS REGULATION IS IMPORTANT
This regulation is important because it protects individuals' health and safety by ensuring the provision of appropriate medical and psychological services.
WHAT HAPPENED?
Individual #1's Dental Hygiene Plan indicates that they are to receive 1mg of Lorazepam 30 minutes prior to dental visits for anxiety. However, Individual #1 had a dental exam on 10/30/25, and Lorazepam was not administered 30 minutes prior.
Individual #1 had a bowel protocol that states that if Individual #1 went 72 hours with no bowel movement, they are to receive Bisacodyl suppository. Individual #1 went 72 hours with no bowel movements on 11/23-11/25 and 12/18-12/20 and did not receive Bisacodyl. Individual #1 was also administered Bisacodyl suppository on 10/14 and 10/20. However, the bowel tracking did not support the need for this.
WHY DID IT HAPPEN?
On 10/30/2025, Lorazepam was not administered to Individual #1 prior to their dental visit. Upon investigation, it was determined that either the medication was not administered at all or it was administered but the staff failed to document it. In either case, this constitutes a medication administration error.
During a retraining session for all the staff who work in Individual #1's home on 2/6/26, we identified and confirmed the root cause of the error with the Bowel Movement Tracking and the associated interventions. The issue arose from an attitude of not taking responsibility among the staff. Staff members were not merely required to record information and move on; each staff member needed to actively monitor the tracking process. While the recording was being completed, the essential step of monitoring was neglected.
IMMEDIATE PLAN OF CORRECTION:
Remediation was provided to the staff member responsible for taking Individual #1 to the dental appointment. Additionally, prevention strategies were discussed. The completed Med Admin Remediation Form is attached as Attachment #8. The staff member participated in retraining using Module 6 of the PA Human Services ODP's "Administering Medications the Right Way."
To promptly address the Medication Administration error, all staff members in the home have been retrained on PRN Medications and Documentation, following the guidelines in the Department's Student Training Manual -- Module 6. Attached, you will find a copy of the training sign-up sheet as Attachment # 9.
The staff at the home have undergone retraining to emphasize the importance of diligently recording and monitoring bowel pattern information. By doing so, they can effectively track individuals' bowel movements, which significantly contributes to better care planning. Meaningful tracking helps identify patterns and changes, enabling staff and healthcare providers to tailor treatments and interventions more effectively. The Training Sign-Up sheet is attached - Attachment # 9.
On February 4, 2026, Individual #1 had an appointment with their primary care physician to review the Bowel Protocol/Regimen. The Protocol has been revised and rephrased to be more straightforward and unambiguous. The Doctor's visit sheet, as well as the updated Protocol is attached as Attachment #10. |
02/09/2026
| Implemented |
| 6400.211(b)(1) | Individual #1's record does not contain the address for the designated contact person. | 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.
| § 6400.211. Emergency Information
The regulation states that,
"(b) Emergency information for each individual shall include the following:
(1) The name, address, telephone number and relationship of a designated person to be contacted in case of an emergency."
WHY THIS REGULATION IS IMPORTANT
This regulation is important because it ensures that critical health information is available in the event of a medical emergency.
WHAT HAPPENED?
Individual #1's record does not contain the address for the designated contact person.
WHY DID IT HAPPEN?
This is a lack of attention to details. The information had been included in previous years. However, in reviewing the Emergency Information forms, this year, that salient information was inadvertently taken out without careful attention to the regulatory requirement. This was an oversight.
IMMEDIATE PLAN OF CORRECTION:
The provider corrected the Emergency Information immediately. The missing piece of information has been added, and it is fully corrected. A copy of the corrected document is attached as Attachment #11.
All the Emergency Information of all Ideal Services Group's individuals are verified to be correct now. |
02/09/2026
| Implemented |
| 6400.165(c) | In October 2025, Individual #1 was prescribed Benzonatate to be administered every 8 hours. The medication was administered at 7am, 2pm, and 9pm. This is not every 8 hours. On 10/14/25, Individual #1's Benzonatate was discontinued. They continued to receive this medication through 10/17/25. | A prescription medication shall be administered as prescribed. | § 6400.165. Prescription medications.
(c) A prescription medication shall be administered as prescribed.
WHY THIS REGULATION IS IMPORTANT
This regulation is important because it prevents medication errors that could result in injury.
WHAT HAPPENED?
In October 2025, Individual #1 was prescribed Benzonatate to be administered every 8 hours. The medication was administered at 7am, 2pm, and 9pm. This is not every 8 hours. On 10/14/25, Individual #1's Benzonatate was discontinued. They continued to receive this medication through 10/17/25.
WHY DID IT HAPPEN?
The adjustment in timing was made to avoid waking the individual from sleep for medication administration for the third dose. However, this consideration should not override the prescribed doctor's orders. Additionally, the instruction to discontinue Benzonatate likely wasn't communicated to the home promptly, resulting in a communication lapse.
IMMEDIATE PLAN OF CORRECTION:
This error cannot be corrected retrospectively. To address it immediately, all Med Admin Trainers have convened to review the mistake and devise a prompt solution. The immediate corrective action is to adhere strictly to the prescribers' orders. |
02/09/2026
| Implemented |
| 6400.166(a)(2) | The prescriber's name was not documented for any of the PRN medications administered. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | § 6400.166. Medication Record
The regulation states that
"(a) A medication record shall be kept, including the following for each individual for whom a prescription medication is administered:
(2) Name of the prescriber."
WHY THIS REGULATION IS IMPORTANT
This regulation is important because the home's staff persons will be able to track all medications an individual receives and to ensure all medications are administered as prescribed.
WHAT HAPPENED?
The prescriber's name was not documented for any of the PRN medications administered.
WHY DID IT HAPPEN?
The information was in the Medication Record, but staff was unable to locate it at the time of the inspection. So, it was not available to the Department during the onsite inspection upon request.
IMMEDIATE PLAN OF CORRECTION:
The provider contacted the electronic record provider to seek assistance on getting the prescriber's information in. They walked Ideal Services staff through to the section where it is recorded. A hard copy of the document with individual's PRN information, including the prescribers' name is attached as Attachment #12.
The same information has been located for all Ideal Services Group's individuals. |
02/09/2026
| Implemented |
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