Alexander Youth Network

Deficiency cited, annual complaint and follow-up survey : V315

Based on record review and interview, the facility failed to ensure at least 2 direct care staff were present with every 6 children or adolescents at all times. The findings are: Review on 6/23/26 of the facility's Investigation Report for the incident on 6/5/26 signed by the Former Program Manager revealed: -Based on video review, "it was noted that [Staff #7] remained in the gym with clients without his assigned partner (Staff #13) for an extended period of time." Interview on 6/26/26 with Client #6 revealed: -" don't want to talk today." -Refused to answer any questions. Interview on 6/26/26 with Client #7 revealed: -There were 2 staff on first shift and 2 to 3 staff on second shift. Interview on 6/26/26 with Client #9 revealed: -There were "either 1 or 2 (staff on shift) last night there was 3 (staff working).” ~"It is rare for 3" staff to work on a shift. -1 staff on shift happened "every little bit (dates unknown)." Interview on 6/26/26 with Client #10 revealed: -There were two staff present in the mornings. -There were two staff, sometimes 3 staff at night. Interview on 6/26/26 with Client #11 revealed: f . PRINTED: 07/10/2026 -There were 2 to 3 staff on each shift. -There were never less than 2 "unless staff is running late (unknow how often or for how long).” Interview on 6/26/26 with Client #12 revealed: -There were usually 2 staff in the morning and 3 at night. -There was never less than 2 staff. Attempted review on 6/30/26, 7/6/26 and 7/7/26 of the facility's ...

Deficiency cited, annual complaint and follow-up survey : V 315

Based on record review and interview, the facility failed to ensure at least 2 direct care staff were present with every 6 children or adolescents at all times. The findings are: Review on 6/23/26 of the facility's Investigation Report for the incident on 6/5/26 signed by the Former Program Manager revealed: -Based on video review, "it was noted that [Staff #7] remained in the gym with clients without his assigned partner (Staff #13) for an extended period of time." nterview on 6/26/26 with C! -" don't want to talk today." -Refused to answer any questions. ient #6 revealed: nterview on 6/26/26 with Client #7 revealed: -There were 2 staff on first shift and 2 to 3 staff on second shift. nterview on 6/26/26 with Client #9 revealed: -There were “either 1 or 2 (staff on shift) last night here was 3 (staff working)." -"It is rare for 3" staff to work on a shift. -1 staff on shift happened "every little bit (dates unknown)." nterview on 6/26/26 with Client #10 revealed: -There were two staff present in the mornings. -There were two staff, sometimes 3 staff at night. nterview on 6/26/26 with Client #11 revealed: -There were 2 to 3 staff on each shift. -There were never less than 2 "unless staff is running late (unknow how often or for how long)." Interview on 6/26/26 with Client #12 revealed: -There were usually 2 staff in the morning and 3 at night. -There was never less than 2 staff. Attempted review on 6/30/26, 7/6/26 and 7/7/26 of the facility's video from 6/5/26 was ...

Deficiency cited, complaint survey : V132

Based on record review and interview, the facility failed to protect clients from harm during an investigation and failed to report, within 5 working days, the results of the investigation to the Department. The findings are: Review on 11/14/25 of the North Carolina Incident Response and Reporting (IRIS) revealed: -9/10/25 incident submitted on 9/11/25, client #1 “broke a [toy product] piece that belong to a peer (client). The peer got upset and went to staff (staff #4). Staff (staff #4) told client (client #1) to return the [toy product] to the peer, but client refused. Client was directed to their (client #1) room (bedroom) but continued to argue with staff. Another staff (staff #3) intervened and attempt to help client de-escalate. Client (client #1) pushed past that staff (staff #3) and attempted to strike the staff (staff #4) who initially redirected her (client #1)" resulting in a restraint of client #1 and client #1’s allegation that staff #4 pulled her pants down and put his elbow in client #1's crotch "on purpose" during the restraint. No investigation result were attached. Review on 12/8/25 of the facility's Internal Investigation Report dated 9/10/25 revealed: -"On 9/19/25 Program Supervisor [Previous Program Supervisor] informed the Program c Manager [Program Manager] that during a restraint the staff (staff #4) intentionally pulled pulled her (client #1) pants down during the restraint. -Pre-investigation actions: Program Supervisor was advised to follow ...

Deficiency cited, complaint survey : V 367] 27G .0604 Incident Reporting Requirements

use of established reporting systems and audits will be Based on record reviews and interview, the enforced to ensure timely and traceable facility failed to submit Level II incident reports to documentation of all incident reports. the Local Management Entity/Managed Care Monitoring: Performance tmprovement team will Organization (LME/MCO) within 72 hours as audit repots weekly for completeness in addition to required. The findings are: more detailed review of incident documentation of randomly selected client file during quarterly tracer Review on 12/3/25 of the facility's incident reports and record review for client #1 from 8/1/25 to 11/17/25 revealed: -10/17/25 "During big muscle time as the clients were transitioning from the playground, the client (client #1) was upset at how her day started. The client (client #1) then kicked a chair causing her toe to hurt, the client was seen by the nurses for the incident." 11/3/25 "Client (client #1) was outside engaging with peer (client #2). Client approached a nearby staff member with peer to talk briefly before walking away. Shortly after, the client (client #1) was observed running across the parking lot and leaving the campus grounds. Multiple staff members, including the supervisor, began searching for client within the nearby neighborhoods and surrounding areas. During the search, the client (client #1) was observed by staff returning to campus. Upon her return, the client proceeded directly to the nurse 's station, where ...

Deficiency cited, complaint survey : V 132} G.S. 131E-256(G) HCPR-Notification,

Based on record review and interview, the facility failed to protect clients from harm during an investigation and failed to report, within 5 working days, the results of the investigation to the Department. The findings are: Review on 11/14/25 of the North Carolina Incident Response and Reporting (IRIS) revealed: -9/10/25 incident submitted on 9/11/25, client #1 "broke a [toy product] piece that belong to a peer (client). The peer got upset and went to staff (staff #4). Staff (staff #4) told client (client #1) to return the [toy product] to the peer, but client refused. Client was directed to their (client #1) room (bedroom) but continued to argue with staff. Another staff (staff #3) intervened and attempt to help client de-escalate. Client (client #1) pushed past that staff (staff #3) and attempted to strike the staff (staff #4) who initially redirected her (client #1)" resulting in a restraint of client #1 and client #1's allegation that staff #4 pulled her pants down and put his elbow in client #1's crotch "on purpose" during the restraint. No investigation result were attached. Review on 12/8/25 of the facility's Internal Investigation Report dated 9/10/25 revealed: -"On 9/19/25 Program Supervisor [Previous Program Supervisor] informed the Program Cc Cc Manager [Program Manager] that during a restraint the staff (staff #4) intentionally pulled pulled her (client #1) pants down during the restraint. -Pre-investigation actions: Program Supervisor was advised to follow ...

Deficiency cited, complaint survey : V 314

Based on record review and interviews, the facility failed to coordinate client care with other individuals and agencies affecting one of six audited current clients (#1). The findings are: Review on 11/14/25 of client #1's record revealed: -Age 12 years old -Admission 6/27/25 -Admission Assessment dated 6/28/25 noted history with "concerning behaviors including Cc running away, physical aggression, and reports of auditory and visual hallucinations...reported interactions with '[entity's name],' an entity [client #1] reports seeing, hearing and feeling physically...led to concerning behaviors, including following commands to run into traffic...disruptive attachments due to multiple foster placement...before age 2 and prenatal exposure to illicit substances. ..significant childhood trauma... -Diagnoses: Major Depressive Disorder, Recurrent, Severe with Psychotic Symptoms; Disruptive Mood Dysregulation Disorder; Generalized Anxiety Disorder; Post-Traumatic Stress Disorder, Unspecified; Autistic Disorder, level 1; Attention-Deficit Hyperactivity Disorder, Unspecified Type; Oppositional Defiant Disorder. Review on 11/18/25 of facility Internal Incident Reports revealed: -Incident dated 10/17/25, 3:00pm; report submitted 10/24/25, 5:27am. -"Description of incident: During big muscle time as the clients were transitioning from the playground, the client (client #1) was upset at how her day started. The client (client #1) kicked a chair causing her toe to hurt, the client was seen ...

Deficiency cited, complaint survey : V 315

Based on interviews and record review the facility failed to insure proper staffing ratio. The findings are: Review on 11/24/25 of the facility's video surveillance dated 9/10/125 revealed: -Approximately 5:31:00pm, staff #4 was sitting at a desk in the common area of the cottage alone. -Approximately 5:31:17pm, staff #3 entered the cottage as client #1 and staff #4 engage in an escalating verbal altercation that results in client #1 being physically restrained by staff #3 and staff #4. Interview 11/14/25 and with client #1 revealed: -Two staff worked on shift, "never just one (staff); if there is one staff, another staff will come in, the longest time a staff worked alone was two months." Interview 11/14/25 and with client #2 revealed: -Two staff worked on shift. -" think there was only one time since been here that there was one staff working alone (date unknown), [Program Supervisor]." -There had been times when one staff worked and had to "wait for another staff to arrive, it takes about five minutes for the other staff to come." Interview 11/14/25 and with client #3 revealed: -Two staff worked shifts. -"There is times when one staff work and they (staff) let us do what we (clients) want to do because they don't feel like putting us on restriction. It's not often, but it happens (one staff). It happened the day before yesterday (11/22/25), it happened last week and the last Cc week after that (week before last), there was one staff." Interview 11/14/25 and with client #4 ...

Deficiency cited, complaint survey : V 367] 27G .0604 Incident Reporting Requirements

Based on record reviews and interview, the facility failed to submit Level II incident reports to the Local Management Entity/Managed Care Organization (LME/MCO) within 72 hours as required. The findings are: Review on 12/3/25 of the facility's incident reports for client #1 from 8/1/25 to 11/17/25 revealed: -10/17/25 "During big muscle time as the clients were transitioning from the playground, the client (client #1) was upset at how her day started. The client (client #1) then kicked a chair causing her toe to hurt, the client was seen by the nurses for the incident." 11/3/25 "Client (client #1) was outside engaging with peer (client #2). Client approached a nearby staff member with peer to talk briefly before walking away. Shortly after, the client (client #1) was observed running across the parking lot and leaving the campus grounds. Multiple staff members, including the supervisor, began searching for client within the nearby neighborhoods and surrounding areas. During the search, the client (client #1) was observed by staff returning to campus. Upon her return, the client proceeded directly to the nurse 's station, where staff ensured her safety and well-being. Client (client #1) returned with no injuries." Cc Reviews on 11/14/25 and 12/7/25 of the North revealed: -Date of incident: 11/23/25; Provider learned of incident: 11/23/25; Date submitted: 11/27/25; -"The client attempted to attack a peer in her cottage during an active crisis by grabbing staff intervened with ...

Deficiency cited, complaint survey : V 132} G.S. 131E-256(G) HCPR-Notification,

Based on record reviews and interviews, the facility failed to protect clients during an investigation of abuse, neglect or exploitation. The findings are: Cc Review on 4/21/25 of the Qualified Professional's (QP) personnel record revealed: -Date of hire 2/28/22 -Job Title QP. Review on 4/21/25 at 12:00pm of the Facility's Video Footage dated 3/14/25 revealed: -Client #1 was seen sitting in his chair. -The QP got up from her seat, walked over to Client #1, pulled him to the floor and then walked back to her seat. -Client #1 got up off the floor and sat in his chair. Review on 4/16/25 of the North Carolina Incident Response Improvement System (IRIS) revealed: -On 3/19/25 while reviewing video footage in reference to another incident, the Program Supervisor saw the QP walk over to Client #1 and pushed him out of his chair on 3/14/25. -Client #1 fell to the floor. -The QP walked back over to her seat and Client #1 got up and sat in his chair. Review on 4/21/25 of the facility's document titled "Internal Review Findings of Fact Summary- 3.31.24: Incident 3.19.25" revealed: -"Allegation: While reviewing video for another Internal Investigation, program manager saw staff (QP) pull client (Client #1) off a desk and ‘throw the to the floor.'" -"The video shows the staff member (QP) approaching the youth (Client #1) after an exchange of words and then the youth is on the floor. The video is dark." -"The youth (Client #1) is repeatedly saying ‘dummy.’ The staff member (QP) can be ...

Deficiency cited, complaint survey : V 132) G.S. 131E-256(G) HCPR-Notification,

Based on record reviews and interviews, the facility failed to protect clients during an investigation of abuse, neglect or exploitation. The findings are: Review on 4/21/25 of the Qualified Professional's (QP) personnel record revealed: -Date of hire 2/28/22 -Job Title QP. Record Review on 4/21/25 at 12:00pm of the Facility's Video Footage dated 3/14/25 revealed: -Client #1 was in the classroom standing in a chair yelling, "Dummy! Dummy! Dummy!" -The QP said, "Don't start with me today, I'm the wrong one." -Staff #2 walked over to Client #1 and asked him to sit in the chair but he continued standing in the chair. -There was an unintelligible exchange of words between Client #1 and the QP. -The QP got up from her seat, walked over to Client #1, grabbed both of his shoulders and pushed him to the floor then walked back over to her seat. -Client #1 fell over to the right out of his chair on to the floor. -Client #1 got up off the floor, sat in his chair and Cc made an unintelligible comment to the QP then Client #1 said, "Do something about it." in which the QP replied, "I just did.” Review on 4/16/25 of the North Carolina Incident Response Improvement System (IRIS) revealed: -On 3/19/25 while reviewing video footage in reference to another incident, the Program Supervisor saw the QP walk over to Client #1 and pushed him out of his chair on 3/14/25. -Client #1 fell to the floor. -The QP walked back over to her seat and Client #1 got up and sat in his chair. Review on 4/21/25 ...

Deficiency cited, complaint survey : V 132, G.S. 131£-256(G) HCPR-Notification v132 HR Director and Vice President for 5/23/2025

Based on record reviews and interviews, the facility failed to protect clients during an investigation of abuse, neglect or exploitation. The findings are: Review on 4/21/25 of the Qualified Professional's (QP) personnel record revealed: -Date of hire 2/28/22 -Job Title QP. Record Review on 4/21/25 at 12:00pm of the Facility's Video Footage dated 3/14/25 revealed: -Client #1 was in the classroom standing in a chair yelling, "Dummy! Dummy! Dummy!" -The QP said, "Don't start with me today, I'm the wrong one." -Staff #2 walked over to Client #1 and asked him to sit in the chair but he continued standing in the chair. -There was an unintelligible exchange of words between Client #1 and the QP. -The QP got up from her seat, walked over to Client #1, grabbed both of his shoulders and pushed him to the floor then walked back over to her seat. -Client #1 fell over to the right out of his chair on to the floor. -Client #1 got up off the floor, sat in his chair and Cc

Deficiency cited, complaint survey, Type A1 violation : V 512 27D .0304 Client Rights - Harm, Abuse, Neglect

Based on record reviews and interviews, 1 of 1 Qualified Professional (QP) abused 1 of 14 client (#1). The findings are: Review on 4/16/25 of Client #1's record revealed: - 9 years old The Day Treatment Program Manager will 5/23/2025 continue to have staffing meetings with each staff member. In this meeting the program manager will reiterate the importance of appropriate therapeutic interventions. The program staff will conduct frequent check-ins with each client, especially with children that have a tendency or history of constantly antagonizing others for long periods of time. When staff become frustrated staff will tag out, reach out to the supervisor, and step away to take a break outside away from the escalated client. The program manager will use the model of care (MOC) observation forms monthly to monitor each staff member regardless of the staff's credentials of QP, AP or paraprofessional, to prevent the problem from occurring again. The Program Manager will use the MOC Observation Forms to ensure the staff are engaging in therapeutic interventions, effectively regulating their own emotions and following effective classroom guidelines and expectations. The Program Manager will give feedback to each staff member after the observation. The Program Manager will routinely monitor each classroom throughout the days to provide oversight and support as needed. The Regional Director will review compliance and quality of the MOC forms monthly to ensure monitoring is ...