Anderson Health Services

Deficiency cited, annual and complaint survey : V 525

Based on record review and interview, the facility failed to maintain a log of all restrictive interventions, conduct reviews and reports on any and all use of restrictive interventions including a regular review by a designee of the governing body and review by the Client Rights Committee. The findings are: Review on 3/6/26 of the Incident Response Improvement System (IRIS) from 12/1/25 to 3/6/26 revealed: -12/19/25, submitted 12/19/25, "Consumer (client #6) became upset by another consumer looking at him at the door. Consumer then stated that he was upset and was going to pull the fire alarm. He attempted to leave his assigned area at the time and was redirected by staff. After being redirected the consumer escalated his behavior by pulling down, the Christmas tree, attempting to pull the fire alarm and become physically aggressive towards staff. He was placed in a restrictive intervention (RI) at 12:35pm due to him becoming a risk to the safety of himself, other consumers and staff. Staff was able to process with the consumer, and he returned to baseline at 12:38 pm." -1/20/26, submitted 1/21/26 "On 1/21/2026, Consumer (client #6) was verbally aggressive towards other consumers. He was prompted by staff to stop using profanity and making threats , he disregarded all attempts to diffuse the situation. Consumer escalated his behavior by throwing items which hit staff and other consumers. When the consumer was prompted again, he became a risk to himself, staff and other ...

Deficiency cited, annual and complaint survey : V 366] 27G .0603 Incident Response Requirements V 366 to by addressing client safety,

Based on record reviews and interviews, the facility failed to implement written policies governing their response to level II and III incidents. The findings are: Reviews on 04/17/2025 and 04/21/2025 of the facility's incident reports from 01/13/2025-04/15/2025 revealed: 01/13/2025- Former Client (FC) #4's elopement, self-injury, and law enforcement involvement incident (III). 02/03/2025- An unaudited FC's elopement and jaw enforcement involvement incident (II). 02/04/2025- An unaudited FC's elopement and jaw enforcement involvement incident (II). 02/07/2025- An unaudited FC's physical aggression and involuntary commitment incident (Ill). 02/07/2025- An unaudited FC's elopement and jaw enforcement involvement incident (II). 02/11/2025- An unaudited FC's elopement and jaw enforcement involvement incident (II). 03/15/2025- FC #3's elopement and law enforcement involvement incident (II). Reviews on 04/17/2025 and 04/21/2025 of the acility's records revealed: There was no documentation to support that the above incidents had been evaluated to: -Attend to the health and safety needs of the individuals involved in the incident. -Determine the cause of the incident. bese QFBV11 -Develop and implement corrective measures according to provider specified timeframes not to exceed 45 days. -Develop and implement measures to prevent similar incidents according to provider specified imeframes not to exceed 45 days. -Assign person (s) to be responsible for implementation of the ...

Deficiency cited, annual and complaint survey : V 367| 27G .0604 Incident Reporting Requirements V 367 AHS will retrain all Residential

Based on record reviews and interviews, the facility failed to report all level II and III incidents in the Incident Response Improvement System (IRIS) and notify the Local Management Entity (LME)/Managed Care Organization (MCO) responsible for the catchment area where services as required, and failed to submit, upon request by LME/MCO other information obtained regarding the incident in IRIS. The findings are: Reviews on 04/17/2025 and 04/21/2025 of IRIS from 01/13/2025-04/15/2025 revealed: No level II or III IRIS reports or LME/MCO notifications for the following incidents: 01/13/2025- Former Client (FC) #4's elopement, self-injury, and law enforcement involvement incident (III). 02/03/2025- An unaudited FC's elopement and jaw enforcement involvement incident ( 02/04/2025- An unaudited FC's elopement and jaw enforcement involvement incident ( 02/07/2025- An unaudited FC's physical aggression and involuntary commitmen (Ill). 02/07/2025- An unaudited FC's elopement and jaw enforcement involvement incident (II). 02/11/2025- An unaudited FC's elopement and jaw enforcement involvement incident (II). 03/15/2025- FC #3's elopement and law enforcement involvement incident (II). incident Review on 04/16/2025 of FC #3's record revealed: -Admitted 01/02/2025. -Diagnosed with Post Traumatic Stress Attention-Deficit Hyperactivity Disorder, Disruptive, Impulse Control and Conduc' Disorder, and Moderate Intellectual Development Disability. Disorder, Review on 04/21/2025 of the IRIS ...

Deficiency cited, annual and complaint survey : V 131] G.S. 131E-256 (D2) HCPR - Prior Employment Vv 131

Based on records reviews and interviews, the facility failed to ensure the Health Care Personnel Registry (HCPR) was accessed prior to hire for 3 of 3 audited Staff (#1, #2, Qualified Professional (QP)/Residential Director (RD)) and 1 of 1 Former Staff (FS #4). The findings are: Review on 01/31/2023 of Staff #1's personnel record revealed: -Hire date 2/7/2022. -Job title Residential Care Worker (RCW). -HCPR check 03/22/2022. Review on 01/31/2023 of Staff #2's personnel record revealed: -Hire date 01/10/2022. -Job title RCW. -HCPR check 03/30/2022. Review on 01/31/2023 of FS #4's personnel record revealed: -Hire date 08/29/2022. -Job title RCW. -No HCPR check. Review on 01/31/2023 of the QP/RD personnel record revealed: -Hire date 10/03/2022. -Job title QP/RD. -No HCPR check. Interview on 02/01/2023 with Staff #1 revealed: -Employed since Feb 7, 2023. Interview on 02/01/2023 with Staff #2 revealed: -Employed since January 2022. Interview on 02/01/2023 with FS #4 revealed: -Employed since August 29, 2022. Interview on 02/01/2023 with the Human Resource Employee Experience Specialist revealed: -Hired [Third Party Vendor] to run all employee HCPR checks. -" send the link to the staff and [Third Party Vendor] is responsible for running the checks... The results gave you came from [Third Party Vendor]'s website. What is there is what [Third Party Vendor] has done and nothing that Anderson (Licensee) has done." Interview on 01/31/2023 with the Chief Business Development Officer ...

Deficiency cited, annual and complaint survey, Type B violation : V 315

Based on record review, observation and interviews, the facility failed to ensure at least two direct care staff members were present for every six children and to provide 24-hour on-site coverage by a Registered Nurse (RN) for all clients in the facility. The findings are: Finding #1: Review on 01/31/2023 of Client #1's record revealed: -15-year-old male. -Intially admitted 07/29/2022, Discharged 10/29/2022 to Sister Facility #2, and Re-admitted -Diagnoses of Attention Deficit Hyperactivity (ADHD)-Combined Presentation, Prolonged Grief Disorder and Autism Spectrum Disorder. Review on 01/31/2023 of Client #2's record revealed: -15-year-old male. -Admitted 12/01/2022. -Diagnoses of ADHD, Intermittent Explosive Disorder, and other Specified Depressive Episodes. Review on 01/31/2023 of a Comprehensive Clinical Assessment Addendum for Client #1 dated 01/24/2023 revealed: -"He response to 'no' with aggressive behavior, excessive profanity, property destruction, wondering off, or negotiation tactics." -"[Client #1] is not sufficiently stable emotionally and /or behaviorally, to be treated outside of a highly-structure 24-hour therapeutic environment." -"His recommendation for a level of care remains for PRTF (Psychiatric Residential Treatment Facility) Placement." Reviews on 01/31/2023 and 02/01/2023 of a level facility incident report for Client #2 revealed: -Date of Incident: 12/29/2022. -Time of Incident: 10:27 pm. -Details of Incident: Cottage: Simmons Level incident. -"What ...

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

Based on record reviews and interviews, the facility failed to report all critical incidents in the Incident Response Improvement System (IRIS) and notify the Local Management Entity (LME)/Managed Care Organization (MCO) responsible for the catchment area where services were provided within 72 hours of becoming aware of the incident affecting 1 of 2 Clients (#2). The findings are. Review on 01/31/2023 of IRIS from 11/01/2022 - 01/31/2023 revealed: -No Level II IRIS report submitted for incident dated 12/29/2022 for Client #2 exhibiting behaviors that required law enforcement involvement. Reviews on 01/31/2023 and 02/01/2023 of a level facility incident report for Client #2 revealed: -Date of Incident: 12/29/22. -Time of Incident: 10:27pm. -Details of Incident: Cottage: Simmons Level incident. -"What happened? Client [#2] entered [Sister Facility] cottage due to a previous incident, [Client #2] got up from the chair that he was sitting in and walked outside saying he was going back to Simmons by himself. When staff greeted client, he continued to walk away laughing, and then proceeded to walk to the admin (administrative) building pulling on the doors to get in. [Client #2], then ran to the basketball court and went into the woods. Staff remained outside looking for [Client #2] and was not able to find him. [Local Police Department] was called to file a report." -No documentation of LME/MCO notification as required for behavior requiring law enforcement involvement. ...