Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00239099 Renewal 02/13/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.63(a)On 2/14/24 at 9:53AM, the hot water temperature, at the sink in the kitchen of the home, measured 130.2 degrees Fahrenheit. On 2/14/24 at 9:55AM, the hot water temperature, at the sink in the bathroom on the first floor of the home, measured 127.7 degrees Fahrenheit. On 2/14/24 at 10:02AM, the hot water temperature at the sink in the bathroom on the first floor of the home, measured 132.6 degrees Fahrenheit.Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. The water temperature on the water heater tank was turned down on 2/14/24. The temperature of the water in the sinks and showers was measured again on 2/16 and was below 120 degrees. 02/14/2024 Implemented
6400.46(b)Direct Service Worker #1 had fire safety training completed on 4/26/23. There was not a record of the previous fire safety training; therefore, compliance could not be measured. [Repeated violation-2/28/23, et al]Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).All 2023 fire safety trainings were reviewed on 10/30/23 and were found in compliance. All 2024 fire safety trainings are scheduled to be completed in March and October via the agency's training software. 10/30/2023 Implemented
SIN-00203050 Renewal 03/29/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(c)(6)Individual #1 had a Tuberculin skin test by Mantoux method on 1/24/2020 and then again on 2/10/2022.The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. All TB testing dates were requested to be submitted to the Assistant Directors no later than 4/25/22. The ADs will keep all testing dates on file and will alert the appropriate supervisor one month prior to the expiration date of their TB test. The Supervisors will be trained on TB testing time frames on 4/25/22. 04/25/2022 Implemented
SIN-00164648 Renewal 10/22/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.151(a)Direct Service Worker #1, date of hire 10/4/19, had an initial physical examination completed 5/27/18. (Repeated Violation-11/19/19, et al) 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. All current temp staff records were reviewed by the Office Manager on 10/23/19 to ensure that no other non-compliances were found with physicals or TB testing. The IDD Res. Director will draft a letter for all contracted agencies that states that no employee shall be permitted to work at a residential site without prior clearance by the Office Manager from their agency by 11/15/19. A spreadsheet that is kept separately from Milestone employees will be created and monitored by the Assistant Residential Directors; however, the standards for maintaining compliance with required medical clearances will be communicated via the letter drafted by the IDD Res. Director. The Office Manager will review the temp. staff due date spreadsheet monthly and communicate to the appropriate agency when physicals and TB testing is due prior to the expiration of their current physical. Any temp staff agencies or employees who fail to submit updated physicals and TB tests will not be placed on a residential schedule until documentation is provided. The AD/Res Director will review the process quarterly and all documentation requesting initial or ongoing physicals and/or TB testing results will be kept by the Office Manager. 11/15/2019 Implemented
6400.151(c)(2)Direct Service Worker #1, date of hire 10/4/19, had an initial Tuberculin skin testing by Mantoux method with negative results completed 7/20/15. The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. All current temp staff records were reviewed by the Office Manager on 10/23/19 to ensure that no other non-compliances were found with physicals or TB testing. The IDD Res. Director will draft a letter for all contracted agencies that states that no employee shall be permitted to work at a residential site without prior clearance by the Office Manager from their agency by 11/15/19. A spreadsheet that is kept separately from Milestone employees will be created and monitored by the Assistant Residential Directors; however, the standards for maintaining compliance with required medical clearances will be communicated via the letter drafted by the IDD Res. Director. The Office Manager will review the temp. staff due date spreadsheet monthly and communicate to the appropriate agency when physicals and TB testing is due prior to the expiration of their current physical. Any temp staff agencies or employees who fail to submit updated physicals and TB tests will not be placed on a residential schedule until documentation is provided. The AD/Res Director will review the process quarterly and all documentation requesting initial or ongoing physicals and/or TB testing results will be kept by the Office Manager. 11/15/2019 Implemented
6400.165(g)Individual #1, date of admission 9/10/18, who was prescribed Buspirone 7.5mg for anxiety to be given before doctor visits and medical procedures has not had medication reviews. Individual #1 was administered Buspirone 7.5mg on 11/12/18, 11/26/18, 1/6/18, 1/9/18, 1/10/18, 1/11/18, 1/12/18, 2/4/19, 2/5/19, 2/6/19, 4/9/19, 4/22/19 4/23/19, 5/8/19, 5/9/19, 7/16/19, and 7/18/19.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.By 11/15/19, all PRN medications prescribed to individuals living in 6400 residential will be reviewed by the IDD Nurse to determine the frequency, type of medication, purpose, and dosage. The IDD Nurse will document all PRN medications to be shared with the Director of IDD Residential. Medications that are prescribed for a psychiatric issue prior to a doctor¿s visit will be flagged as requiring quarterly review by their physician. Protocols for notifying the IDD Nurse of any changes to PRN medications will be established and shared with the Site Supervisors at the next team meeting in December. The IDD Nurse will review the universal PRN medication spreadsheet monthly to ensure that all changes and updates are documented properly. 11/15/2019 Implemented
SIN-00107772 Unannounced Monitoring 01/17/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.185(b)The current ISP, last updated 11/16/16 for Individual #1 states Individual #1 is to have awake overnight staff supervision with a 2:3 staff to individual ratio. On 11/17/16, Direct Service Workers #1 and #2 were asleep from 1:00 AM to 6:00 AM.The ISP shall be implemented as written.The staff at the site were retrained on all the individuals ISPs on 2/10/17 by the Systems and Compliance Specialist. Signs for all sites are currently in draft that states that all sites are 24 hour awake sites and that sleeping will result in a neglect incident due to the individual's ISP ratio not being met. These signs will be completed and distributed to each site by 3/31/17 by the Asst. Residential Director. Additionally, the lead Program Specialist will monitor the ISP alerts daily in HCSIS and communicate all changes to the appropriate Site Supervisor to communicate to the DSPs. Documentation of the training of all ISP revisions and updates will be maintained at the main office. [At least quarterly for 1 year, the program specialist(s) or designated staff person shall complete an onsite monitoring of a 25% sample of community homes during sleeping hours to ensure ISPs are being implemented as written to include staff being awake during overnight hours. (AS 2/27/17)] 02/16/2017 Implemented
SIN-00104490 Renewal 12/06/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.33(g)The agency is utilizing video cameras to monitor and record in the hallways, living room, dining room and other common areas of the home. An individual has the right to receive scheduled and unscheduled visitors, communicate, associate and meet privately with family and persons of the individual's own choice. The use of the cameras was discontinued and will not be utilized in the future. Residential staff are trained on Client Rights including the right to privacy at orientation and annually thereafter. 01/30/2017 Implemented
6400.141(c)(14)Individual #1's physical examination, completed 3/22/16, did not include medical information pertinent to diagnosis and treatment in case of an emergency. The section on the physical examination form to address this area was left blank.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Individual #1's physical was returned to the PCP for completion and reviewed for completion by the Asst. Res. Director. The updated physical was submitted to BHSL on 1/23/17. An audit of all physicals will be completed by 3/31/17 by the Asst. Res Director to ensure completion. Any physicals that are found to have blanks will be returned to the doctor. Supervisors will be trained on completion requirements of the physical by the Asst. Res Director by 2/15/17. [At least quarterly for 1 year, a designated management staff person shall review a 25% sample of completed physical examinations to ensure all required information is included and there are required areas left blank. (AS 2/3/17)] 01/30/2017 Implemented
SIN-00086534 Renewal 11/09/2015 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71The telephone number for the fire department, police department and ambulance were not on or by each of three telephones in the home.Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line. New Emergency Phone Lists were printed and placed by each phone. The Phone Lists list the separate emergency numbers for all emergencies, rather than listing 911 for the group as a whole..[CEO or designee will immediately go to each home and check every telephone to ensure the required telephone numbers are accurate and on or by each telephone. CEO or designee will add required telephone numbers to the "Health and Safety Facility Inspection Checklist" and designee will complete at least monthly checks. CEO will review the checklist for accuracy and completion at least quarterly. (AS 12/30/15)] 11/28/2015 Implemented