Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00203055 Renewal 03/29/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.63(a)The hot water temperature measured 127.8°F at 12:02PM at the bathroom sink. The hot water temperature measured 125.6°F at 12:10PM at the kitchen sink.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 hot water was immediately adjusted onsite to a temperature within an acceptable range. By 7/31/22, an onsite review will be completed by the AD, including checking and recording the temperature of all water sources. 03/30/2022 Implemented
6400.112(e)The most recent fire drill held during sleeping hours was conducted on 8/17/2021.A fire drill shall be held during sleeping hours at least every 6 months. An overnight fire drill will be conducted no later than 4/30/22. The AD will review the fire drill documentation to ensure it was completed within the proper time frame and that all documentation is completed. 04/30/2022 Implemented
SIN-00164653 Renewal 10/22/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.151(a)Direct Service Worker #1 had a physical examination completed on 8/10/16 and then again on 9/9/18. (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 had Tuberculin skin testing completed on 8/10/16 and then again on 9/9/18. 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
6400.46(b)Direct Service Worker #1 had fire safety training on 6/5/18 and then again on 6/19/19.Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a).Assistant Directors will complete a full audit of the most recent quarters fire drills to ensure that exits that are being used for evacuation are ¿man doors¿. They will also review that all individuals are evacuating the site within 2 mins 30 secs. The Site Supervisors will be trained in the following areas of fire safety by 11/13/19: 1) Types of exits to use as an alternate exit 2) How to properly time an evacuation 3) Reporting an evacuation that exceeds 2:30 to management 4) When/how to alert the Fire Chief of individuals that require assistance living at a site and requesting a waiver for evacuation times 5) Requirements for times frames to complete annual fire safety training with DSPs and individuals. Documentation of the training provided by the Directors will be kept. Site Supervisors will train the DSPs at each site on the above information by 12/18/19 and submit all records to the Office Manager. [Immediately, the CEO or designee shall develop and implement a tracking system to ensure timely completion of staff fire safety training to include all required information. At least quarterly for 1 year, the CEO or designee shall audit the tracking documentation and a 10% sample of staff fire safety training to ensure timely completion. (DPOC by AES,HSLS on 11/5/19)] 11/13/2019 Implemented
SIN-00110462 Unannounced Monitoring 01/24/2017 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.44(b)(18)On 2/7/16, Individual #2 was prescribed a diet that included "nectar thick liquids" when discharged from Forbes Regional hospital. Interviews revealed that staff prepared the individual's liquids in various ways such as honey thick consistency, using "the big side of spoon [and putting] 2 spoons in if it's a full cup", and putting "3 little cups into 4 oz" and did not know how to accurately prepare Individual #2's liquids.The program specialist shall be responsible for the following: Coordinating the training of direct service workers in the content of health and safety needs relevant to each individual. The staff at the site were retrained on the individual's diets on 5/23/17. The Program Specialists compiled a list of all of the diet needs of every individual per their ISP. The Program Specialists began attending monthly staffing meetings to confirm that the individuals ISPs were correct. Any inaccuracies are being communicated to the Supports Coordinator. The Program Specialists will review all alerts in HCSIS for updated ISPs and communicate any changes in diet to the Site Supervisor. They will also attend staff meetings to deliver diet trainings as needed/required. [Prior to the direct service workers, providing supervision to the individuals the program specialist(s) will ensure the direct service workers are trained in the health and safety needs relevant to each individual including special diets. Documentation of trainings shall be kept. (AS 6/13/17)] 05/29/2017 Implemented
6400.61(b)The ISP, updated 12/7/16 for Individual #1, reads under the Physical Development section "A Hoyer lift will need to be present in home." On 1/24/17, there was not a Hoyer lift being utilized to assist Individual #1 at the home.A home serving individuals with a physical disability, blindness, a visual impairment, deafness or a hearing impairment shall have adaptive equipment necessary for the individuals to move about and function at the home.A hoyer was secured for the home in February 2017.[Immediately and prior to providing supervision, all direct service workers shall be trained in the use of the Hoyer lift with respect to the health and safety needs of Individual #1. Documentation of the training shall be kept. Within 30 days of receipt of the plan of correction and as needed the program specialist(s) shall review all individuals ISPs, assessments and medical professional orders to ensure individuals with a physical disability, blindness, a visual impairment, deafness or a hearing impairment have adaptive equipment necessary for the individuals to move about and function at the home. (AS 6/13/17)] 05/29/2017 Implemented
6400.144On 2/7/16, Individual #2 was prescribed a diet that included "nectar thick liquids" when discharged from Forbes Regional hospital. Interviews revealed that staff prepared the individual's liquids in various ways such as honey thick consistency, using "the big side of spoon [and putting] 2 spoons in if it's a full cup", and putting "3 little cups into 4 oz" and did not know how to accurately prepare Individual #2's liquids.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 staff at the site were retrained on the individual's diets on 5/23/17. The Program Specialists compiled a list of all of the diet needs of every individual per their ISP. The Program Specialists began attending monthly staffing meetings to confirm that the individuals ISPs were correct. Any inaccuracies are being communicated to the Supports Coordinator. The Program Specialists will review all alerts in HCSIS for updated ISPs and communicate any changes in diet to the Site Supervisor. They will also attend staff meetings to deliver diet trainings as needed/required. [Immediately after services from a hospital or medical appointment, the program specialist(s) shall review the doctors' orders, discharge summaries etc. and immediately implement and educate staff as need to ensure health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual are arranged for or provided for the health and safety of the individual. Documentation of the reviews and trainings shall be kept. (AS 6/13/17)] 05/29/2017 Implemented
6400.167(b)Florastar, 250 mg, twice daily at 8:00 AM and 8:00 PM prescribed for Individual #1 was not administered at 8:00 AM on 1/1/17. Albuterol inhaler, 750 ML, three times daily prescribed for Individual #2 was administered two doses of Albuterol at 8:00AM on 12/12/16. In addition, Albuterol inhaler, prescribed for Individual #2 was not administered at 8:00 AM on 12/19/16, 12/26/16 and 1/16/17. Budesonide, 0.5 MG twice daily at 8:00 AM and 8:00 PM prescribed for Individual #2 was not administered at 8:00AM on 12/12/16 and 1/16/17. Carbidopa/Levo, 10/100, twice daily at 8:00 AM and 8:00 PM prescribed for Individual #2 was not administered at 8:00 AM on 1/24/17. Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant.Audits of residential sites were completed by the Assistant Res. Directors in April and May, including the review of each individual's MAR. The Program Specialists are attending Medication Train the Trainer trainings in June and October and will conduct monthly audits at staff meetings. Any issues with the MAR will be shared with the Asst. IDD Director. [Immediately and at least monthly, the program specialist(s) shall review all individuals' medications, medication administration records and physician orders to ensure all individuals are administered medications as prescribed and documented as required. The Assistant IDD director shall develop and implement procedures for additional training for staff persons certified to administer medications as needed to ensure prescription medication is administered as prescribed and documented as required. Documentation of reviews and trainings shall be kept. (AS 6/13/17) 05/29/2017 Implemented
6400.181(e)(13)(iii)On 2/7/16, Individual #2 was discharged from the hospital with a prescribed diet of "nectar thick liquids." Individual #2's assessment, completed 4/28/16, does not include the change in Individual #2's prescribed diet. The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. Out of respect for the Individual, who has since passed away, his Functional Assessment will not be updated. However, the Program Specialists were trained to include diet needs for all assessments on 5/31/17. Assessments will be updated per their current due dates. Assessments will be reviewed by the Office Manager, who is responsible for the distribution of the assessment. Any assessments that are missing this information will not be mailed until additions are made. [Within 30 days of receipt of the plan of correction, a designated management staff person shall develop and implement policies and procedures to ensure the program specialists are updating and completing assessments accurately to include the required information regarding each individual including each individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. At least quarterly, for 1 year a designated management staff person shall review a 10% sample of individuals' assessments to ensure the program specialists completing assessments with the required information for the health and safety of each individual. (AS 6/13/17)] 05/29/2017 Implemented
SIN-00104496 Renewal 12/05/2016 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
6400.112(f)The monthly fire drills conducted between November 2015 and November 2016 used the front door to evacuate. The home has two means of egress.Alternate exit routes shall be used during fire drills. The side entrance of the home will be widened and a ramp will be added by the maintenance staff of the agency when the weather improves in the Spring. The staff will be retrained on fire evacuation procedures when the entrance construction is completed. The Asst. IDD Director will review fire drill logs quarterly and retrain the staff members immediately if multiple exits are not utilized. Documentation of the fire drills will be maintained at each site and trainings will be maintained by the office manager.[Within 30 days of receipt of the plan of correction, all staff persons responsible for conducting fire drills shall be trained in the requirements as per 6400.112(a)-(i).Immediately, CEO shall develop procedures for the Asst. IDD Directors to follow if upon review of fire drill records it is found fire drills are not being conducted as required and train the Asst IDD Directors on the procedures. Documentation of trainings, procedures and reviews shall be kept. (AS 2/3/17)] 01/30/2017 Implemented
6400.195(e)(3)Individual #1's restrictive procedure plan does not include methods for modifying or eliminating the targeted behavior. The restrictive procedure plan shall include: Methods for modifying or eliminating the behavior, such as changes in the individual's physical and social environment, changes in the individual's routine, improving communications, teaching skills and reinforcing appropriate behavior. [On 3/6/17 the program specialist contacted Individual #1's supports coordinator who is working to secure a behavior specialist to develop methods for modifying or eliminating Individual #1's target behavior of ingesting and smearing feces while in bed such as changes in the individual's physical and social environment, changes in the individual's routine, improving communications, teaching skills and reinforcing appropriate behavior. On 5/16/17, the Department of Human Services, Office of Developmental Programs granted a waiver of 6400.200(b) with six condition which must continue to be met including updating Individual #1's ISP and restrictive procedure plan and continuing to work with Individual #1 in developing less restrictive methods of intervention. Immediately and prior to staff providing supervision to Individual #1, staff persons shall be trained in a face to face training by the program specialist on Individual #1's current and updated restrictive procedures/SEE Plan and Fade plans and procedures and documentation for utilization of mitts. The restrictive procedure review committee shall review and revise Individual #1's restrictive procedures/SEE Plan and Fade plan as needed and as required. Documentation of trainings and monthly reviews shall be kept. (AS 5/19/17)] 03/13/2017 Implemented
6400.200(b)Individual #1 has been on a restrictive procedure utilizing Posey mitts since 11/21/13.The use of a mechanical restraint is prohibited except for use of helmets, mitts and muffs to prevent self-injury on an interim basis not to exceed 3 months after an individual is admitted to the home. By 3/31/17, the system and compliance specialist shall submit a regulatory waiver to the Department of Human services to extend the use of Posey mitts as part of Individual #1¿s restrictive procedure plan. If the waiver is denied, an appeal will be filed. If the wavier is denied, then the individual will be given a 30 day notice for discharge, as his health and safety cannot be maintained without the use of Posey mitts.[On 5/16/17, the Department of Human Services, Office of Developmental Programs granted a waiver of 6400.200(b) with six condition which must continue to be met including updating Individual #1¿s ISP and restrictive procedure plan and continuing to work with Individual #1 in developing less restrictive methods of intervention. Immediately and prior to staff providing supervision to Individual #1, staff persons shall be trained in a face to face training by the program specialist on Individual #1¿s current and updated restrictive procedures/SEE Plan and Fade plans and procedures and documentation for utilization of mitts. The restrictive procedure review committee shall review and revise Individual #1¿s restrictive procedures/SEE Plan and Fade plan as needed and as required. Documentation of trainings and monthly reviews shall be kept. (AS 5/19/17)] 03/13/2017 Implemented
6400.200(c)(1)Per Individual #1's restrictive procedure plan, implemented October 2015, Individual #1 is to utilize Posey mitts "during 'overnight hours'. Essentially, the mitts should be worn when [s/he] is placed in bed and removed, when [s/he] wakes."If a mechanical restraint is used as specified in subsection (b), the following apply: The use of a mechanical restraint may not exceed 2 hours, unless a licensed physician examines the individual and gives written orders to continue use of the restraint. Reexamination and new orders by a licensed physician are required for each 2-hour period the restraint is continued. If a restraint is removed for any purpose other than for movement and reused within 24 hours after the initial use of the restraint, it is considered continuation of the initial restraint. A new form was developed and implemented on 3/14/17 to document whether Individual #1 was awake or asleep during overnight hours and if the posey mitts are in use. The form also includes an area for the details surrounding the use or removal of the mitts. The staff at the site will be trained that the posey mitts cannot exceed 2 hours of use and on how to complete the 15 minute check form. Monthly, the Asst. IDD Director will review the forms to determine that the documentation was completed in its entirety and that the posey mitts were used properly.[On 5/16/17, the Department of Human Services, Office of Developmental Programs granted a waiver of 6400.200(b) with six condition which must continue to be met including updating Individual #1¿s ISP and restrictive procedure plan and continuing to work with Individual #1 in developing less restrictive methods of intervention. Immediately and prior to staff providing supervision to Individual #1, staff persons shall be trained in a face to face training by the program specialist on Individual #1¿s current and updated restrictive procedures/SEE Plan and Fade plans and procedures and documentation for utilization of mitts. The restrictive procedure review committee shall review and revise Individual #1¿s restrictive procedures/SEE Plan and Fade plan as needed and as required. Documentation of trainings and monthly reviews shall be kept. (AS 5/19/17)] 03/13/2017 Implemented
6400.213(11)Individual #1's ISP, updated on 10/19/16, the "Know and Do" section reads: "[Individual #1] moved into a Milestone home this past year." Individual #1's date of admission is 7/24/13. The "Current Health Status" section reads: "[Individual #1] will need a Hoyer lift at [his/her] new home (which insurance will provide)." The "Adaptive/Self Help" section reads: "[Individual #1] uses a wheelchair and Hoyer lift in the home and at the day program." The home does not currently utilize a Hoyer lift for Individual #1. The "Social/Emotional" section reads: If "[Individual #1] begins to attempt to eat [his/her] feces then redirect [him/her] to [his/her] Posey mitts." Per Individual #1's restrictive procedure, the Posey mitts are to be worn only during "overnight hours." Individual #1's record does not include content discrepancy in the ISP. Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. The Program Specialist spoke to the Supports Coordinator regarding the discrepancies and followed up with her via email on 12/29/16. This was submitted to BHSL on 1/6/17. The Program Specialist will review all ISPs and communicate discrepancies via email by 3/31/17. All emails will be kept by the Program Specialist. The Site Supervisors were trained on 1/24/17 by the Systems and Compliance Specialist to bring information to the annual ISP where changes are needed..[On 5/16/17, the Department of Human Services, Office of Developmental Programs granted a waiver of 6400.200(b) with six condition which must continue to be met including updating Individual #1¿s ISP and restrictive procedure plan and continuing to work with Individual #1 in developing less restrictive methods of intervention. Immediately and prior to staff providing supervision to Individual #1, staff persons shall be trained in a face to face training by the program specialist on Individual #1¿s current and updated restrictive procedures/SEE Plan and Fade plans and procedures and documentation for utilization of mitts. The restrictive procedure review committee shall review and revise Individual #1¿s restrictive procedures/SEE Plan and Fade plan as needed and as required. Documentation of trainings and monthly reviews shall be kept. (AS 5/19/17)] 01/30/2017 Implemented
SIN-00102564 Unannounced Monitoring 08/26/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.21(a)Direct Service Worker #1, who was scheduled to work on 8/13/16, from 4:30 PM to 11:00 PM and 8/14/16, from 8:00 AM to 3:30 PM had another person who is not an employee of the facility report to the home in his/her place. The person who provided supervision to the individuals during the aforementioned dates and shifts did not have a Pennsylvania criminal background check completed. 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. Our contract with Capital HealthCare Solutions Staffing Company (attached) states, in #2 ¿Statement of Services¿, that the staff they provide to Milestone will meet criteria as required by our regulations and that they will ensure that, among other things, the staff have a valid pre-employment physical and criminal background check. The contract also states that Capital HealthCare will provide us with these documents upon request. Attached is the physical and the criminal history for ¿Direct Service Worker #1¿ who was scheduled by Capital HealthCare Solutions to work at Penhurst and Howell on 8/4, 8/6 and 8/7. Capital HealthCare provides information to their staff upon assignment to orient them to the site (subsequent to meeting with each Site Supervisor to gather pertinent and necessary information). The violations occurred because the employee of Capital HealthCare Solutions, Direct Service Worker #1, did not work at Howell and Penhurst as scheduled and expected. Rather the individual who worked these shifts at these sites fraudulently impersonated Direct Service Worker #1. To ensure that, in the future, any Capital HealthCare Solutions staff (or any staff from any contracted staffing agency) who appears on site to work a scheduled shift, is who he/she is supposed to be and therefore does meet all regulatory requirements ¿ Milestone established the attached Procedure with Capital HealthCare Solutions. All Residential Site Supervisors were informed of this procedure at their department meeting on 9/14/16 and it was implemented immediately there-after. [Addition to POC on 11/21/16 All of the temp staff vendors that we work with have been notified that there are new training binders at each site with information specific to the individuals that the temp staff are to read and sign prior to beginning direct care at the site on their initial shift. The temp staff will leave the training records for the Site Supervisor to review. The Site Supervisor will then bring the training records to the Administrative Assistant, who maintains the required Qualification documentation for temp staff (physicals, clearances, etc). The training information will be kept in the employee¿s file. The Residential Program Specialist will maintain the binders and update information as needed. Attached is the email sent to the Temp Staff vendors, the meeting minutes from the Supervisor¿s meeting to discuss the protocol, the training record for the Adminstrative Assistant, and the table of contents from the training binder.] (AS 11/23/16) 11/06/2016 Implemented
6400.46(a)Direct Service Worker #1, who was scheduled to work on 8/13/16, from 4:30 PM to 11:00 PM and 8/14/16, from 8:00 AM to 3:30 PM had another person who is not an employee of the facility report to the home in his/her place. The person who provided supervision to the individuals during the aforementioned dates and shifts did not have orientation training relevant to the responsibilities, the daily operations of the home and policies and procedures of the home prior to working with the individuals.The home shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the home and policies and procedures of the home before working with individuals or in their appointed positions. Our contract with Capital HealthCare Solutions Staffing Company (attached) states, in #2 ¿Statement of Services¿, that the staff they provide to Milestone will meet criteria as required by our regulations and that they will ensure that, among other things, the staff have a valid pre-employment physical and criminal background check. The contract also states that Capital HealthCare will provide us with these documents upon request. Attached is the physical and the criminal history for ¿Direct Service Worker #1¿ who was scheduled by Capital HealthCare Solutions to work at Penhurst and Howell on 8/4, 8/6 and 8/7. Capital HealthCare provides information to their staff upon assignment to orient them to the site (subsequent to meeting with each Site Supervisor to gather pertinent and necessary information). The violations occurred because the employee of Capital HealthCare Solutions, Direct Service Worker #1, did not work at Howell and Penhurst as scheduled and expected. Rather the individual who worked these shifts at these sites fraudulently impersonated Direct Service Worker #1. To ensure that, in the future, any Capital HealthCare Solutions staff (or any staff from any contracted staffing agency) who appears on site to work a scheduled shift, is who he/she is supposed to be and therefore does meet all regulatory requirements ¿ Milestone established the attached Procedure with Capital HealthCare Solutions. All Residential Site Supervisors were informed of this procedure at their department meeting on 9/14/16 and it was implemented immediately there-after.[Addition to POC on 11/21/16 All of the temp staff vendors that we work with have been notified that there are new training binders at each site with information specific to the individuals that the temp staff are to read and sign prior to beginning direct care at the site on their initial shift. The temp staff will leave the training records for the Site Supervisor to review. The Site Supervisor will then bring the training records to the Administrative Assistant, who maintains the required Qualification documentation for temp staff (physicals, clearances, etc). The training information will be kept in the employee¿s file. The Residential Program Specialist will maintain the binders and update information as needed. Attached is the email sent to the Temp Staff vendors, the meeting minutes from the Supervisor¿s meeting to discuss the protocol, the training record for the Adminstrative Assistant, and the table of contents from the training binder.] (AS 11/23/16) 11/06/2016 Implemented
6400.151(a)Direct Service Worker #1, who was scheduled to work on 8/13/16, from 4:30 PM to 11:00 PM and 8/14/16, from 8:00 AM to 3:30 PM had another person who is not an employee of the facility report to the home in his/her place. The person who provided supervision to the individuals during the aforementioned dates and shifts did not have a physical examination. 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. Our contract with Capital HealthCare Solutions Staffing Company (attached) states, in #2 ¿Statement of Services¿, that the staff they provide to Milestone will meet criteria as required by our regulations and that they will ensure that, among other things, the staff have a valid pre-employment physical and criminal background check. The contract also states that Capital HealthCare will provide us with these documents upon request. Attached is the physical and the criminal history for ¿Direct Service Worker #1¿ who was scheduled by Capital HealthCare Solutions to work at Penhurst and Howell on 8/4, 8/6 and 8/7. Capital HealthCare provides information to their staff upon assignment to orient them to the site (subsequent to meeting with each Site Supervisor to gather pertinent and necessary information). The violations occurred because the employee of Capital HealthCare Solutions, Direct Service Worker #1, did not work at Howell and Penhurst as scheduled and expected. Rather the individual who worked these shifts at these sites fraudulently impersonated Direct Service Worker #1. To ensure that, in the future, any Capital HealthCare Solutions staff (or any staff from any contracted staffing agency) who appears on site to work a scheduled shift, is who he/she is supposed to be and therefore does meet all regulatory requirements ¿ Milestone established the attached Procedure with Capital HealthCare Solutions. All Residential Site Supervisors were informed of this procedure at their department meeting on 9/14/16 and it was implemented immediately there-after.[Addition to POC on 11/21/16 All of the temp staff vendors that we work with have been notified that there are new training binders at each site with information specific to the individuals that the temp staff are to read and sign prior to beginning direct care at the site on their initial shift. The temp staff will leave the training records for the Site Supervisor to review. The Site Supervisor will then bring the training records to the Administrative Assistant, who maintains the required Qualification documentation for temp staff (physicals, clearances, etc). The training information will be kept in the employee¿s file. The Residential Program Specialist will maintain the binders and update information as needed. Attached is the email sent to the Temp Staff vendors, the meeting minutes from the Supervisor¿s meeting to discuss the protocol, the training record for the Adminstrative Assistant, and the table of contents from the training binder.] (AS 11/23/16) 11/06/2016 Implemented
SIN-00072070 Renewal 11/14/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.71None of the required emergency numbers were listed on or by each telephone with an outside line.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. The list of emergency numbers was placed near the phone with an outside line prior to the admission of clients to the home. [The program specialist or designee will audit the location of the emergency phone list weekly in each community home to ensure that it remains on or by each telephone with an outside line. (CHG 12/22/14)] 12/21/2014 Implemented
6400.77(a)A first aid kit was not present in the home. A home shall have a first aid kit. A first aide kit was purchased and placed at the home. The requirement to have the first aid kit present prior to licensing and prior to individual's admission will be reviewed with Directors and Supervisors. [The first aid kit will be checked that the kit is available in each community home and checked for regulatory monthly by the program specialist or designee. (CHG 12/22/14)] 12/21/2014 Implemented
SIN-00220427 Renewal 02/28/2023 Compliant - Finalized
SIN-00065241 Initial review 07/01/2014 Compliant - Finalized