Christ Church Cottage Thompson Child & Family Center

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

Based on record reviews and interviews, the facility failed to file a required incident report within 72 hours and failed to submit to the Local Management Entity (LME)/Managed Care Organization (MCO) upon requests other information regarding the incident. The findings 809 uapatt are: Review on 02/20/2026 of the facility's incident reports from 11/01/2025 - 02/10/2026 revealed: -01/12/26; FC #4's concussion incident. -01/27/26; Client #2's allegation of abuse incident. -02/10/26; FC #6's aggressive and destructive behavior incident. -02/10/26; Client #2's behavior outburst and Urgent Care visit incident. Review on 02/20/2026 of the Incident Response Improvement System (IRIS) from 11/01/2025 - 02/10/2026 revealed: -01/12/26; FC #4's concussion incident. -01/27/26; Client #2's allegation of abuse incident. -02/10/26; FC #6's aggressive and destructive behavior incident. -02/10/26; Client #2's behavior outburst and Urgent Care visit incident. Review on 02/20/2026 an IRIS Report dated 01/12/2026 for FC #4 revealed: -The incident occurred on 01/12/2026. -The provider learned of the incident on -The report was submitted 01/13/2026. -LME/MCO Comments dated 01/13/2026: " Incident reviewed. Please add Medicaid ID number." -There was no response to the LME/MCO request. Review on 02/20/2026 an IRIS Report dated 01/27/2026 for Client #2 revealed: -The incident occurred on 01/27/2026. -The provider learned of the incident on -The report was submitted 01/28/2026. -LME/MCO Comments dated ...

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

Based on record review and interview 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 areas where services were provided within 72 hours of becoming aware of the incident affecting 1 of 4 audited clients (Former Client #4). The findings are: Review on 5/3/25 of Former Client (FC) #4's record revealed: - Admission date 2/12/25; - Age 15 years; - Diagnoses Attention Deficit Hyperactivity Disorder, Combined Type; Intermittent Explosive Disorder; Dysthymic Disorder; - Discharge date 3/28/25. Review on 5/1/25 of the facility's Internal Investigations from October 1, 2024-May 1, 2025

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

Based on record review and interview 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 areas where services were provided within 72 hours of becoming aware of the incident affecting 1 of 4 audited clients (Former Client #4). The findings are: Review on 5/3/25 of Former Client (FC) #4's record revealed: - Admission date 2/12/25; - Age 15 years; - Diagnoses Attention Deficit Hyperactivity Disorder, Combined Type; Intermittent Explosive Disorder; Dysthymic Disorder; - Discharge date 3/28/25. Review on 5/1/25 of the facility's Internal Investigations from October 1, 2024-May 1, 2025

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

Based on record review and interviews 1 of 3 audited direct care staff (staff #1) abused 1 of 1 audit client (client #1). The findings are: Review on 4/15/24 of Client #1's record revealed: - Admission 3/12/24. - Age 15. - Diagnoses: Oppositional Defiant Disorder, Moderate; Unspecified Attention Deficit Hyperactivity Disorder; Unspecified Trauma-and Stressor-Related Disorder; Childhood-Onset Fluency Disorder. Review on 4/15/24 of Staff #1's record revealed: - Hire date 7/20/20. - Job Title Residential Care Specialist. Review on 4/12/24 of the Incident Response mprovement System (IRIS) dated 3/20/24 revealed: - "Date of Incident 3/18/24. - Date last submitted 3/20/24. - Completed by Residential Coach. - Provider learned of incident on 3/19/24. - Incident Comments: The client (client #1) reported that a staff (Staff #1)member pulled the string of his hoodie while in the café at the facility which resulted in a scratch on his neck." Review on 4/12/24 of the facility's Internal Investigation dated 3/20/24 revealed: -"The Complaint Allegations: c Incident: QIS (Quality Improvement Specialist) received word of the allegation of abuse (3/18/24) from staff member [Program Supervisor] and [Residential Coach] via email at 9:35pm on 3/19/24 stating "Good evening [QIS], received a call from my coach, [Residential Coach] informing me that a client (client #1) stated that the mark on his neck is a result of a staff (staff #1) person grabbing his sweatshirt and pulling it tight around his ...

Deficiency cited, annual and complaint survey : V512 27D .0304 Client Rights - Harm, Abuse, Neglect =. V.512 Correction: 2324

Based on record review and interviews 1 of 3 audited direct care staff (staff #1) abused 1 of 1 audit client (client #1). The findings are: Review on 4/15/24 of Client #1's record revealed: - Admission 3/12/24. - Age 15. - Diagnoses: Oppositional Defiant Disorder, Moderate; Unspecified Attention Deficit Hyperactivity Disorder; Unspecified Trauma-and Stressor-Related Disorder; Childhood-Onset Fluency Disorder. Review on 4/15/24 of Staff #1's record revealed: - Hire date 7/20/20. - Job Title Residential Care Specialist. Review on 4/12/24 of the Incident Response Improvement System (IRIS) dated 3/20/24 revealed - "Date of Incident 3/18/24. - Date last submitted 3/20/24 - Completed by Residential Coach. - Provider learned of incident on 3/19/24. - Incident Comments: The client (client #1) reported that a staff (Staff #1)member pulled the string of his hoodie while in the café at the facility which resulted in a scratch on his neck." Review on 4/12/24 of the facility's Internal Investigation dated 3/20/24 revealed: -"The Complaint Allegations: c PROVIDER'S PLAN OF CORRECTION (x5) Incident: QIS (Quality Improvement Specialist) received word of the allegation of abuse (3/18/24) from staff member [Program Supervisor] and [Residential Coach] via email at 9:35pm on 3/19/24 stating "Good evening [QIS], received a call from my coach, [Residential Coach] informing me that a client (client #1) stated that the mark on his neck is a result of a staff (staff #1) person grabbing his ...

Deficiency cited, annual and complaint survey : V 132

Based on interviews and record reviews, the facility failed to notify the Department of all allegations against health care personnel. The findings are: Review on 5-27-22 of Level incident report dated 4-5-22 revealed: -"The following information was gathered the vice president of residential services as well as the youth himself: -Sometime between 3/2-3/7- Conversation with staff [Staff #1] about being fat. This led to staff pulling up her shirt to show her stomach and also pulled her waistband to her pants. This completely shocked [Former Client #1 (FC#1)] and he was a bit confused about what happened.

Deficiency cited, annual and complaint survey : V 366

Based on record reviews and interviews, the facility failed to implement corrective measures for incidents. The findings are: record revealed: -Admitted 10-21-21. -17 years old. -Diagnoses include: Disruptive Mood Dysregulation, Oppositional Defiance Disorder, Borderline Intellectual Functioning, Major Depressive Disorder. -Assessment dated 12-16-21 revealed: "Previously reported paranoid ideation involving into his behavior is limited, judgement is impaired...spends considerable amount of time posturing for peers by speaking in a defiant and brazen manner to staff." Review on 6-6-22 of Staff #1's record revealed: -Hire date of 1-4-22. -Trainings include: Therapeutic Crisis Intervention (TCI) 1-7-22, CARE (Child-Adult Relationship Enhancement) training 1-13-22, 4-5-22 revealed: president of residential services as well as the youth himself: -Sometime between 3/2-3/7- Conversation with Review on 6-11-22 of Former Client #1's (FC#1) people attacking him or talking about him...Insight Client Rights 2-10-22, New Employee Orientation Review on 5-27-22 of Level incident report dated -"The following information was gathered the vice staff [Staff #1] about being fat. This led to staff pulling up her shirt to show her stomach and also pulled her waistband to her pants. This completely shocked [Former Client #1 (FC#1)] and he was a bit confused about what happened. -[FC#1] asked another resident (Former Client #4) if he saw what happened and he stated that he did see the staff ...

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

Based on record reviews and interviews the facility failed to ensure that all Level II incidents were reported to the LME responsible for the catchment area were services are provided within 72 hours of learning of the incident. The findings are: Review on 5-27-22 of Level incident report dated 4-5-22 revealed: -"The following information was gathered the vice president of residential services as well as the youth himself: -Sometime between 3/2-3/7- Conversation with staff [Staff #1] about being fat. This led to staff pulling up her shirt to show her stomach and also pulled her waistband to her pants. This completely shocked [Former Client #1 (FC#1)] and he was a bit confused about what happened. -[FC#1] asked another resident (Former Client #4) if he saw what happened and he stated that he did see the staff flashing [FC#1]. - As reported from the VP (Vice President) of Residential Operations on 4/4/22, this matter has been addressed. Residential called DSS (Department of Social Services) to make a report of the allegation, created an incident report, completed an IRIS (Incident Response Improvement System), separated the accused staff member from [FC#1] and addressed this issue with all staff involved. - ...will complete an Incident report in Echo to document this allegation and document Residential 's report to the state-level IRIS and the DSS report regarding the allegation." Interview on 6-9-22 with the Quality Improvement Specialist revealed: -She thought that an IRIS ...

Deficiency cited, annual and complaint survey : V 132] G.S. 131E-256(G) HCPR-Notification, Vv 132 V132- 7/1/2022

Based on interviews and record reviews, the facility failed to notify the Department of all allegations against health care personnel. The findings are: Review on 5-27-22 of Level incident report dated 4-5-22 revealed: -"The following information was gathered the vice president of residential services as well as the youth himself: -Sometime between 3/2-3/7- Conversation with staff [Staff #1] about being fat. This led to staff pulling up her shirt to show her stomach and also pulled her waistband to her pants. This completely shocked [Former Client #1 (FC#1)] and he was a bit confused about what happened. -[FC#1] asked another resident (Former Client #4) if he saw what happened and he stated that he did see the staff flashing [FC#1]. - Acouple of days after the incident, [FC#1] attempted to gain an understanding about the incident with [Staff #1] and she told him she would know if he's lying if he can describe what her private area looks like. They continued to have a discussion about the visual state of her private area (waxed vs. unwaxed) and [FC#1] stated this ‘threw him back’ and he did not know how to handle the situation. [Staff #1] did state that if she did flash [FC#1], it was by accident. - [FC#1] also shared that other inappropriate comments were made as well. - On Friday, [FC#1] requested to talk to [Supervisor] about this situation. According to [FC#1], [Staff #6] told him that [Supervisor] had his notebook and had taken it from his room. He continued to want to ...

Deficiency cited, annual and complaint survey : V 366

Based on record reviews and interviews, the facility failed to implement corrective measures for incidents. The findings are: record revealed: -Admitted 10-21-21. -17 years old. -Diagnoses include: Disruptive Mood Dysregulation, Oppositional Defiance Disorder, Borderline Intellectual Functioning, Major Depressive Disorder. -Assessment dated 12-16-21 revealed: "Previously reported paranoid ideation involving into his behavior is limited, judgement is impaired...spends considerable amount of time posturing for peers by speaking in a defiant and brazen manner to staff." Review on 6-6-22 of Staff #1's record revealed: -Hire date of 1-4-22. -Trainings include: Therapeutic Crisis Intervention (TCI) 1-7-22, CARE (Child-Adult Relationship Enhancement) training 1-13-22, 4-5-22 revealed: president of residential services as well as the youth himself: -Sometime between 3/2-3/7- Conversation with Review on 6-11-22 of Former Client #1's (FC#1) people attacking him or talking about him...Insight Client Rights 2-10-22, New Employee Orientation Review on 5-27-22 of Level incident report dated -"The following information was gathered the vice staff [Staff #1] about being fat. This led to staff pulling up her shirt to show her stomach and also pulled her waistband to her pants. This completely shocked [Former Client #1 (FC#1)] and he was a bit confused about what happened. -[FC#1] asked another resident (Former Client #4) if he saw what happened and he stated that he did see the staff ...

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

Based on record reviews and interviews the facility failed to ensure that all Level II incidents were reported to the LME responsible for the catchment area were services are provided within 72 hours of learning of the incident. The findings are: Review on 5-27-22 of Level incident report dated 4-5-22 revealed: -"The following information was gathered the vice president of residential services as well as the youth himself: -Sometime between 3/2-3/7- Conversation with staff [Staff #1] about being fat. This led to staff pulling up her shirt to show her stomach and also pulled her waistband to her pants. This completely shocked [Former Client #1 (FC#1)] and he was a bit confused about what happened. -[FC#1] asked another resident (Former Client #4) if he saw what happened and he stated that he did see the staff flashing [FC#1]. - As reported from the VP (Vice President) of Residential Operations on 4/4/22, this matter has been addressed. Residential called DSS (Department of Social Services) to make a report of the allegation, created an incident report, completed an IRIS (Incident Response Improvement System), separated the accused staff member from [FC#1] and addressed this issue with all staff involved. - ...will complete an Incident report in Echo to document this allegation and document Residential 's report to the state-level IRIS and the DSS report regarding the allegation." Interview on 6-9-22 with the Quality Improvement Specialist revealed: -She thought that an IRIS ...