Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00278201 Renewal 11/18/2025 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.62(a)On 11/19/2025 at 1:34PM, a container of Cascade Dishwasher Pods, Easy Off Oven Cleaner, Grill and Fryer Cleaner was unlocked and accessible under the sink in the kitchen of the home. At 1:44PM, Clorox Clean-Up Cleaner and Bleach and Comet Bathroom Spray were unlocked and accessible in the basement of the home. Individual #1's assessment, completed 10/30/2025, states that Individual #1 requires verbal assistance to use or avoid poisons.Poisonous materials shall be kept locked or made inaccessible to individuals. Poisons were immediately locked at the site. All Supervisors were trained on the regulations with poisons and assessments on 12/11/25 and are required to confirm that poisons are locked if all individuals are not assessed as independent with poisons no later than 12/15. Signs for the sites for the inside of the cabinets will be distributed no later than 12/31/25. Documentation of all trainings will be kept in a shared file by the Res ADs 12/31/2025 Implemented
6400.141(c)(1)Individual #1's physical examination, completed 3/27/2025, does not include a review of previous medical history.The physical examination shall include: A review of previous medical history. If an individual is admitted through respite or residential who is not receiving any services through Milestone, a new physical on agency specific paperwork will be required prior to move in or within 30 days depending on individual circumstances. This will be communicated to new admissions and the Supports Coordinators in the team meeting planning as well as the pre-admission packet that was updated on 12/15/25. 12/15/2025 Implemented
6400.141(c)(11)Individual #1's physical examination, completed 3/27/2025, does not include an assessment of the individual's health maintenance needs and the need for blood work at recommended intervals.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. If an individual is admitted through respite or residential who is not receiving any services through Milestone, a new physical on agency specific paperwork will be required prior to move in or within 30 days depending on individual circumstances. This will be communicated to new admissions and the Supports Coordinators in the team meeting planning as well as the pre-admission packet that was updated on 12/15/25. 12/15/2025 Implemented
6400.216(a)On 11/19/2025 at 1:38PM, a binder containing the personal, identifiable information, service plan, assessment, medical documents and psychiatric evaluations of Individuals #1 and #2 and an individual that does not reside in the home were unlocked and unattended in the staff office in the basement of the home. An individual's records shall be kept locked when unattended. Site Supervisors will be trained on storage of medical binder information on 12/11/25. All Supervisors will confirm where the designated storage area in each assigned site is located and whether the locking mechanism is functional no later than 12/15/25. 12/15/2025 Implemented
6400.34(a)Individual #1, date of admission 8/17/2025, was informed of and explained individual rights on 9/18/2025.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.The Site Supervisors will be trained on the new admissions process on 12/11/15 including regulatory needs in addition to agency specific paperwork. Documentation of this training will be kept in a shared residential drive and maintained by the ADs. 12/15/2025 Implemented
6400.46(d)Direct Service worker #1, date of hire 2/8/2021, was trained in first aid, Heimlich techniques and cardio-pulmonary resuscitation on 5/25/2023 and then again on 6/17/2025. [Repeat Violation, 2/5/2025]Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation.Employee was recertified in CPR/FA as soon as it was discovered that the employee missed their scheduled recertification training. 12/15/2025 Implemented
6400.165(c)Individual #1's prescribed medications, Montelukast, Finasteride, Cetirizine were not administered as prescribed on 11/8/2025 at 800AM.A prescription medication shall be administered as prescribed.The medication error was entered into EIM on 11/11/25 by the assigned Program Specialist. The site was visited the following day on 11/12/25 by the PS and the medication error was documented on the MAR. The MAR will be maintained in the individual's record. 12/18/2025 Implemented
SIN-00239100 Renewal 02/13/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.34(a)Individual #1, date of admission 9/8/23 was informed and explained individual rights on 9/18/23.The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter.An admissions packet and checklist will be developed no later than 3/15/24. 03/07/2024 Implemented
6400.182(c)Individual #1's assessment, completed 11/3/23 assessed Individual #1 with the ability to use and avoid poisonous materials with verbal assistance with instructions and reminders. Individuals #1's individual plan, last updated on 12/13/23 in the safety precaution section reads "[Individual #1] is aware of poisonous substances and danger labels. He can properly use and store cleaning items. [Individual #1] would not eat a non-food item." Individual #1 was assessed with the ability to safely use and avoid heat sources with verbal assistance with instructions and reminder. Individuals #1's individual plan in the general health and safety section reads "[Individual #1] is safe around heat sources, electrical outlets, and knives." Individual #1 was assessed with the ability to evacuate in a fire with verbal assistance with instructions and reminders. Individuals #1's individual plan in the fire safety section reads "[Individual #1] is able to recognize and respond accordingly to smoke detectors and other signs of fire. His family feels in the event of a fire he would be able to evacuate the home independently."The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment.The Program Specialist requested revisions to the ISP on 2/21/24 via email. All Program Specialists were instructed to review and compare all Functional Assessments and ISPs no later than 3/31/24 and report requested changes to the Dir of IDD Systems. 02/21/2024 Implemented
SIN-00184011 Renewal 02/23/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.106The furnace inspection was completed on 9/27/19 and then again 12/01/20.Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept. The Director of Res spoke to the Maintenance Director regarding time frames for annual furnance inspections. A tentative date was scheduled for furnace inspections for 2021 in September. Furnance inspections will be added for discussion to the Health and Safety agenda for the September and October meetings as a reminder for upcoming inspections and subsequent review of completed inspections by the Health and Safety Committee. [Documentation of all audits and trainings shall be kept (DPOC by RM, HSLS on 3/25/2021)] 03/10/2021 Implemented
6400.141(c)(3)Individual #1's physical examination completed, 7/27/20 does not include immunizations.The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. Prior to a new admission for an individual, the AD of Residential will send a letter of requested required documentation to the individual and their team. All medical paperwork will be expected prior to the move in date of the individual for review. If the physical paperwork is missing or incomplete prior to move in, a new physical will be requested on paperwork provided by Milestone. If the paperwork is still incomplete, the AD will work with the individuals PCP to receive documentation of required missing information. The Res Director will review preadmission and admission paperwork in it's entirety for the next 3 new admissions. Documentation of review will be maintained.[Documentation of all audits and trainings shall be kept (DPOC by RM, HSLS on 3/25/2021)] 03/15/2021 Implemented
6400.141(c)(6)Individual #1, date of admission 10/13/20, had a physical examination completed, 7/27/20 which did not include Tuberculin skin testing by Mantoux method.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. Prior to a new admission for an individual, the AD of Residential will send a letter of requested required documentation to the individual and their team. All medical paperwork will be expected prior to the move in date of the individual for review. If the physical paperwork is missing or incomplete prior to move in, a new physical will be requested on paperwork provided by Milestone. If the paperwork is still incomplete, the AD will work with the individuals PCP to receive documentation of required missing information. The Res Director will review preadmission and admission paperwork in it's entirety for the next 3 new admissions. Documentation of review will be maintained.[Documentation of all audits and trainings shall be kept (DPOC by RM, HSLS on 3/25/2021)] 03/15/2021 Implemented
6400.141(c)(10)Individual #1's physical examination completed, 7/27/20 did not address communicable disease.The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. Prior to a new admission for an individual, the AD of Residential will send a letter of requested required documentation to the individual and their team. All medical paperwork will be expected prior to the move in date of the individual for review. If the physical paperwork is missing or incomplete prior to move in, a new physical will be requested on paperwork provided by Milestone. If the paperwork is still incomplete, the AD will work with the individuals PCP to receive documentation of required missing information. The Res Director will review preadmission and admission paperwork in it's entirety for the next 3 new admissions. Documentation of review will be maintained.[Documentation of all audits and trainings shall be kept (DPOC by RM, HSLS on 3/25/2021)] 03/15/2021 Implemented
6400.141(c)(11)Individual #1's physical examination completed, 7/27/20 did not include an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals.The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. Prior to a new admission for an individual, the AD of Residential will send a letter of requested required documentation to the individual and their team. All medical paperwork will be expected prior to the move in date of the individual for review. If the physical paperwork is missing or incomplete prior to move in, a new physical will be requested on paperwork provided by Milestone. If the paperwork is still incomplete, the AD will work with the individuals PCP to receive documentation of required missing information. The Res Director will review preadmission and admission paperwork in it's entirety for the next 3 new admissions. Documentation of review will be maintained.[Documentation of all audits and trainings shall be kept (DPOC by RM, HSLS on 3/25/2021)] 03/15/2021 Implemented
6400.141(c)(12)Individual #1's physical examination completed, 7/27/20 did not include physical limitations of the individual.The physical examination shall include: Physical limitations of the individual. Prior to a new admission for an individual, the AD of Residential will send a letter of requested required documentation to the individual and their team. All medical paperwork will be expected prior to the move in date of the individual for review. If the physical paperwork is missing or incomplete prior to move in, a new physical will be requested on paperwork provided by Milestone. If the paperwork is still incomplete, the AD will work with the individuals PCP to receive documentation of required missing information. The Res Director will review preadmission and admission paperwork in it's entirety for the next 3 new admissions. Documentation of review will be maintained.[Documentation of all audits and trainings shall be kept (DPOC by RM, HSLS on 3/25/2021)] 03/15/2021 Implemented
6400.141(c)(14)Individual #1's physical examination completed, 7/27/20 did not include medical information pertinent to diagnosis and treatment in case of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Prior to a new admission for an individual, the AD of Residential will send a letter of requested required documentation to the individual and their team. All medical paperwork will be expected prior to the move in date of the individual for review. If the physical paperwork is missing or incomplete prior to move in, a new physical will be requested on paperwork provided by Milestone. If the paperwork is still incomplete, the AD will work with the individuals PCP to receive documentation of required missing information. The Res Director will review preadmission and admission paperwork in it's entirety for the next 3 new admissions. Documentation of review will be maintained.[Documentation of all audits and trainings shall be kept (DPOC by RM, HSLS on 3/25/2021)] 03/15/2021 Implemented
6400.141(c)(15)Individual #1's physical examination completed, 7/27/20 did not include special instructions for the individual's diet.The physical examination shall include: Special instructions for the individual's diet.Prior to a new admission for an individual, the AD of Residential will send a letter of requested required documentation to the individual and their team. All medical paperwork will be expected prior to the move in date of the individual for review. If the physical paperwork is missing or incomplete prior to move in, a new physical will be requested on paperwork provided by Milestone. If the paperwork is still incomplete, the AD will work with the individuals PCP to receive documentation of required missing information. The Res Director will review preadmission and admission paperwork in it's entirety for the next 3 new admissions. Documentation of review will be maintained.[Documentation of all audits and trainings shall be kept (DPOC by RM, HSLS on 3/25/2021)] 03/15/2021 Implemented
SIN-00164650 Renewal 10/22/2019 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(c)Direct Service Worker #1, date of hire 8/12/19, was not trained before working with the individuals in first aid techniques.Program specialists and direct service workers and at least one person in a vehicle while individuals are being transported by the home shall be trained before working with individuals in first aid techniques.The Assistant Directors will identify all temp to hire staff within the 2019 calendar year by 11/15/19. They will review their credentials and notify the Office Manager to update their hire date from their original date as a temp staff to their hire date as a Milestone employee and verify that their certifications are accurate and up to date. Any temp to hire employees who have not supplied up to date documents will not be permitted to work at a residential site until documentation has been turned into the Office Manager. The Office Manager will notify the Assistant Directors of any temp to hire staff that will need an updated physical or training prior to the expiration of their current documents. The Assistant Directors will review the tracking spreadsheet and employee status with the Res Director quarterly. Documentation of reviews will be maintained by the Res. Director. 11/15/2019 Implemented
SIN-00104491 Renewal 12/05/2016 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.31(b)The statement signed and dated by Individual #1 acknowledging receipt of the information on individual rights was most recently completed 7/30/15.Statements signed and dated by the individual, or the individual's parent, guardian or advocate, if appropriate, acknowledging receipt of the information on rights upon admission and annually thereafter, shall be kept. The signature sheet for Individual 1s Annual Rights Packet was found in a different binder by the Site Supervisor and submitted to BHSL on 1/26/17. All individual rights sign off sheets will by audited by 3/31/17 to ensure that they were signed off in a timely manner. An annual rights packet to accompany the ISP time frames was created and submitted to BHSL on 1/26/17. All Site Supervisors were trained on this packet and time frames for client rights on 1/24/17. The training was submitted to BHSL on 1/30/17. 01/30/2017 Implemented
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
6400.68(b)At 12:31 PM, the hot water temperature measured 128.3°F in the shower in the bathroom in the hallway of the home. [Repeated violation 11/10/15] Hot water temperatures in bathtubs and showers may not exceed 120°F. The water temperature was adjusted when the temperature read too high at annual licensing by the Site Supervisor. The water temperature is checked weekly by the Site Supervisor, and has been checked weekly since the citation in 2015. The issue was that the thermometer was not calibrated and the licensor's thermometer read a different temperature than the Supervisor's thermometer. The thermometer was replaced at the site for weekly checks and the thermometer that the Asst. IDD Director uses for monthly checks was also replaced. The Site Supervisor and Asst. IDD Director maintain documentation of checks. Documentation for weekly and monthly temperatures were sent to BHSL on 1/23/17. The Site Supervisors will be retrained on accurately taking temperatures by 2/15/17 and the Asst. IDD Director will replace any thermometers that are not matching temperatures when comparing the weekly and monthly check. [Within 60 days of receipt of the plan of correction, all staff persons responsible for measuring hot water temperatures shall be trained that the hot water temperatures may not exceed 120°F in bathtubs and showers and to measure in these locations at all community homes; in addition the training shall include the agency's procedures to follow if the hot water temperature exceeds 120°F in bathtubs and showers. Documentation of trainings shall be kept. (AS 2/3/17)] 01/30/2017 Implemented
SIN-00072062 Renewal 11/13/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.112(f)The fire drill records from 1/25/14 to 10/22/14 indicate that only the front exit was used for all drills. Alternate exit routes shall be used during fire drills. Currently all three residents at this site are ambulatory so the down-stairs exit can and will be used as an alternate exit during fire drills - at least quarterly - which will be tracked /documented on the fire drill record. Site supervisors will ensure that alternate exit routes will be used during fire drills. 12/21/2014 Implemented
SIN-00054187 Renewal 09/23/2013 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)There was a 3" x 3" hole in the hallway wall between two of the individuals' bedrooms. (a) Floors, walls, ceilings and other surfaces shall be in good repair. The hole was filled and patched by maintenance department. (9/30/13) (Photo will be submitted via e-mail attachment) The issue was verbally reported to the maintenance department verbally in May 2013, but was never fixed. All maintenance requests will be emailed to the maintenance director in an attempt to increase communication. Site Supervisors will confirm that work is done within a month of the request or follow up with Maintenance. Supervisor Training in this process will occur at the next staff meeting (10/9/13) 09/30/2013 Implemented
6400.151(c)(2)A mantoux test for Staff #1 was planted on 7/03/2013 and read on 8/02/2013 as positive. There was no chest X-Ray completed. (2) 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. Residential Management and Human Resources discussed the importance of ensuring that newly hired staff members receive a chest x-ray, if needed, with their pre-employment physical. Staff member had chest x-ray completed and was instructed to turn verification of completion of chest x-ray to Site Supervisor. [A management staff person will be identified to perform an audit of all current staff members records to check for regulatory requirements including staff physical and TB skin testing. (CHG 10/24/13)] 10/26/2013 Implemented
6400.164(b)The medication log for Individual #1 did not include the name of the staff person who administered Individual #1's 10:00 PM dose of Buspar, on 12/27/2012. (b) The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. Supervisors were reminded of proper documentation and review of Individual MARs at staff meeting on 10/16/13. The ADs were reminded to examine this in the future, while completing LII. [The Program Specialist will audit the medication log once per week for completeness and accuracy. The Program Director/Quality Assurance Representative will audit the MARs at the community home once a month for completeness and accuracy. Documentation of the monthly MAR audit will be maintained. (CHG 10/24/13)] 10/16/2013 Implemented