Fresh Start for Children

Deficiency cited, annual survey : V 296

Based on observations, record reviews and interviews, the facility failed to ensure two direct care staff were present, the minimum number required, when clients were present and awake in the facility, for 3 of 3 clients (#1, #2 and #3). The findings are: Observations on 7/22/24 from 9:17am to 10:25am of the facility revealed: -The Associate Professional (AP) was alone on first shift with clients #1, #2 and #3 present. -At 10:25am, the Qualified Professional (QP) arrived at the facility. Review on 7/22/24 of client #1's record revealed: -An admission date of 12/28/23 -Diagnoses of Conduct Disorder, Disruptive Mood Dysregulation Disorder, Attention Deficit Hyperactivity Disorder (ADHD), Combined Type, and Other Specified Anxiety Disorder -Age 16 -An assessment dated 12/4/23 noted "stated her daily life is a work in process considering she's trying to learn how to follow and not be disrespectful, stated that she never had to question her safety due to the environment she's in and people around her, stated that she has a great social life and that she loves socializing with people, stated that in the community settings she wants to follow expectations and rules accordingly, stated that she's food at advocating for herself, but sometimes advocating for herself comes off as rude, needs to comply with rules and expectations in the home and the school, develop appropriate ways of expressing feels and emotions and will refrain from using substances, and given her persistent ...

Deficiency cited, complaint survey : V 296] 27G .1704 Residential Tx. Child/Adol - Min.

Based on interview and record review, the facility staff failed to ensure two direct care staff were present, the minimum number required, when clients were present and awake in the facility, for three (client #1, client #2 and client #3) of three clients. The findings are: Review on 10-9-20 and 10-13-20 of client #1's facility record revealed: - admitted 6-2-20 - 15 years old - diagnosed with: - Post Traumatic Stress Disorder - Oppositional Defiant Disorder - Assessed on 5-14-20: Cc - multiple incidences of assaulting staff and peers - easily distracted - intrudes - makes threats of harm - destroys property - History of AWOL (absent without leave), stealing, lying and oppositional Review on 10-9-20 and 10-13-20 of client #2's facility record revealed: - admitted - 15 years old - diagnosed with - Bipolar Disorder - Attention-Deficit Hyperactivity Disorder Combined Type - Generalized Anxiety Disorder - assessed 4-27-20: - history of multiple psychiatric placements - endorses feelings of anxiousness and depressed mood - impulsivity - physically aggressive and destructive Review on 10-9-20 and 10-13-20 of client #3's facility record revealed: - admitted 8-12-20 - 16 years old - diagnosed with: - Oppositional Defiant Disorder - Mood Disorder - Attention-Deficit Hyperactivity Disorder - Parent-Child Relational Disorder - assessed 7-15-20: - lying - oppositional - unruly and hyperactive - sexually inappropriate behaviors Cc - AWOL (absent without (permission to) leave) - ...

Deficiency cited, complaint survey : V 296] 27G .1704 Residential Tx. Child/Adol - Min.

Based on interview and record review, the facility staff failed to ensure two direct care staff were present, the minimum number required, when clients were present and awake in the facility, for three (client #1, client #2 and client #3) of three clients. The findings are: Review on 10-9-20 and 10-13-20 of client #1's facility record revealed: - admitted 6-2-20 - 15 years old - diagnosed with: - Post Traumatic Stress Disorder - Oppositional Defiant Disorder - Assessed on 5-14-20: Cc - multiple incidences of assaulting staff and peers - easily distracted - intrudes - makes threats of harm - destroys property - History of AWOL (absent without leave), stealing, lying and oppositional Review on 10-9-20 and 10-13-20 of client #2's facility record revealed: - admitted - 15 years old - diagnosed with - Bipolar Disorder - Attention-Deficit Hyperactivity Disorder Combined Type - Generalized Anxiety Disorder - assessed 4-27-20: - history of multiple psychiatric placements - endorses feelings of anxiousness and depressed mood - impulsivity - physically aggressive and destructive Review on 10-9-20 and 10-13-20 of client #3's facility record revealed: - admitted 8-12-20 - 16 years old - diagnosed with: - Oppositional Defiant Disorder - Mood Disorder - Attention-Deficit Hyperactivity Disorder - Parent-Child Relational Disorder - assessed 7-15-20: - lying - oppositional - unruly and hyperactive - sexually inappropriate behaviors Cc - AWOL (absent without (permission to) leave) - ...

Deficiency cited, complaint survey : V 296

Based on interview and record review, the facility staff failed to ensure two direct care staff were present, the minimum number required, when clients were present and awake in the facility, for three (client #1, client #2 and client #3) of three clients. The findings are: Review on 10-9-20 and 10-13-20 of client #1's facility record revealed: - admitted 6-2-20 - 15 years old - diagnosed with: - Post Traumatic Stress Disorder - Oppositional Defiant Disorder - Assessed on 5-14-20: Cc - multiple incidences of assaulting staff and peers - easily distracted - intrudes - makes threats of harm - destroys property - History of AWOL (absent without leave), stealing, lying and oppositional Review on 10-9-20 and 10-13-20 of client #2's facility record revealed: - admitted - 15 years old - diagnosed with - Bipolar Disorder - Attention-Deficit Hyperactivity Disorder Combined Type - Generalized Anxiety Disorder - assessed 4-27-20: - history of multiple psychiatric placements - endorses feelings of anxiousness and depressed mood - impulsivity - physically aggressive and destructive Review on 10-9-20 and 10-13-20 of client #3''s facility record revealed: - admitted 8-12-20 - 16 years old - diagnosed with: - Oppositional Defiant Disorder - Mood Disorder - Attention-Deficit Hyperactivity Disorder - Parent-Child Relational Disorder - assessed 7-15-20: - lying - oppositional - unruly and hyperactive - sexually inappropriate behaviors Cc - AWOL (absent without (permission to) leave) - ...

Deficiency cited, complaint and follow-up survey, Type A1 violation : V 296 anything management staff will be asked to put

Based on record reviews and interviews, the received a copy of the memo. Staff will have a facility failed to have two direct care staff present copy of the review so that it can be reviewed at while the clients were awake or asleep for one, any time. two, three or four clients affecting 1 of 3 current clients (#3) and 3 of 5 former clients (FC #4, FC #5 and FC #7). The findings are: Review on 11/13/19 of client #3's record revealed: - Admission Date: 7/24/19 - Diagnoses: Oppositional Defiant Disorder (D/O); Cannabis Dependence, uncomplicated - Age: 15 years-old - Review of client #3's goals in the Person-Centered Profile (PCP) updated 9/19/19 revealed: -" ..will receive Residential Level Ill services and supports and learn how to verbalize feelings of frustrations, disagreement, and anger in a controlled assertive and positive manner." -" ...will learn and develop positive coping skills -" ...will demonstrate improved ability to show respect to authority figures and peers..." - Review of page 2 of client #3's PCP revealed: - "An assessment was completed on 6/12/19 due to the client needed a higher level of care ...During that time there was an increase in inappropriate behaviors that included that skipping classes, refusing to go to school, running away, suspension from school, suspicion of stealing from her peers, suspected substance use..." - Review of client #3's Support/Interventionon page 4 of the PCP revealed: - "Client can be transported one on one by staff to ...

Deficiency cited, complaint and follow-up survey : V 293] 27G .1701 Residential Tx. Child/Adol - Scope

Based on record reviews and interviews, the facility failed to 1) ensure continuous and individualized supervision, 2) minimize the occurrence of behaviors and 3) ensure safety and deescalate out of control behaviors affecting 1 of 3 current clients (#3) and 3 of 5 former clients (FC #4, #5 and #7). The findings are: Cross reference: 10A NCAC 27G .0203 Competencies of Qualified Professionals and Associate Professionals (V109). Based on record reviews and interviews 1 of 2 qualified professionals (Licensee/Qualified Professional/Executive Director (L/QP/ED)) failed to demonstrate the knowledge skills and abilities required by the population served. Cross reference: 10A NCAC 27G .0204 Competencies and Supervision of Paraprofessionals (V110). Based on record reviews and interviews, 1 of 6 current paraprofessional staff (staff #4) failed to demonstrate the knowledge skills and abilities required by the population served. Cross reference: 10A NCAC 27G .0205 Assessment and Treatment/Habilitation or Service Plan (V112). Based on record reviews and interviews, the facility staff failed to implement strategies in the treatment/habilitation plans to address 1 of 3 current clients (#3) and 3 of 5 former clients' needs (FC #4, FC #5 and FC Cross reference: 10A NCAC 27G .1704 Minimum Staffing Requirements (V296). Based on record reviews and interviews, the facility failed to have two direct care staff present while the clients were awake or asleep for one, two, three or four clients ...

Deficiency cited, complaint and follow-up survey, Type A1 violation : V 296

Based on record reviews and interviews, the facility failed to have two direct care staff present while the clients were awake or asleep for one, two, three or four clients affecting 1 of 3 current clients (#3) and 3 of 5 former clients (FC #4, FC #5 and FC #7). The findings are: Review on 11/13/19 of client #3's record revealed: - Admission Date: 7/24/19 - Diagnoses: Oppositional Defiant Disorder (D/O); Cannabis Dependence, uncomplicated - Age: 15 years-old - Review of client #3's goals in the Person-Centered Profile (PCP) updated 9/19/19 revealed: -" ...will receive Residential Level III services and supports and learn how to verbalize feelings of frustrations, disagreement, and anger ina controlled assertive and positive manner." -"...will learn and develop positive coping skills -" ...will demonstrate improved ability to show respect to authority figures and peers ..." - Review of page 2 of client #3's PCP revealed: - "An assessment was completed on 6/12/19 due to the client needed a higher level of care ...During that time there was an increase in inappropriate behaviors that included that skipping classes, refusing to go to school, running away, suspension from school, suspicion of stealing from her peers, suspected substance use..." - Review of client #3's Support/Intervention on page 4 of the PCP revealed: - "Client can be transported one on one by staff to community outings, medical appointment and school events." - here were no treatment goals or strategies that ...

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

Based on interviews, the facility failed to report allegations against health care personnel to the Health Care Personnel Registry. The findings are: Interview on 8/22/19 with the Licensee revealed: - She had been told by client #2 that staff #3 punched her in the face. - "On that Monday (8/5/19) she (client #2) said that [staff #3] punched her in the face and said how did she punch you in the face? And said don't see any marks." - After being told that a staff member allegedly punched a client, she failed to notify the Health Care Personnel Registry (HCPR) about the abuse allegations of client #2.

Deficiency cited, complaint survey : V 367

Based on interview and record review, the facility failed to report all Level II incidents that occurred during the provision of billable services to the LME (Local Management Entity) within 72 hours of becoming aware of the incident. The findings are: Interview on 8/22/19 with the Licensee revealed: - She had been told by client #2 that staff #3 punched her in the face. - "On that Monday (8/5/19) she (client #2) said that [staff #3] punched her in the face and said how did she punch you in the face? And said don't see any marks." - After being told that a staff member allegedly punched a client, she completed an incident report but did not ensure that the allegations against staff were put into the Incident Response Improvement System (IRIS). - An internal investigation of the staff member who allegedly punched a client was not completed. Review on 8/21/19 of IRIS revealed: - An incident report was submitted on 8/5/19 by the group home. - "Client became upset with staff because she didn't want to go on a outing with her one on one worker. One on one worker had already planned an activity for [client #2] but she did not want to attend unless the other clients were going with her. Client then went to her room and threw her personal belonging at staff and became verbally aggressive. Client then ran outside and started throwing rocks at staff. Once staff managed to talk her down she came back inside the facility. Staff offered client to use her coping skills but Cc Cc client ...

Deficiency cited, annual survey : V 367

Based on record reviews and interviews the facility failed to ensure Level II incidents were reported to the Local Management Entity/Managed Care Organization (LME/MCO) within 72 hours of becoming aware of the incident affecting 1 of 3 clients (#1). The findings are: Review on 6-18-19 of incident reports from 3-1-19 to 6-18-19 revealed: -A level incident report was completed 6-3-19; -Client #1 cut her ankle while getting into the facility van on 6-2-19; -The client was transported to a local hospital and diagnosed with an external laceration which required sutures. Interviews on 6-18-19 and 6-19-19 with the Qualified Professional (QP) revealed: -She was responsible for determining the level for incidents; -"We have a guide that we go by to determine the level;" -She thought since the incident wasn't related to a behavior , she didn't have to report it to the Review on 6-18-19 of the guide the QP used to determine the level of incidents revealed: -Resident injuries that required first aid only were level incidents; -Resident injuries that required treatment by a licensed health professional beyond first aid were level Il incidents.

Deficiency cited, annual survey : V 367

Based on record reviews and interviews the facility failed to ensure Level II incidents were reported to the Local Management Entity/Managed Care Organization (LME/MCO) within 72 hours of becoming aware of the incident affecting 1 of 3 clients (#1). The findings are: Review on 6-18-19 of incident reports from 3-1-19 to 6-18-19 revealed: -A level incident report was completed 6-3-19; -Client #1 cut her ankle while getting into the facility van on 6-2-19; -The client was transported to a local hospital and diagnosed with an external laceration which required sutures. Interviews on 6-18-19 and 6-19-19 with the Qualified Professional (QP) revealed: -She was responsible for determining the level for incidents; -"We have a guide that we go by to determine the level;" Incident report was placed in iris systery on the same date of survey. Incident was placed into iris. QP and AP watched Online refresher on incident reporting to detect appropriate incident levels. Incident level pamphlet is in the facility to be able to refer to ensure that the appropriate incident level is reported -She thought since the incident wasn't related to a behavior , she didn't have to report it to the Review on 6-18-19 of the guide the QP used to determine the level of incidents revealed: -Resident injuries that required first aid only were level incidents; -Resident injuries that required treatment by a licensed health professional beyond first aid were level Il incidents.

Deficiency cited, complaint and follow-up survey : V 295 27G .1703 Residential Tx. Child/Adol - Reg. for A

Based on record reviews and interviews, the facility failed to have at least one full-time direct care staff who met the requirements of the Associate Professional (AP), and performed the duties required by the AP's position related to responsibilities to implement the day to day operations of the facility and provide supervision to paraprofessionals and participation in service planning affecting 1 of 1 AP (the Program Manager/Owner/Associate Professional (PM/O/AP). The findings are: Review on 4/20/18 of the Program Manager/Owner/Associate Professional's (PM/O/AP) employee record revealed: -A hire date of 10/15/05 -Multiple job descriptions were present for various positions including: -For the position of Executive Director, signed by the PM/O/AP on 6/18/05, noted “Job Summary: This position develops, directs and leads the organization's mission and goals. Develop and implement strategic and business plans and facilitates the implementation of the programs and activities to ensure the success of the organization. Manage and supervise division managers, coordinate their cohesive managerial efforts and ensures they have the recourses to execute the establish plans to attain the individual department objectives towards the organization's goals. Research, develop and ascertains necessary funding to maintain operations and programs.” -For an unspecified position, signed by the PM/O/AP on 12/19/07, noting, "Reports to: QP (Qualified Professional). Purpose: to provide one-on-one ...

Deficiency cited, complaint and follow-up survey : V512

Based on record reviews and interviews, 1 of 8 current staff (#2) and 1 of 1 Former Staff (FS) (FS #9) neglected and failed to protect 2 of 3 current clients #1 & #2) and 1 of 3 Former Clients (FC) (FC #4) from harm, abuse and exploitation. The findings are: (Note: Facility documents used various titles for the Program Director/Qualified Professional (PD/QP), the Program Manager/Owner/Associate Professional (PM/O/AP) and the Licensed Professional (LP). Clarification of position titles will be noted where relevant). Review on 4/20/18 of staff #2's employee record revealed: -Ahire date of 9/25/14 -Ajob description of Paraprofessional -Abuse/Neglect/Exploitation training on 10/4/13 Review on 4/20/18 of FS #9's employee record revealed: A hire date of 4/15/14 -A job description of Paraprofessional -A termination date of 4/2/18 -Abuse/Neglect/Exploitation training on 5/1/14 Vv 512 Licensed Professional 2x per month to address administrative needs, corrective action needs, and individual review of policy and procedures, roles and responsibilities as it relates to overall job performance and adhering to DHSR and Medicaid standards. * Facility has had the consumers assessed for safety fo determine any underlying or existing issues. Facility has taken the liberty to review incident reporting procedures with all staff members. * Facility has increased communication surrounding reporting of whereabouts of staff and clients when in the community setting. * Outings will be scheduled in ...

Deficiency cited, complaint and follow-up survey : V 293

Based on record reviews and interviews, the facility failed to have at least one full-time direct care staff who met the requirements of the Associate Professional (AP), and performed the duties required by the AP's position related to responsibilities to implement the day to day operations of the facility and provide supervision fo paraprofessicnals and participation in service planning affecting 1 of 1 AP (the Program Manager/Owner/Associate Professional (PW/O/AP). The findings are: Review on 4/20/18 of the Program Manager/Owner/Associate Professional's (PM/O/AP) employee record revealed: -A hire date of 10/15/05 -Multiple job descriptions were present for various positions including: i -For the position of Executive Director, signed by the PM/O/AP on 6/18/05, noted "Job Summary: This position develops, directs and leads the organization's mission and goals. Develop and implement strategic and business plans and facilitates the implementation of the programs and activities to ensure the success of the otganization. Manage and supervise division managers, coordinate their cohesive managerial efforts and ensures they have the recourses to execute the establish plans to attain the individual department objectives towards the organization's goals. Research, develop and ascertains necessary funding to maintain operations and programs." -For an unspecified position, signed by the PMI/O/AP on 12/19/07, noting, “Reports to: QP (Qualified Professional). Purpose: to provide ...

Deficiency cited, complaint and follow-up survey, Type A1 violation : V512

Based on record reviews and interviews, 1 of 8 current staff (#2) and 1 of 1 Former Staff (FS) (FS #9) neglected and faited to protect 2 of 3 current clients G1 & #2) and 1 of 3 Former Clients (FC) (FC #4) from harm, abuse and exploitation. The findings are: {Note: Facility documents used various titles for the Program Director/Qualified Professional (PD/QP), the Program Manager/Owner/Associate Professional (PM/O/AP) and the Licensed Professional (LP). Clarification of position titles will be noted where relevant). Review on 4/20/18 of staff #2's employee record revealed: -Ahire date of 9/25/14 -A job description of Paraprofessional -Abuse/Neglect/Exploitation training on 10/4/13 Review on 4/20/18 of FS #9's employee record revealed: -A hire date of 4/15/14 ~Ajob description of Paraprofessional ~A termination date of 4/2/18 ~Abuse/Neglect/Expioitation training on 5/1/14 iD Licensed Professional 2x per month fo address administrative needs, corrective action treeds, end individual review of policy and procedures, roles and responsibilities as it relates to overall job performance and adhering to DHSR and Medicaid standards. « Facility has had the consumers assessed for safety to determine any undertying or existing Issues, Facility has taken the ilberty to review Incident reporting procedures with ali statT members. « Factlity has increased communication surrounding reporting of whereabouts of stalf and cfients when in the community setting. + Outings will be scheduled in ...