North Spring Behavioral Healthcare Horizons Program

Non-compliance, DBHDS investigation : 12VAC35-105-693. D. The content of the discharge plan and the determination to discharge the individual shall be consistent with the ISP and the criteria for ...

The record review revealed Individual #1 was not discharged in accordance with the provider's discharge criteria and ISP. This was evidenced by Individual #1 not being discharged appropriately to the legal custodian, Entity #2, on 1-16-2025.

Non-compliance, DBHDS death or serious incident inspection : 12VAC35-46-1070. C. The provider shall notify the department within 24 hours of any serious illness or injury, any death of a resident, and all other ...

CHRIS Number: 20250046 Date/Time of Discover: 06/25/2025 9:00AM Enter Date/Time: 07/01/2025 12:41PM Reporting Delay: 123:41:00 Location Name: North Spring Behavioral Health CHRIS Number: 20250047 Date/Time of Discover: 06/25/2025 9:00AM Enter Date/Time: 07/01/2025 1:02PM Reporting Delay: 124:2:00 Location Name: North Spring Behavioral Health

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

"Abuse" means any act or failure to act by an employee or other person responsible for the care of an individual in a facility or program operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, that was performed or was failed to be performed knowingly, recklessly, or intentionally, and that caused or might have caused physical or psychological harm, injury, or death to a person receiving care or treatment for mental illness, intellectual disability, or substance abuse. • Due to a preponderance of evidence, including eyewitness statements, staff admissions, and witness credibility, the provider has substantiated A#20240021. • While attempting to de-escalate a situation, Employee #1 resulted to physically abusing Individual #1. Camera footage showed that Employee #1 slapped Individual #1 on top of their head when they were dysregulated. • The Provider failed to protect Individual #1 from harm.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

-"Neglect" means failure by a person, program, or facility operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, responsible for providing services to do so, including nourishment, treatment, care, goods, or services necessary to the health, safety, or welfare of an individual receiving care or treatment for mental illness, intellectual disability, or substance abuse. -Due to a preponderance of evidence, including eyewitness statements, staff admissions, failure to follow policy, and witness credibility, the provider has substantiated neglect for A#20230188. -Individual #1 accessed and used Employee #1's personal Nicotine Vape. -The provider failed to protect Individual #1 from harm.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

"Neglect" means failure by a person, program, or facility operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, responsible for providing services to do so, including nourishment, treatment, care, goods, or services necessary to the health, safety, or welfare of an individual receiving care or treatment for mental illness, intellectual disability, or substance abuse. - Based on the preponderance of evidence, provider has substantiated neglect for CHRIS #A20230117. - Employee #1 and Employee #2 did not provide sufficient monitoring services to individual #1 to keep Individual #1 safe while receiving services. - The provider failed to adequately treat and protect Individual from harm.

Non-compliance, DBHDS investigation : 12VAC35-46-270. B. (3) A person who assumes or is designated to assume the responsibilities of a position or any combination of positions described in these ...

Employee #1 did not demonstrate a working knowledge of the program provider’s policy titled “Patient Access Areas Policy #999a”, which stated, “Items not allowed” on the service units that included. “Medications – staff medications are not allowed in patient access areas and must remain in staff cars outside of the building”. However, Employee #1 brought their personal belongs, including Medication #1, Medication #2 and Medication #3 on the service unit where the individuals receiving services could have access to the employee’s personal belongings. Also, it was reported by Entity #5 that the video footage on August 27, 2022 also included Employee #1 taking their medication in front of Individual #1. Employee #1, did not demonstrate a working knowledge of the provider’s policy #907 tilted, ”Cellular Phones and Other Electronic Devices”, which prohibited the use of cellular phones, cameras, laptops, personal organizers, beepers, music players and all other electronic devices. Video footage revealed between 3:00pm and 5:00pm on August 27, 2022, that Employee #1 was using their cellular phone on the service unit. Video footage also revealed that Employee #1 also handed their cellular device to Individual #1 for use.

Non-compliance, DBHDS investigation : 12VAC35-46-300. B. (9) The records of each employee shall include: 9. Documentation of all training required by these regulations and any other training ...

The personnel records for Employee #1, Employee #5 and Employee #6 did not contain documentation of training on the PowerPoint titled, “Facility Safety Training”. The PowerPoint included unit hazards such as blind spots near the bedroom doors and around the corners where residents could be out of “line of sight” due to the lack of coverage by the video camera system. The PowerPoint also provided instruction for the employees to continuously monitor and complete rounds whenever individuals are in their bedrooms and bathrooms.

Non-compliance, DBHDS investigation : 12VAC35-46-60. K. Providers shall not engage in willful action or gross negligence that jeopardizes the care or protection of residents.

Video evidence footage on August 27, 2022 indicated that Employee #1 did not properly secure their personal belongings that contained Medication #1, Medication #2 and Medication #3 offsite of the service unit per policy #999a titled, “Patient Access Areas”. Individual #1 was able to obtain large quantities of each medication from Employee #1’s personal belongings, and later ingest these medications while on the unit, which resulted in the individual being hospitalized and whom later died. In addition, video footage indicated Employee #1, Employee #5 and Employee #6 did not consistently provide supervision (direct observation or routine room checks) of individuals receiving services on the service unit per their Orientation Safety Training PowerPoint, from 3:00pm – 5:00pm on August 27, 2022. During this period while, unsupervised, Individual #1 had the opportunity to obtain and ingest Medication #1, Medication #2 and Medication #3 that belonged to Employee #1.

Non-compliance, DBHDS investigation : 12VAC35-46-70. Each provider shall guarantee resident rights as outlined in § 37.2-400 of the Code of Virginia and in the Rules and Regulations to Assure the ...

Please see Office of Human Rights citations below.

Non-compliance, DBHDS investigation : 12VAC35-46-800. A. (2) There shall be evidence of a structured program of care designed to: 2. Provide protection, guidance, and supervision;

The program provider failed to provide a structured program of care that provided protection, guidance and supervision. Video footage presented that Employee #1, Employee #5 and Employee #6 failed to protect and supervise Individual #1 by monitoring and completing rounds when Individual #1 was in their bedroom or out of line of sight. Therefore, Individual #1 had an opportunity to ingest Employee #1’s medications, which resulted in the individual being hospitalized, and whom later died. Employee #1, Employee #5 and Employee #6 failed to conduct an environmental check to ensure the unit was safe and free from potential hazards per the provider’s policy #260 titled, “Supervision of Patients (inpatient)”. Policy #260 also instructed staff to position themselves around the perimeters of the patient group during the dayroom activity, providing careful attention to the individuals. The policy also stated, “Carefully structure and supervise patient activity to assure safety. Video footage from 3:00pm to 5:00pm on August 27, 2022 revealed that Employee #1, Employee #5 and Employee #6 were sitting at a desk during that time period, rather than positioning themselves around the perimeters of the group dayroom activity area. A review of Individual #1’s record revealed the individual had a history of physical aggression, self-injurious behaviors, and ingesting non-prescribed medications and non-edible items such as metal screws. The individual’s updated treatment plan (dated 9/2/2022) ...

Non-compliance, DBHDS investigation : 12VAC35-46-870. D. There shall be at least one trained child care worker on duty and actively supervising residents at all times that one or more residents are ...

From approximately 3:00pm - 5:00pm on August 27, 2022, video footage evidence revealed that Employee #1, Employee #5 and Employee #6 sat at one desk while allowing individuals receiving services to travel unsupervised throughout the service unit in the bedrooms and bathroom areas. During this same period of video footage, Individual #1 was not directly supervised, allowing an opportunity to take medications from Employee #1’s personal belongings, and ingest the medications without the staff knowledge which resulted in the individual being hospitalized and placed on life support. Per the provider’s Facility and Safety PowerPoint Training, employees are to continuously monitor and complete rounds whenever individuals are in their bedrooms and bathrooms. In addition, policy #260 titled “Supervision of Patients (inpatient) also indicated that staff would be positioned around the perimeter of the patient group during the dayroom activity, providing careful attention to the individuals. However, evidence presented that Employee #1, Employee #5 and Employee #6 neglected to complete rounds as instructed in their policy and did not actively supervise the individuals.

Non-compliance, DBHDS investigation : 12VAC35-115-260. B. (2c) - Providers shall require their employees to: 2. Protect individuals from any form of abuse, neglect, or exploitation by: 2c. Not ...

"Neglect" means failure by a person, program, or facility operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, responsible for providing services to do so, including nourishment, treatment, care, goods, or services necessary to the health, safety, or welfare of an individual receiving care or treatment for mental illness, intellectual disability, or substance abuse. See § 37.2-100 of the Code of Virginia. • By a preponderance of the evidence, which included camera footage review, documentation review, and failure to follow internal policy and procedure, the provider failed to ensure a safe environment for Individual #1. As a result, Individual #1's right to be free from neglect was violated. • Provider camera footage revealed Individual #1 was able to gain access to Employee #1's personal bag and remove Employee #1's prescription medications and ingest them. Individual #1 swallowed approximately a total of 120 pills, 88 pills of Medication #1, 20 pills of Medication #2 and 20 pills of Medication #3. • Provider camera footage revealed Employee #1 bringing their personal bag onto the residential unit and keeping it with them while interacting with Individual #1. Employee #1 is seen putting the bag onto the floor next to Employee #1's chair where Individual #1 is later seen sitting down next to the bag and reaching into it to retrieve the medications.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

Neglect means failure by a person, program, or facility operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, responsible for providing services to do so, including nourishment, treatment, care, goods, or services necessary to the health, safety, or welfare of an individual receiving care or treatment for mental illness, intellectual disability, or substance abuse. See § 37.2-100 of the Code of Virginia. • By a preponderance of the evidence, which included camera footage review, eyewitness statements, staff admissions, witness credibility, and failure to follow policy and procedure, the provider substantiated the allegation of neglect. • Per provider's CHRIS report #A20230050, Individual #1 was sitting at a fold up table during mealtime and would not respond to Employee #1's verbal requests to stand up; therefore in an effort to get Individual #1 to stand up, Employee #1 folded up the table while Individual #1 was sitting at it and in doing so, the table legs caught Individual #1's feet which caused Individual #1 to fall to the floor. • As a result of Employee #1's inappropriate actions, Individual #1's right to a safe environment was violated.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

Abuse means any act or failure to act by an employee or other person responsible for the care of an individual in a facility or program operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, that was performed or was failed to be performed knowingly, recklessly, or intentionally, and that caused or might have caused physical or psychological harm, injury, or death to a person receiving care or treatment for mental illness, intellectual disability, or substance abuse. Examples of abuse include acts such as: …Use of physical or mechanical restraints on a person that is not in compliance with federal and state laws, regulations, and policies; professionally accepted standards of practice; or the person's individualized services plan. • By a preponderance of the evidence, which included camera footage review, eyewitness statements, staff admissions, and witness credibility, the provider substantiated the allegation of abuse. • Per provider's CHRIS report #A20230013, it was reported that Employee #1 used an inappropriate physical restraint on Individual #1 during a physical peer on peer aggression incident. • As a result of Employee #1's inappropriate actions, Individual #1's right to be free from abuse was violated.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

Neglect means failure by a person, program, or facility operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, responsible for providing services to do so, including nourishment, treatment, care, goods, or services necessary to the health, safety, or welfare of an individual receiving care or treatment for mental illness, intellectual disability, or substance abuse. See § 37.2-100 of the Code of Virginia. • By a preponderance of the evidence, which included camera footage review, eyewitness statements, staff admissions, failure to follow policy and procedure and witness credibility, the provider substantiated the allegation of neglect. • Per provider's CHRIS report #A20220255, #A20220256, and #A20220257, it was reported that Individuals #1, #2 and #3 were able to be alone together at various times in one of the individual's bedrooms during their bedtime routine. • Per provider's CHRIS report #A20220255, #A20220256, and #A20220257, Individuals #1, #2 and #3 were able to at various times distract and block staff's line of sight of what was occurring on the unit, which allowed Individuals #1, #2 and #3 to be in one of the bedrooms together unsupervised. • Employees #1 and #2 also did not complete rounds as required and were observed using their personal cell phones, which added to the distraction caused by Individuals #1, #2 and #3. • In addition, Employees #1 and #2 failed to document Individuals' behavior and report to ...

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

Neglect means failure by a person, program, or facility operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, responsible for providing services to do so, including nourishment, treatment, care, goods, or services necessary to the health, safety, or welfare of an individual receiving care or treatment for mental illness, intellectual disability, or substance abuse. See § 37.2-100 of the Code of Virginia. • By a preponderance of the evidence, which included camera footage review, eyewitness statements, failure to follow policy and procedure and witness credibility, the provider substantiated the allegation of neglect. • Per provider's CHRIS report #A20220235 and #A20220236, it was reported that Individual #1 and Individual #2 engaged in sexual activity in Individual #2's bedroom during hygiene time. • Per provider's CHRIS report #A20220235 and A#20220236, Employee #1 and Employee #2 did not follow provider's internal policy and procedure regarding appropriate supervision levels when one of the employees left the unit, which resulted in inadequate supervision, allowing Individual #1 and Individual #2 to be alone in Individual #2's bedroom. • Provider failed to protect Individual#1 and Individual#2 from potential harm.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

Neglect means failure by a person, program, or facility operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, responsible for providing services to do so, including nourishment, treatment, care, goods, or services necessary to the health, safety, or welfare of an individual receiving care or treatment for mental illness, intellectual disability, or substance abuse. See § 37.2-100 of the Code of Virginia. • By a preponderance of the evidence, which included camera footage, eyewitness statements, staff admissions, failure to follow behavior/mgmt. plan and witness credibility, the provider substantiated the allegation of neglect in CHRIS report #A20220175. • Per provider CHRIS report #A20220175, Individual #1 was able to gain access to another individual's medications while Individual #1 was receiving first aid treatment for a minor self-inflicted wound. Individual #1 ingested the medications they grabbed after jumping over the Dutch door to the nurse's station. • Per provider's CHRIS report #A20220175, Individual #1's treatment plan was updated after a previous similar incident to include an alternative, private location for their medication administration, minor medical care and other nursing related duties. • Per provider's CHRIS report #A20220175, Employee #1 failed to adhere to the updated treatment plan and brought Individual #1 to the nurse's station for first aid care after which, Individual #1 was able to grab ...

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

"Neglect" means failure by a person, program, or facility operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, responsible for providing services to do so, including nourishment, treatment, care, goods, or services necessary to the health, safety, or welfare of an individual receiving care or treatment for mental illness, intellectual disability, or substance abuse. See § 37.2-100 of the Code of Virginia. • By a preponderance of the evidence, which included camera footage, record reviews, and discussions with staff, the provider substantiated the allegation of neglect in CHRIS report #A20220142. • Per provider CHRIS report #A20220142, Employee #1 administered another Individual's medications (Medication #1) to Individual #1 and failed to notify the appropriate parties regarding the error, including the oncoming RN, the guardian and physician. • Per provider's CHRIS report #A20220142, the oncoming RN completed a follow up assessment with Individual #1 and made the appropriate notifications. • As a result of Employee #1's actions, Individual #1's right to be free from abuse and neglect was violated.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

Neglect means failure by a person, program, or facility operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, responsible for providing services to do so, including nourishment, treatment, care, goods, or services necessary to the health, safety, or welfare of an individual receiving care or treatment for mental illness, intellectual disability, or substance abuse. See § 37.2-100 of the Code of Virginia. • By a preponderance of the evidence, which included camera footage, record reviews, and discussions with staff, the provider substantiated the allegation of neglect in CHRIS report #A20220066. • Per provider CHRIS report #A20220066, Individual #1 has Allergy #1. Individual #1 chose not to eat what they had originally indicated for their meal and requested from Employee #1 an alternative option within their dietary guidelines. Employee #1 then gave Individual #1 what Employee #1 thought was the alternative item. • Per provider's report to advocate and CHRIS report 20220066, the alternative trays and menu items were labeled per internal protocol, however Employee #1 chose the wrong item that had Allergen #1 in it and gave it to Individual #1. Individual #1 then had an allergic reaction, was administered an EpiPen and Benadryl and was sent to the ER for follow up. • As a result of Employee #1's actions, Individual #1 had an allergic reaction and required emergency services, resulting from negligence on the part of the staff

Non-compliance, systemic, DBHDS death or serious incident inspection : 12VAC35-46-1070. C. The provider shall notify the department within 24 hours of any serious illness or injury, any death of a resident, and all other ...

North Spring Behavioral Health This regulation was NOT MET (SYSTEMIC) as evidenced by: CHRIS Number: 20220293 Date/Time of Discover: 04/30/2022 6:45PM Enter Date/Time: 05/01/2022 8:03PM Reporting Delay: 1:18:00 Location Name: North Spring Behavioral Health Note: As this is provider's second step in the Progressive Citation Cycle for the same regulation within a one-year period, measured on a rolling basis, provider has demonstrated systemic noncompliance. Provider was previously cited for late reporting • The first citation was issued on 7/9/21 and is now a non- compliant.