state: NC

facility_name: Better Connections Midland Ct.

summary: Plan of Correction - MHLCS Annual and Follow-up

raw_content:
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

MHL074-195

BETTER CONNECTIONS MIDLAND CT

A. BUILDING:

B. WING

STREET ADDRESS, CITY, STATE, ZIP CODE
3309 MIDLAND COURT
GREENVILLE, NC 27833

(X2) MULTIPLE CONSTRUCTION

PRINTED: 12/02/2021
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
11/19/2021

(X4) ID
PREFIX
TAG

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

ID
PREFIX
TAG

PROVIDER'S PLAN OF CORRECTION (x5)
(EACH CORRECTIVE ACTION SHOULD BE COMPLETE

CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

V 000

INITIAL COMMENTS

A limited follow up survey for the Type A1 rule
violation was completed on November 19, 2021.
This was a limited follow up survey, only 10A
NCAC 27G .5601 Scope (V289) Type A1 and
cross referenced deficiencies 10A NCAC 27G
.0202 Personnel Requirements (V108); 10A
NCAC 27G .0205 Assessment and
Treatment/Habilitation Plan (V112); 10A NCAC
27G .208 Medication Requirements (V118); 10A
NCAC 27G .5603 Operations (V291) were
reviewed for compliance. The following were
brought back into compliance: 10A NCAC 27G
.5601 Scope (V289) Type A1 and cross
referenced deficiencies 10A NCAC 27G .0202
Personnel Requirements (V108); 10A NCAC 27G
.0205 Assessment and Treatment/Habilitation
Plan (V112); 10A NCAC 27G .208 Medication
Requirements (V118); 10A NCAC 27G .5603
Operations (V291). No Deficiencies were cited.

This facility is licensed for the following service
category: 10A NCAC 27G .5600F Supervised
Living for Alternative Family Living.

Division of Health Service Regulation
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

STATE FORM

V 000

6899

XQB911

TITLE (X6) DATE

If continuation sheet 1 of 1

inspection_type: MHLCS Annual and Follow-up

document_type: Plan of Correction


summary: Statement of Deficiency - MHLCS Annual and Follow-up

raw_content:
PRINTED: 09/16/2021
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
R
MHL074-195 B. WING _____ 09/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

3309 MIDLAND COURT

BETTER CONNECTIONS MIDLAND CT GREENVILLE, NC 27833

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)
V 000} INITIAL COMMENTS V 000

An annual and follow up survey was completed
on September 2, 2021. Deficiencies were cited.

This facility is licensed for the following service
category: 10A NCAC 27G .5600F Supervised
Living for Alternative Family Living.

V 108] 27G .0202 (F-I) Personnel Requirements V 108

10A NCAC 27G .0202 PERSONNEL
REQUIREMENTS

(f) Continuing education shall be documented.
(g) Employee training programs shall be
provided and, at a minimum, shall consist of the
following:

(1) general organizational orientation;

(2) training on client rights and confidentiality as
delineated in 10A NCAC 27C, 27D, 27E, 27F and
10A NCAC 26B;

(3) training to meet the mh/dd/sa needs of the
client as specified in the treatment/habilitation
plan; and

(4) training in infectious diseases and
bloodborne pathogens.

(h) Except as permitted under 10a NCAC 27G
.5602(b) of this Subchapter, at least one staff
member shall be available in the facility at all
times when a client is present. That staff
member shall be trained in basic first aid
including seizure management, currently trained
to provide cardiopulmonary resuscitation and
trained in the Heimlich maneuver or other first aid
techniques such as those provided by Red Cross,
the American Heart Association or their
equivalence for relieving airway obstruction.

(i) The governing body shall develop and
implement policies and procedures for identifying,
reporting, investigating and controlling infectious
and communicable diseases of personnel and

Division of Health Service Regulation
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

STATE FORM 6899 SBIZ11 If continuation sheet 1 of 27

PRINTED: 09/16/2021
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
R
MHL074-195 B. WING _____ 09/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

3309 MIDLAND COURT

BETTER CONNECTIONS MIDLAND CT GREENVILLE, NC 27833

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 108] Continued From page 1 V 108
clients.

This Rule is not met as evidenced by:

Based on record review and interview the facility
failed to ensure 1 of 3 audited staff (#2) received
diabetic training to meet the needs of a client.
The findings are:

Review on 8/24/21, 9/01/21 and 9/02/21 of client
#1's record revealed:

- 42 year-old male admitted 1/01/20.

- Diagnoses included: Type 1 Diabetes Mellitus
with Hyperglycemia, Intellectual/Developmental
Disability, moderate, Paranoid Schizophrenia,
Chronic Kidney Disease, stage 3, Essential
Hypertension, Hyperlipidemia, and Myalgia.

- Physician's orders signed 6/15/21 for Humalog
100 units/milliliters (u/ml) Kwikpen (treats
diabetes) by sliding scale at mealtime if blood
sugar is under 90 inject 0 units, 90-150 inject 6
units, 151 - 200 inject 7 units, over 200 inject 8
units; Lantus (treats diabetes) 100u/ml inject 34
units in each morning regardless of breakfast
intake unless blood sugar is lower than 70;
Januvia 50 milligrams (mg) 1 tablet daily;
Metformin (treats diabetes) 1000 mg 1 tablet
twice daily with meals; check blood sugar four
times daily, before meals and bedtime; signed
8/03/21 for Humulin N 100 units/ml! Kwikpen
(treats diabetes) inject 5 units subcutaneously at
suppertime.

Review on 8/24/21 of staff #2's personnel record
revealed:

- Title of Direct Care Professional.

Division of Health Service Regulation

STATE FORM 6899 SBIZ11 If continuation sheet 2 of 27

PRINTED: 09/16/2021
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
R
MHL074-195 B. WING _____ 09/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

3309 MIDLAND COURT

BETTER CONNECTIONS MIDLAND CT GREENVILLE, NC 27833

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)
V 108} Continued From page 2 V 108

- Hire date of 5/24/19.
- No documentation of training in diabetes
management or diabetes care.

During interview on 8/24/21 staff #2 stated:

- She only worked on weekends if the AFL
Provider needed to be away from the facility.

- As a direct care staff she administered
medications, assisted client #1 to check his blood
sugar and assisted him to administer his insulin.
- She was supposed to have diabetes training.

- She could not remember if she had completed
diabetes training.

- She had not worked at the facility in
approximately 2 months.

This deficiency is cross referenced into 10A
NCAC 27G .5601 Scope (V289) for a Type A1
rule violation and must be corrected within 23
days.

V 112] 27G .0205 (C-D) v112
Assessment/Treatment/Habilitation Plan

10A NCAC 27G .0205 ASSESSMENT AND
TREATMENT/HABILITATION OR SERVICE
PLAN

(c) The plan shall be developed based on the
assessment, and in partnership with the client or
legally responsible person or both, within 30 days
of admission for clients who are expected to
receive services beyond 30 days.

(d) The plan shall include:

(1) client outcome(s) that are anticipated to be
achieved by provision of the service and a
projected date of achievement;

(2) strategies;

(3) staff responsible;

(4) a schedule for review of the plan at least

Division of Health Service Regulation
STATE FORM 6899 SBIZ11 If continuation sheet 3 of 27

PRINTED: 09/16/2021

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHLO074-195 B. WING ____ 09/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
3309 MIDLAND COURT
BETTER CONNECTIONS MIDLAND CT
GREENVILLE, NC 27833
(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

V 112| Continued From page 3 Vv 112

annually in consultation with the client or legally
responsible person or both;

(5) basis for evaluation or assessment of
outcome achievement; and

(6) written consent or agreement by the client or
responsible party, or a written statement by the
provider stating why such consent could not be
obtained.

This Rule is not met as evidenced by:

Based on record reviews and interviews the
acility failed to develop and implement goals and
strategies based on assessment for 1 of 2 clients
(#1). The findings are:

Review on 8/24/21 and 9/01/21 of client #1's
record revealed:

- 42 year-old male admitted 1/01/20.

- Diagnoses included: Type 1 Diabetes Mellitus
with Hyperglycemia, Intellectual/Developmental
Disability, moderate, Paranoid Schizophrenia,
Chronic Kidney Disease, stage 3, Essential
Hypertension, Hyperlipidemia, and Myalgia.

- "Risk/Support Needs Assessment" dated
12/08/20 included that client #1 could be easily
victimized; "would let anyone into his home;"
engaged in "risky behaviors" such as leaving his
home in the middle of the night to go to the store
to beg for cigarettes; wearing all black at night so
that he could not be seen by traffic; history of
delusions, paranoia, self-injurious behaviors, and
suicidal ideation; "requires close supervision due
Division of Health Service Regulation

STATE FORM 6899 SBIZ11 If continuation sheet 4 of 27

PRINTED: 09/16/2021

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHLO074-195 B. WING ____ 09/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
3309 MIDLAND COURT
BETTER CONNECTIONS MIDLAND CT
GREENVILLE, NC 27833
(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

V 112| Continued From page 4 Vv 112

to risk of wandering away."

- "Case Note Entered By [Qualified Professional
(QP)] on 08/31/2021 03:13 PM . . . Service Date
06/30/2021 . . ." included "Team meeting was
held to discuss . . . [client #1's] placement, having
unsupervised time, and eating schedule. The
team agreed that [client #1] could have up to 2
hours of unsupervised time. Prior to leaving for
his unsupervised time, [client #1] agreed to check
his glucose levels, take a snack and a bottle of
water, and provide staff with his plans. [Client #1]
will also receive a food card to use to start
learning how to manage his funds on a monthly
basis. The team will meet in a couple of months
to assess [client #1's] progress."

- "Intake/Output" record 6/02/21 8:00 am -
8/31/21 12:30 pm included documentation of 133
meal refusals.

- Physician's orders signed 6/15/21 and 3/18/20
for Humalog 100 units/milliliters (u/ml) Kwikpen
(treats diabetes) by sliding scale at mealtime if
blood sugar is under 90 inject 0 units, 90-150
inject 6 units, 151 - 200 inject 7 units, over 200
inject 8 units; signed 6/15/21 for Lantus (treats
diabetes) 100u/ml inject 34 units in each morning
regardless of breakfast intake unless blood sugar
is lower than 70; Januvia 50 milligrams (mg) 1
tablet daily; Metformin (treats diabetes) 1000 mg
1 tablet twice daily with meals; check blood sugar
four times daily, before meals and bedtime;
signed 8/03/21 for Humulin N 100 units/ml
Kwikpen (treats diabetes) inject 5 units
subcutaneously at suppertime.

- "Admin (Administration) History for [client #1] -
Humalog 100 units/milliliter (ml) Kwikpen" 8/12/21
7:00 pm - 8/31/21 12:36 pm included
documentation of 43 refusals of Humalog 100
units/ml.

- Medication Administration Records (MARs)
June 2021 - August, 2021 included

Division of Health Service Regulation

STATE FORM 6899 SBIZ11 If continuation sheet 5 of 27

PRINTED: 09/16/2021
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
R
MHL074-195 B. WING _____ 09/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

3309 MIDLAND COURT

BETTER CONNECTIONS MIDLAND CT GREENVILLE, NC 27833

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)
V 112| Continued From page 5 Vv 112

documentation of 121 blood sugar check
refusals; documentation of blood sugar levels
ranging from 54 at 6:00 pm 8/12/21 to too high for
the glucometer instrument to register at 7:00 am
8/23/21, 7/12/21, and 7/19/21; documentation of
153 refusals of Humalog 100 units/ml.

- "Consultation Form" dated 3/04/21 with signed
Physician's order". . . take Lantus even if he
(client #1) does not eat breakfast;" the
"Consultation Form" was also signed by the
Direct Care Professional, the Residential Director,
and the QP.

- "SCS (Special Consultative Services)
Nutritionist 01/1/21 - 12/31/21 (ISP Program)"
included ". . . Goal/Service Individual will receive
specialized consultative services in order to have
a comprehensive nutritional assessment plan
development, training and monitoring/revising
throughout the plan year to promote compliance
with a healthier diet."

- "Residential Supports . . . 1/1/21-12/31/21 (ISP
[Individual Support Plan] Program) . . . Start Date
1/01/2021..."

- No goal or strategies to address management of
client #1's Type 1 Diabetes Mellitus with
Hyperglycemia or his refusal to comply with blood
sugar checks, and medication regimen.

- No goal or strategies for unsupervised time,
overnight eating, leaving his home during the
night, or the appropriate use of his food card.

- No strategies to address SCS Nutritionist's
recommendatons or dietary considerations for
Type 1 Diabetes Mellitus with Hyperglycemia.

During interview on 8/26/21 client #1's
Department of Social Services (DSS) Guardian
Representative stated:

- She attended the 6/30/21 treatment team
meeting via telephone for approximately one
hour.

Division of Health Service Regulation

STATE FORM 6899 SBIZ11 If continuation sheet 6 of 27

PRINTED: 09/16/2021
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
R
MHL074-195 B. WING _____ 09/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

3309 MIDLAND COURT

BETTER CONNECTIONS MIDLAND CT GREENVILLE, NC 27833

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)
V 112| Continued From page 6 Vv 112

- The team's approval for client #1 to have
unsupervised time was an attempt to afford him
some "autonomy."

- She agreed to client #1's unsupervised time
despite his history of non-compliance with his
diabetes treatment regimen and history of risky
behaviors.

- She believed that client #1 did not comprehend
his need for supervision because he had lived
independently and had been married prior to his
current AFL placement.

- The team was "trying to meet him in the middle."
- She was concerned for client #1's safety
because "if he refuses his blood sugar checks or
medications there could be a terrible outcome."

- She acknowledged that the team "can't stop his
behavior."
- She was aware client #1 stayed up at night and
ate and had asked the Alternative Famly Living
(AFL) staff to leave healthy snacks out and
available for client #1.

- "He is difficult to manage. He thinks he knows
more than we do. He wants his independence
and is resistive to treatment. He will say the devil
made him do things."

- She had not spoken with client #1 recently.

During interview on 8/24/21 staff #1 stated client
#1 had "down time" (unsupervised time) but he
did not know how much.

During interview on 8/24/21 staff #2 stated:

- Client #1 had 2 hours of unsupervised time.
- She only worked on weekends when the AFL
Provider needed to be away from the facility.

- She had not worked at the facility in about 2
months.

During interview on 8/24/21 the AFL Provider
stated:

Division of Health Service Regulation

STATE FORM 6899 SBIZ11 If continuation sheet 7 of 27

PRINTED: 09/16/2021
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
R
MHL074-195 B. WING _____ 09/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

3309 MIDLAND COURT

BETTER CONNECTIONS MIDLAND CT GREENVILLE, NC 27833

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)
V 112| Continued From page 7 Vv 112

- Client #1 had 2 hours of unsupervised time in
the community and home each day; the
unsupervised time was not included in client #1's
treatment plan.

- The treatment team discussed unsupervised
time for client #1 "about a month ago."

- Client #1's Care Coordinator completed the
assessment for unsupervised time, but there was
not a copy of the assessment in client #1's
record.

- Client #1 had unsupervised time for "no more
than a month."

- The team's agreement for client #1 to have
unsupervised time was "more of a verbal type
thing."
- The team agreed that they wanted client #1 to
"be more independent because he's so high
functioning."
- Client #1 often refused to have his blood sugar
checked and to take his insulin as ordered.

- Client #1 did not refuse his Lantus.

- Client #1 had high blood sugar all his life and felt
“funny" if his blood sugar was low.
- Client #1 slept during the day and stayed up
during the night.
- The QP was responsible for writing the
residential goals, the Care Coordinator finalized
and approved the goals, and residential staff
executed the goals.

- Staff #1 and staff #2 only worked on the
weekends if he needed to be away from the
facility.

During interview on 8/25/21 the Residential
Director stated client #1 was "very high
functioning" and "got his down time sometime in
the last three months or so."

During interview on 8/25/21 the QP stated:

- She began providing QP services at the facility a
Division of Health Service Regulation

STATE FORM 6899 SBIZ11 If continuation sheet 8 of 27

PRINTED: 09/16/2021

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHLO074-195 B. WING ____ 09/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
3309 MIDLAND COURT
BETTER CONNECTIONS MIDLAND CT
GREENVILLE, NC 27833
(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

V 112| Continued From page 8 Vv 112

couple of months ago.

- Treatment plans for the individuals at the facility
were already in place when she assumed the QP
responsibilities.

- Client #1's team developed short range goals
for each service the client received.

- The QP "formulated the plan from long range
goals and team's input;" short term goals were
based on long range goals.

- Other responsibilities of the QP included
ensuring coordination of care and making sure
staff carried out recommendations made by the
clients' Physicians.

- Client #1 "demanded" unsupervised time, so his
team agreed for him to have up to 2 hours per
day.
- Client #1 "had a system to follow to make sure
he's safe."

- Client #1's "system" included checking client
#1's blood sugar, keeping his glucometer with
him, taking a bottle of water and a snack with him
and letting staff know where he was going.

- Client #1 also agreed to let the AFL staff know
when he got up in the night and when he ate;

- "He was supposed to take Humalog when he
ate something and not cook in the middle of the
night. But he hasn't followed through with any of
that."
- Client #1 had 3 scheduled meals each day.

- "In [client #1's] mind he eats one meal a day,
but he eats one meal during the day because he
hasn't been eating breakfast or lunch; he gets up
in middle of night and eats and is not taking
anything (insulin as ordered) for that."

- "We've been working on that. We want a third
shift person that could stay up and manage [client
#1] through the night."

- "[Client #1] has had friends come over to bring
him money - it happened last week, at midnight;
[AFL staff] happened to get up and heard a
Division of Health Service Regulation

STATE FORM 6899 SBIZ11 If continuation sheet 9 of 27

PRINTED: 09/16/2021
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
R
MHL074-195 B. WING _____ 09/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

3309 MIDLAND COURT

BETTER CONNECTIONS MIDLAND CT GREENVILLE, NC 27833

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)
V 112| Continued From page 9 Vv 112

commotion; if he hadn't gotten up, he would
never have known."

- Aperson, whom client #1 identified as a friend,
came to the facility to give client #1 some money;
client #1 went outside and got into his friend's car.
- Client #1's friend didn't enter the facility; the AFL
staff went out to the car, client #1 was given
money by the friend and came back into the
facility without incident.

- Client #1 had been "refusing medications for a
very, very long time; I'm not sure an extra staff
will be an improvement on that but it's worth a
try."
- Client #1 "takes his glucometer everywhere he
goes, including into the community and to the day
program so his blood sugar should be checked
and medications administered accordingly."

- The frequency of client #1's nutritional therapy
increased from once a month to twice a month.

- "It's worth the effort; he's been meeting with her
(the Nutritionist) for at least all of this year (2021)
and he hasn't done a single thing she has
suggested."

- "He doesn't want to feel like he's being
micro-managed or treated like a child; he had life
experiences; he was married and had at least 1
child; he is struggling a lot with the changes in his
life; he's not calling the Care Coordinator as often
as he once was so that's good."

- Client #1 wanted to be more independent.

- Client #1's unsupervised time started 6/30/21.

- "We were trying to put structure to what he was
already doing; he would walk to the store; he was
banned from the [a chain discount store] due to a
previous incident that occurred there."

- No revisions were made to short range goals as
a result of the 6/30/21 team meeting

- She was not sure if the Care Coordinator made
any revisions to the long range goals.

- Residential plans were updated if there was a
Division of Health Service Regulation

STATE FORM 6899 SBIZ11 If continuation sheet 10 of 27

PRINTED: 09/16/2021
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
R
MHL074-195 B. WING _____ 09/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

3309 MIDLAND COURT

BETTER CONNECTIONS MIDLAND CT GREENVILLE, NC 27833

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)
V 112| Continued From page 10 Vv 112

significant change in the client's life.

During interview on 9/02/21 the Clinical Director
stated:

- Client #1 was once married and had a child and
had difficulty adjusting to the changes in his life.
- When team meetings were held, the team
focused on honoring client #1's rights.

- Client #1 would verbalize that it was his choice
to eat one meal per day.
- She understood and agreed that it was
incumbent on the Licensee to ensure client #1's
safety.
- Negative consequences of client #1's continued
refusals of insulin and extremely high blood sugar
readings were discussed with him.

- "We've talked with him about all this."

- She agreed that there were no goals or
strategies to address management of client #1's
Type 1 Diabetes Mellitus with Hyperglycemia; his
refusal to comply with blood sugar checks and
medication regimen, unsupervised time,
overnight eating, leaving his home during the
night, and the appropriate use of his food card;
she also agreed there were no strategies to
address nutritional counseling or dietary
considerations for Type 1 Diabetes Mellitus with
Hyperglycemia included in his
treatment/habilitation plan.

This deficiency is cross referenced into 10A
NCAC 27G .5601 Scope (v289) for a Type A1 rule
violation and must be corrected within 23 days.

V 118] 27G .0209 (C) Medication Requirements Vv 118

10A NCAC 27G .0209 MEDICATION
REQUIREMENTS
(c) Medication administration:

Division of Health Service Regulation
STATE FORM 6899 SBIZ11 If continuation sheet 11 of 27

PRINTED: 09/16/2021

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHLO074-195 B. WING ____ 09/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
3309 MIDLAND COURT
BETTER CONNECTIONS MIDLAND CT
GREENVILLE, NC 27833
(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

V 118| Continued From page 11 V 118

(1) Prescription or non-prescription drugs shall
only be administered to a client on the written
order of a person authorized by law to prescribe
drugs.

(2) Medications shall be self-administered by
clients only when authorized in writing by the
client's physician.

(3) Medications, including injections, shall be
administered only by licensed persons, or by
unlicensed persons trained by a registered nurse,
pharmacist or other legally qualified person and
privileged to prepare and administer medications.
(4) A Medication Administration Record (MAR) of
all drugs administered to each client must be kept
current. Medications administered shall be
recorded immediately after administration. The
MAR is to include the following:

(A) client's name;

(B) name, strength, and quantity of the drug;

(C) instructions for administering the drug;

(D) date and time the drug is administered; and
(E) name or initials of person administering the
drug.

(5) Client requests for medication changes or
checks shall be recorded and kept with the MAR
file followed up by appointment or consultation
with a physician.

This Rule is not met as evidenced by:

Based on record reviews, observations and
interviews the facility failed to ensure medications
were administered as ordered by a physician for 1
of 2 clients (#1). The findings are:

Division of Health Service Regulation
STATE FORM 6899 SBIZ11 If continuation sheet 12 of 27

PRINTED: 09/16/2021
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
R
MHL074-195 B. WING _____ 09/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

3309 MIDLAND COURT

BETTER CONNECTIONS MIDLAND CT GREENVILLE, NC 27833

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118] Continued From page 12 V 118

Review on 8/24/21, 9/01/21 and 9/02/21 of client
#1's record revealed:

- 42 year-old male admitted 1/01/20.

- Diagnoses included: Type 1 Diabetes Mellitus
with Hyperglycemia, Intellectual/Developmental
Disability, moderate, Paranoid Schizophrenia,
Chronic Kidney Disease, stage 3, Essential
Hypertension, Hyperlipidemia, and Myalgia.

- Physician's orders signed 6/15/21 and 3/18/20
for Humalog 100 units/milliliters (u/ml) Kwikpen
(treats diabetes) by sliding scale at mealtime if
blood sugar is under 90 inject 0 units, 90-150
inject 6 units, 151 - 200 inject 7 units, over 200
inject 8 units; Lantus (treats diabetes) 100u/ml
inject 34 units in each morning regardless of
breakfast intake unless blood sugar is lower than
70; Januvia 50 milligrams (mg) 1 tablet daily;
Metformin (treats diabetes) 1000 mg 1 tablet
twice daily with meals; check blood sugar four
times daily, before meals and bedtime; signed
8/03/21 for Humulin N 100 units/ml! Kwikpen
(treats diabetes) inject 5 units subcutaneously at
suppertime.

- "Consultation Form" dated 8/03/21 with signed
Physician's order to "Decrease Lantus (treats
diabetes) to 25 units inAM..."

Review on 8/24/21 of client #1's August 2021
MAR revealed:

- Transcription for Humalog 100 units/ml Kwikpen
according to sliding scale with documentation of
medication administration beginning 8/12/21 7:00
pm.

- No documentation Humalog 100 units/ml
Kwikpen was administered 8/11/21 - 8/12/21, with
no documented explanation for the omissions.

- Transcription for blood sugar checks 4 times
daily with documented blood sugar levels of 314
7:00 am 8/11/21, 379 7:00 am 8/12/21, and 187
8:00 pm 8/12/21.

Division of Health Service Regulation

STATE FORM 6899 SBIZ11 If continuation sheet 13 of 27

PRINTED: 09/16/2021
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
R
MHL074-195 B. WING _____ 09/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

3309 MIDLAND COURT

BETTER CONNECTIONS MIDLAND CT GREENVILLE, NC 27833

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118| Continued From page 13 V 118

- Transcription for Humulin N 100 units/ml
Kwikpen according to sliding scale with
documentation of medication administration
beginning 8/13/21 7:00 pm.

- No documentation Humulin N 100 units/ml
Kwikpen was administered 8/03/21 - 8/08/21 or
8/10/21 - 8/12/21, with no documented
explanation for the omissions.

- Documentation of client #1's refusal of the
Humulin N Kwikpen at 5:00 pm 8/09/21.

- Transcription for Lantus 100 units/ml inject 34
units in the morning; take daily each morning
regardless of breakfast intake unless glucose is
less than 70; no documentation of blood glucose
levels less than 70; the AFL provider's initials that
34 units Lantus were injected daily 8/4/21 -
8/20/21 and 8/23/21 - 8/24/21.

- No transcription for Lantus 100 units/ml inject 25
units in the morning.

Observation on 8/24/21 at approximately 11:00
am of client #1's medications on hand revealed:
- Lantus 100 units/ml inject 34 units in the
morning; ". . . take Lantus daily each morning
regardless of breakfast intake" unless blood
sugar level is less than 70, dispensed by the
pharmacy 7/23/21.

- No Lantus 100 units/ml inject 25 units in the
morning.

During interview on 8/24/21 client #1 stated:

- He took his medications "just about" every day
with staff assistance.

- He went to the doctor the week prior to the
survey.

- Emergency Medical Services came to the facility
once in the past because he "passed out
because of my diabetes" but he chose not to go
to the hospital.

Division of Health Service Regulation
STATE FORM 6899 SBIZ11 If continuation sheet 14 of 27

PRINTED: 09/16/2021
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
R
MHL074-195 B. WING _____ 09/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

3309 MIDLAND COURT

BETTER CONNECTIONS MIDLAND CT GREENVILLE, NC 27833

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118| Continued From page 14 Vv 118

During interview on 8/24/21 the Alternative Family
Living (AFL) Provider stated:

There was "some kind of discrepancy" with
client #1's insurance when the Humulin N
Kwikpen was ordered.

- The Humulin N Kwikpen was not delivered to
the facility until 8/10/21 or 8/11/21.

- The pharmacy was supposed to take the
Humulin N Kwikpen off the MAR since it was not
available but mistakenly removed Humalog
Kwikpen from the MAR.

- It was not protocol to contact a medical provider
when client #1's blood sugar was high; the
pharmacist saw the blood sugar levels on the
electronic MAR.

- There was no order to seek medical attention
for client #1 when his blood sugar level was high.
- The first time client #1's blood sugar was too
high to be registered by the glucometer, he called
the Registered Nurse who told him to just
administer client #1's insulin as ordered.

- He was told to make sure client #1 had plenty of
water available.

- Client #1's blood sugar "did not stay high, it was
high mainly in the mornings because [client #1]
liked to stay up at night" and would eat during the
night.

- Client #1 told him he (client #1) had high blood
sugar all his life and he felt "funny" if his blood
sugar was low.

During interview on 8/25/21 the Residential
Director stated:

- Some of his responsibilities included reviewing
medications, making sure staff "sign off" on
medications and following up on Physicians'
Consultation forms.

- If client #1 refused medications more than two
consecutive days he called the nurse and asked
for advice.

Division of Health Service Regulation

STATE FORM 6899 SBIZ11 If continuation sheet 15 of 27

PRINTED: 09/16/2021
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
R
MHL074-195 B. WING _____ 09/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

3309 MIDLAND COURT

BETTER CONNECTIONS MIDLAND CT GREENVILLE, NC 27833

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)
V 118| Continued From page 15 V 118

- "| just want to make sure he's safe. | talk to him
about staying safe."

- "He (client #1) is adamant about getting out of
the system. . . we can't force him to do anything .
. . he sabotages things; he knows what's going
on; he eats so much at night that his blood sugar
readings are so different."

He advised the AFL staff to set an alarm for
every 3 hours to check on client #1 overnight.
Client #1's unsupervised time was not at night.
He could not force client #1 to comply with
medications or blood sugar checks.

During interview on 8/25/21 the Qualified
Professional stated:

- Her responsibilities included ensuring
coordination of care and making sure staff carried
out recommendations made by the Physicians.

- Client #1's team met to discuss his eating in
iddle of night; client #1 agreed to let the AFL
staff know when he got up and when he ate;"...
he was supposed to take Humalog when he ate
something and not cook in the middle of the
night."

- Client #1 has 3 scheduled meals ". . . in [client
#1's] mind he eats 1 meal a day, but he eats1
meal during the day because he hasn't been
eating breakfast or lunch; he gets up in middle of
night and eats and is not taking anything for that."
- She wanted a 3rd shift awake staff to "manage"
client #1 during the night.

- Client #1 had been refusing medications for "a
very, very long time" and she was not sure an
extra staff would be effective.

- Client #1 "takes his glucometer everywhere he
goes, including into the community and to the day
program so his blood sugar should be checked,
and medications administered accordingly."

3
5

Due to the failure to accurately document
Division of Health Service Regulation
STATE FORM 6899 SBIZ11 If continuation sheet 16 of 27

PRINTED: 09/16/2021
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
R
MHL074-195 B. WING _____ 09/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

3309 MIDLAND COURT

BETTER CONNECTIONS MIDLAND CT GREENVILLE, NC 27833

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)
V 118| Continued From page 16 V 118

medication administration it could not be
determined if the client received his medications
as ordered by the physician.

This deficiency has been cited 3 times since the
original cite on March 28, 2018.

This deficiency is cross referenced into 10A
NCAC 27G .5601 Scope (V289) for a Type A1
rule violation and must be corrected within 23
days.

V 289] 27G .5601 Supervised Living - Scope V 289

10A NCAC 27G .5601 SCOPE

(a) Supervised living is a 24-hour facility which
provides residential services to individuals in a
home environment where the primary purpose of
these services is the care, habilitation or
rehabilitation of individuals who have a mental
illness, a developmental disability or disabilities,
or a substance abuse disorder, and who require
supervision when in the residence.

(b) Asupervised living facility shall be licensed if
the facility serves either:

(1) one or more minor clients; or

(2) two or more adult clients.

Minor and adult clients shall not reside in the
same facility.

(c) Each supervised living facility shall be
licensed to serve a specific population as
designated below:

(1) "A" designation means a facility which
serves adults whose primary diagnosis is mental
illness but may also have other diagnoses;

(2) "B" designation means a facility which
serves minors whose primary diagnosis is a
developmental disability but may also have other
diagnoses;

Division of Health Service Regulation
STATE FORM 6899 SBIZ11 If continuation sheet 17 of 27

PRINTED: 09/16/2021

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHLO074-195 B. WING 09/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
3309 MIDLAND COURT
BETTER CONNECTIONS MIDLAND CT
GREENVILLE, NC 27833
(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 289| Continued From page 17 V 289
(3) "C" designation means a facility which

serves adults whose primary diagnosis is a
developmental disability but may also have other
diagnoses;

(4) "D" designation means a facility which
serves minors whose primary diagnosis is
substance abuse dependency but may also have
other diagnoses;

(5) "E" designation means a facility which
serves adults whose primary diagnosis is
substance abuse dependency but may also have
other diagnoses; or

(6) "F" designation means a facility ina
private residence, which serves no more than
three adult clients whose primary diagnoses is
mental illness but may also have other
disabilities, or three adult clients or three minor
clients whose primary diagnoses is
developmental disabilities but may also have
other disabilities who live with a family and the
family provides the service. This facility shall be
exempt from the following rules: 10A NCAC 27G
.0201 (a)(1),(2),(3),(4).(5)(A)&(B); (6); (7)
(A),(B),(E).(F),(G),(H); (8); (11); (13); (15); (16);
(18) and (b); 10A NCAC 27G .0202(a),(d),(g)(1)
(i); 10A NCAC 27G .0203; 10A NCAC 27G .0205
(a),(b); 10A NCAC 27G .0207 (b),(c); 10A NCAC
27G .0208 (b),(e); 10A NCAC 27G .0209[(c)(1) -
non-prescription medications only] (d)(2),(4); (e)
(1)(A),(D),(E);(f);(g); and 10A NCAC 27G .0304
(b)(2),(d)(4). This facility shall also be known as
alternative family living or assisted family living
(AFL).

This Rule is not met as evidenced by:
Based on record reviews, observations and
Division of Health Service Regulation

STATE FORM 6899 SBIZ11 If continuation sheet 18 of 27

PRINTED: 09/16/2021
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
R
MHL074-195 B. WING _____ 09/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

3309 MIDLAND COURT

BETTER CONNECTIONS MIDLAND CT GREENVILLE, NC 27833

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 289| Continued From page 18 V 289

interviews, the facility failed to ensure care and
habilitation designed to meet the needs of the
individuals served affecting 1 of 2 clients (#1).
The findings are:

Cross reference 10A NCAC 27G .0202 Personnel
Requirements (tag v108). Based on record
review and interview the facility failed to ensure 1
of 3 staff (#2) received diabetic training to meet
the needs of a client.

Cross reference 10A NCAC 27G .0205
Assessment and Treatment/Habilitation or
Service Plan (tag v112). Based on record
reviews and interviews the facility failed to
develop and implement goals and strategies
based on assessment for 1 of 2 clients (#1).

Cross reference 10A NCAC 27G .0209
Medication Requirements (tag v118). Based on
record reviews and interviews the facility failed to
ensure medications were administered as
ordered by a physician for 1 of 2 clients (#1).

Cross Reference 10A NCAC 27G .5603
Operations (tag v291). Based on record reviews
and interviews the facility failed to maintain
coordination between the facility operator and the
professionals who are responsible for the client's
treatment affecting 1 of 2 clients (#1).

During interview on 8/24/21 the Alternative Family
Living (AFL) Provider stated:

- He lived at the facility.

- Staff #1 and staff #2 worked on the weekends if
he needed to be away from the facility.

- He worked with client #1 during the week.

- The Licensee paid the rent for the facility.

- The facility was one of several properties the
Licensee rented.

Division of Health Service Regulation

STATE FORM 6899 SBIZ11 If continuation sheet 19 of 27

PRINTED: 09/16/2021

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHLO074-195 B. WING ____ 09/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
3309 MIDLAND COURT
BETTER CONNECTIONS MIDLAND CT
GREENVILLE, NC 27833
(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

V 289| Continued From page 19 V 289

During interview on 8/25/21 the Residential
Director stated the Licensee paid the rent for the
facility.

During interview on 9/01/21 the Chief Financial
Officer stated:

- The AFL Provider lived at the facility.

- Other paid staff worked only when the AFL staff
needed to be away.

- The manner in which the facility was operated
had not changed.

- The way the facility was operated had never
been cited as a deficiency before.

- The facility was one of several properties the
Licensee rented.

- The facility met the definition of Supervised
Living for Alternative Family Living.

Review on 8/31/21 of the Plan of Protection dated
8/31/21 completed by the Quality
Assurance/Chief Executive Officer, the Chief
Financial Officer, and the Clinical Director
revealed:
- "What immediate action will the facility take to
ensure the safety of the consumers in your care?
There will always be a staff available that has the
appropriate training for the person (diabetes
training). Ensure short range goals (specialized
consultation goal provided) reflect his issues
related to diabetes (diet, management of
diabetes, blood sugar trends, etc.). His current
setting is a licensed AFL with sleep staff, the team
will discuss a more appropriate placement for
24-hour supervision. Periodic bed checks nightly
and document times he checks in Therap. If he
does refuse medication, ensure documentation is
noted on the MAR and continue to notify doctor of
medication refusal."

- "Describe your plans to make sure the above
Division of Health Service Regulation

STATE FORM 6899 SBIZ11 If continuation sheet 20 of 27

PRINTED: 09/16/2021
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
R
MHL074-195 B. WING _____ 09/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

3309 MIDLAND COURT

BETTER CONNECTIONS MIDLAND CT GREENVILLE, NC 27833

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 289| Continued From page 20 V 289

happens. QP will review documentation daily in
Therap for periodic bed checks at night, when
refusal of medication is noted, ensure MARS are
documented daily. Collaboration notes to be
completed as incidents occur. Ongoing meetings
(o discuss progress or lack of progress for his
safety/care."

Client #1 had diagnoses which included Paranoid
Schizophrenia, Moderate
ntellectual/Developmental Disability, Type 1
Diabetes Mellitus with Hyperglycemia, Stage 3
Chronic Kidney Disease, and Essential
Hypertension. Client #1 had a known long-term
history of medication non-compliance,
non-compliance with physician's
recommendations, and a history of risky
behaviors such as leaving the facility in the
middle of the night to walk to a store. He also
refused to comply with dietary recommendations
from his nutritionist, frequently eating only one
meal per day and staying up at night and eating
without consideration of his diabetes. Staff at the
facility were asleep overnight. Client #1's blood
glucose level was ordered to be checked four
times daily and insulin administered according to
a sliding scale. Client #1 refused to have his
blood glucose level checked 121 times between
June 2021 and August 2021. His blood glucose
readings ranged from a low of 54 to so high the
glucometer was unable to record a reading. June
15, 2021 - August 24, 2021, he refused
administration of his Humulog and Humulin 135
times; he refused administration of his Lantus 13
times, his Metformin 15 times, and his Januvia 10
times. Client #1 was approved by his treatment
team to have 2 hours of unsupervised time in the
community and home despite his known
noncompliance with treatment recommendations.
None of these issues were included in his

Division of Health Service Regulation

STATE FORM 6899 SBIZ11 If continuation sheet 21 of 27

PRINTED: 09/16/2021
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
R
MHL074-195 B. WING _____ 09/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

3309 MIDLAND COURT

BETTER CONNECTIONS MIDLAND CT GREENVILLE, NC 27833

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)
V 289] Continued From page 21 V 289

treatment plan and there was no coordination of
care with client #1's Endocrinologist regarding
seeking emergency medical care or treatment
when his blood glucose levels were extremely
high. Staff #2 had no documented training in
diabetes care. The facility's failures to ensure
client #1's medical and behavioral needs were
addressed in his treatment plan; administration of
his medications as ordered; and staff training in
diabetes care constitute serious neglect.

This deficiency constitutes a Type A1 rule
violation for serious neglect and must be
corrected within 23 days. An administrative
penalty of $2000.00 is imposed. If the violation is
not corrected within 23 days, and additional
administrative penalty of $500 per day will be
imposed for each day the facility is out of
compliance beyond the 23rd day.

V 291} 27G .5603 Supervised Living - Operations Vv 291

10A NCAC 27G .5603 OPERATIONS

(a) Capacity. A facility shall serve no more than
six clients when the clients have mental illness or
developmental disabilities. Any facility licensed
on June 15, 2001, and providing services to more
han six clients at that time, may continue to
provide services at no more than the facility's
icensed capacity.
(b) Service Coordination. Coordination shall be
maintained between the facility operator and the
qualified professionals who are responsible for
reatment/habilitation or case management.

(c) Participation of the Family or Legally
Responsible Person. Each client shall be
provided the opportunity to maintain an ongoing
relationship with her or his family through such
means as visits to the facility and visits outside
he facility. Reports shall be submitted at least

Division of Health Service Regulation
STATE FORM 6899 SBIZ11 If continuation sheet 22 of 27

PRINTED: 09/16/2021
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
R
MHL074-195 B. WING _____ 09/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

3309 MIDLAND COURT

BETTER CONNECTIONS MIDLAND CT GREENVILLE, NC 27833

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 291} Continued From page 22 Vv 291

annually to the parent of a minor resident, or the
legally responsible person of an adult resident.
Reports may be in writing or take the form of a
conference and shall focus on the client's
progress toward meeting individual goals.

(d) Program Activities. Each client shall have
activity opportunities based on her/his choices,
needs and the treatment/habilitation plan.
Activities shall be designed to foster community
inclusion. Choices may be limited when the court
or legal system is involved or when health or
safety issues become a primary concern.

This Rule is not met as evidenced by:

Based on record reviews and interviews the
facility failed to maintain coordination between the
facility operator and the professionals who are
responsible for the client's treatment affecting 1 of
2 clients (#1). The findings are:

Review on 8/24/21 and 9/01/21 of client #1's
record revealed:

- 42 year-old male admitted 1/01/20.

- Diagnoses included: Type 1 Diabetes Mellitus
with hyperglycemia, Intellectual/Developmental
Disability, moderate, Paranoid Schizophrenia,
chronic kidney disease, stage 3, essential
hypertension, hyperlipidemia, and myalgia.

- "Intake/Output" record 6/02/21 8:00 am -
8/31/21 12:30 pm included documentation of 133
meal refusals.

- "Admin (Administration) History for [client #1] -
Humalog 100 units/ml Kwikpen" 8/12/21 7:00 pm
- 8/31/21 12:36 pm included documentation of 43
refusals of Humalog 100units/ml (ordered 6/15/21
to be administered by sliding scale at mealtime).
- "Consultation Form" dated 3/04/21 with signed
Endocrinologist's order". . . take Lantus even if
Division of Health Service Regulation

STATE FORM 6899 SBIZ11 If continuation sheet 23 of 27

PRINTED: 09/16/2021

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHLO074-195 B. WING ____ 09/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
3309 MIDLAND COURT
BETTER CONNECTIONS MIDLAND CT
GREENVILLE, NC 27833
(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

V 291 | Continued From page 23 V 291

he does not eat breakfast;" the - "Consultation
Form" was also signed by the Direct Care
Professional, Residential Director, and Qualified
Professional (QP).

- No documentation of discussion with the
Endocrinologist regarding client #1's frequent
refusal of diabetes medications and blood sugar
level checks or clarification of when to seek
medical attention for client #1 for elevated blood
sugar levels.

- Physician's orders signed 6/15/21 and 3/18/20
for Humalog 100 units/milliliters (u/ml) Kwikpen
(treats diabetes) by sliding scale at mealtime if
blood sugar is under 90 inject 0 units, 90-150
inject 6 units, 151 - 200 inject 7 units, over 200
inject 8 units; signed 6/15/21 for Lantus (treats
diabetes) 100 u/ml inject 34 units in each morning
regardless of breakfast intake unless blood sugar
is lower than 70; Januvia 50 milligrams (mg) 1
tablet daily; Metformin (treats diabetes) 1000 mg
1 tablet twice daily with meals; check blood sugar
four times daily, before meals and bedtime;
signed 8/03/21 for Humulin N 100 units/ml
Kwikpen (treats diabetes) inject 5 units
subcutaneously at suppertime.

Review on 8/24/21 of client #1's Medication
Administration Records (MARs) June 2021 -
August 2021 revealed:

- Documentation of 121 blood sugar check
refusals.

- Documentation of blood sugar levels ranging
from 54 at 6:00 pm 8/12/21 to too high for the
glucometer instrument to register at 7:00 am
8/23/21, 7/12/21, and 7/19/21.

- Documentation of 152 refusals of Humalog.
- Documentation of 9 refusals of Humulin N.

- Documentation of 15 refusals of Metformin.
-Documentation of 13 refusals of Lantus.

- Documentation of 10 refusals of Januvia.
Division of Health Service Regulation

STATE FORM 6899 SBIZ11 If continuation sheet 24 of 27

PRINTED: 09/16/2021

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHLO074-195 B. WING ____ 09/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
3309 MIDLAND COURT
BETTER CONNECTIONS MIDLAND CT
GREENVILLE, NC 27833
(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

V 291 | Continued From page 24 V 291

During interview on 8/24/21 the Alternative Family
Living (AFL) Provider stated:

- The first time the glucometer registered an error
reading because client #1's blood sugar was too
high to read, he contacted the Licensee's
Registered Nurse who instructed him to give
client #1 insulin as ordered.

- Neither client #1's primary care provider nor his
Endocrinologist gave instructions to seek medical
attention for high blood sugar levels.

- He was told to make sure there was plenty of
water available to client #1 when his blood sugar
level was high.

- Client #1's blood sugar "never stays high;" it was
high in the mornings because client #1 stayed up
and ate during the night.

- Client #1 did not refuse to take his Lantus;
Lantus was a long acting medication and helped
to keep client #1's blood sugar level "consistent."
- Client #1 had high blood sugar “all his life" and
he "felt funny" when his blood sugar was low.

During interview on 8/25/21 the QP stated some
of her responsibilities included ensuring
coordination of care and making sure staff carried
out recommendations made by the Physicians.

During interview on 9/02/21 the Clinical Director
stated:
- Client #1's August 3, 2021 Endocrinology
appointment prompted a team meeting in August.
- Client #1's team consisted of his Department of
Social Services Guardian, Local Management
Entity Care Coordinator, the QP, and the AFL
staff.

- The team discussed client #1's medical and
behavioral needs.

This deficiency is cross referenced into 10A

Division of Health Service Regulation
STATE FORM 6899 SBIZ11 If continuation sheet 25 of 27

PRINTED: 09/16/2021
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
R
MHL074-195 B. WING _____ 09/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

3309 MIDLAND COURT

BETTER CONNECTIONS MIDLAND CT GREENVILLE, NC 27833

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 291 | Continued From page 25 Vv 291

NCAC 27G .5601 Scope (v289) for a Type A1 rule
violation and must be corrected within 23 days.

V 736| 27G .0303(c) Facility and Grounds Maintenance | V 736

10A NCAC 27G .0303 LOCATION AND
EXTERIOR REQUIREMENTS

(c) Each facility and its grounds shall be
maintained in a safe, clean, attractive and orderly
manner and shall be kept free from offensive
odor.

his Rule is not met as evidenced by:

ased on observation and interviews the facility
was not maintained in a clean, attractive manner.
The findings are:

T
B

Observation on 8/24/21 at approximately 1:20 pm
of the facility revealed:

Heavy dried food splatter on the ceiling of the
microwave.

The laminate surface of the kitchen counter
near the sink was scuffed and faded.

Heavy dark stains to the carpet throughout the
facility.

Damage consistent with water damage to the
hall bathroom wall.

During interview on 8/24/21 the Alternative Family
Living staff stated he and the clients worked
together to keep the facility clean.

During interview on 9/01/21 the Quality
Assurance/Chief Executive Officer stated the
stains in the carpet had been cleaned but kept

Division of Health Service Regulation
STATE FORM 6899 SBIZ11 If continuation sheet 26 of 27

PRINTED: 09/16/2021

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHLO074-195 B. WING 09/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
3309 MIDLAND COURT
BETTER CONNECTIONS MIDLAND CT
GREENVILLE, NC 27833
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 736 | Continued From page 26 V 736
coming back. The only way to eliminate the
stains was to replace the carpet.
Division of Health Service Regulation
6899 SBIZ11 If continuation sheet 27 of 27

STATE FORM

document_type: Statement of Deficiency


raw_content:
Qa/egfeQis TUE Lit25 FAR WV0Ls NOL

PRINTED. 04/15/2019
; FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIER/CLIA SQMULTALE = CONSTRUCTION 4) DATE SURVEY |
AND PLAN OF CORRECTION IDENTIFICATION NUNIBER: ~ A.BUILDING: COMPLETED

R
MHL074-195 B.wiNe | 04/11/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
3309 MIDLAND COURT
BETTER GONNECTION MIDLAND CT GREENVILLE, NC 27833
aD SUMMARY STATEMENT OF DEFICIENCIES iD PROVIDER'S PLAN OF CORRECTION (x5)
PREEIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREEUC (EACH CORRECTIVE ACTION SHOULD BE COMPLETE

TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

¥ 000) INITIAL COMMENTS ¥ 000

An annual and followup survey was completed RECEIVED
on April 11, 2019, A deficiency was cited, By DHSR - Mental Health Li. & Cert. Section at 1:37 pm, Apr 23,2019,

This facitity is licensed for the following service
category: 109A NCAC 27G .5600F Supervised
Living/Alternative Family Living.

V 148) 27 .0209 (C) Medication Requirements Vv 118

10A NCAC 27G .0208 MEDICATION
REQUIREMENTS
(c) Medication administration:
(1) Prescription or non-prescription drugs shall
only be adrninistered to a client on the written
order of a person authorized by law to
prescribe drugs,
(2) Medications shail be self-administered
by clients only when authorized in writing
by the cllent’s physician.
(3) Medications, including injections, shall be
administered only by licensed persons, or by
unlicensed persons trained by a registered nurse,
pharmacist or other legally qualified person and
privileged to prepare and administer medications.
(4) A Medication Administration Record (MAR) of
all drugs administered to each client must be
kept current. Medications administered shall be
recorded immediately after administration. The
MAR Is to Include the following:
(Ajclient’s name;
(B)name, strength, and quantity of the drug;
(C)instructions for administering the drug:
(D)date and time the drug is administered; and
( )name or Initials of person administering the
rug.
(8) Client requests for medication changes or
checks shall be recorded and kept with the MAR
file followed up by appointment or consultation
with a physician,
Olvision of Health Serviea Regulation
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRES#S

&X8) DATE

STATE FORM Y coniinuation sheet 1 of 3

Qas2s/e2eNlLy TYE Li: 2G FAX MVS /00S

PRINTED: 04/15/2019

FORM APPROVED
Division of Health Service Requiation
STATEMENT OF DEFICIENCIES O47) PROVIDER/SUPPLIERJGLIA (QMULTELE CONSTRUCTION X43) DATE SURVEY
AND PLAN OF CORRECTION (OENTIFICATION NUMBER: ABUILDING: COMPLETED
R
MHLO74-195 B.WING, —_— 04/11/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
3309 MIDLAND COURT
BETTER CONNECTION MIDLAND CT GREENVILLE, NG 27833
KOID SUMMARY STATEMENT OF DEFICIENCIES iD PROVIDER'S PLAN OF CORRECTION ost
PREFIX (PACH DEFICIENCY MUST BE PRECEDED BY FULL PREEX (EACH CORRECTIVE ACTION SHOLILD BE COWPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 148} Continued From page 1 V148
VIB:
When individual has appointments with S/LL/19
MorCom or any othor Medical Provider
and AFL does not accompany the
This Rule is not met as evidenced by: Based individual, (he AFL Provider will consult
on record review, observation and interview, with RD and QP for any recommendations
the facility failed to administer medications noted whether new order for medications
on the written order of a physician and failed added/ discontinued, referrals, labs, etc.
lo kaep the MARs current affecting one of Documontation of consultation from ALF
two clients #1), The findings are: Provider will be noted in Therap for each
appointment to note that contact was made
Review on 04/10/19 of client #1's record with both the RD and/or QP for any
revealed: changes.
: A eat eee 12/076. Ifnew orders are written, AFL provider will
« Diagnoses of Autism, Intermittent Explosive ensure that medications are recived timely
Disorder, Moderate Intellectual Developmental and if nat, contact with his supervisor will
Disability and Acid Reflux. be made. RD/QP will notify assigned
Pharmacy and noted in Therap any
Review on 04/10/19 of a signed Nurse communication provided.
Practitioner order dated 03/14/19 revealed: - RD/OP will notify AFL provider via phone
Vitamin D (treats vitamin D deficiency)
, j call to note any changes made as a result of
§0,000units - take one by mouth twice a week on dail intments made Lor thi
Monday and Thursday for 8 weeks. anny’ ante! ay poiniments made Tor tals
individual following appointment.
Review on 04/10/19 of client #1's March 2019 OP will in-service RD on importance of
and April 2019 MARs revealed: following up on all orders to ensure
+ No transcribed entry for Vitamin D. individual's needs are being met to enguro
- No staff initials to indicate the Vitamin D was individual's health and safety focusing on
administered as ordered, providing orders to pharmacy in efforts to
| receive medication.
Observation on 04/10/19 at approximately . . .
3:00pm of client #1's medications revealed QP will provide oversight to cusure
no Vitamin 0 available for administration, medications afte current with matching
orders, Weckly cheeks will be completed
Interview on 04/10/19 the Clinical Director and documented on form provided. See
stated: - Client #1's health care provider had atlached,
prescribed the Vitamin D and the order was
supposed to have been faxed to the pharmacy.
Division of Health Service Ragulatlon
STATE FORM one gvazit oontinuation cheat 2 of 3

Qas2s/eNly TYE Li: 27 FAR

MANOa/Q0S

PRINTED; 04/15/2018

; FORM APPROVED
Division of Health Service Reguilatlon
STATEMENT OF DEFICIENCIES: (X12) PROVIDERASUPPLIER/OLIA KAMULTIPLE CONSTRUCTION (Xa) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED

R
MHL074~195 EAN nner | OA 112019

A.BUILDING:

NAME OF PROVIDER OR GUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
3309 MIDLAND COURT

BETTER CONNECTION MIDLAND CT GREENVILLE, NC 27833

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION xa

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (BACH CORRECTIVE ACTION SHOULD BE COMPLETE

TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118) Continuad Fram page 2 vi 4116

~ The pharmacy had nol filled the Vitamin D.
~ She would follow up to ensure medications were
administered as ordered.

[This deficiency constitutes a re-cited deficiency
and must be corrected with 30 days.]

—!

Dlvisien of Health Sarvica Regulation
STATE FORM

oe SVvAZi4 IfeontInuation aheat 3 of 3

MV0G/008

PAR

Qa/egfeQis TUE Lit a7

‘aivd

3lvd

“IWNOISS3IOUd Gand

STUALVNOIS S,AOLSNIC WILNIGISAd

: ANVd GALON
{aiavorldd’ 4!) SLNFIAIAO3 STVLLUINI S.481S

fon/saa}
61-LE- JONIS
3IANWN/Q3LON
SYaquO M3N

fon/s3A)
avi
NO GON ONY
LNaYuND HINO

SIAVN NOLLDVOIGIVE

6T-ST-P daLVd 20d GNYVTGIA
HOLITUIG TWLLNIGISIY ONY TWNOISSAIOud GAldITWND GINSISSY AG GALS Td NOD As OL
Qa8ICHO SV GAH ISINIINGY Juv SNOILVOIGAIA) 1Tv SHNSNA OL LSIIDSH3 NOILYSIGIW

6l-it-+ cl 40 NGS
JW ASIAN S,IVNIAIGNI

MV06/008

PAR

Qa/egfeQis TUE Lit a7

“Lyd

LV

“TWNOISS3IO¥d Gala vd

SSUNLYNDSIS S.WOLDFNIC TWILNAGISIY

=

(a1avoflddy Ji} SLNAIAINOD

fon/sa lon/sa
6T-£é-b JONIS uv
AlWd GaLON ZIWVN/GZLON| NO G3LON ONY
SIVLLINI S.45V1S SYaqYO GN | INayYND wId"O JIAVN NOLLOIGa

6T-ST-P G3L¥d0 90d GNVIOIA
YOIIuIG IWLINIOISSY ONY THNOISSS4Oud Gi[dITWND GANDISSY Ad G3LITdIAIOD 3d OL
O3d30YO S¥ GAYILSINIAGY JYV SNOILYDIGSW T1v SHMSNI OL LSITIDIH> NOLLY3IdsIAI

6l-rs Ea 40 NFIM
‘TW CSIAVN S.TYNGIAIGNE

VOT 008

PAR

Qa/egfeQis TUE Lit 2g

“Lyd

ivd

“IWNOISSSIONd GaldNvNd

SUNLYNOIS S HOLINIG TWLLNAGISaY

{On/s3A) {on/siA)
GE-£2-b JONIS Uy
AltWd G3LON ZWYN/G3LON | NO G3LON ONY
(Q1avol dd 41} SLNSININOD STVLUNI S,43,71S S¥30HO MIN} LNINUND yao JINVN NOILWOIGIW

6T-ST-P 0410 90d ONVIGIN
YOLIFUIG WILNIGISAY GNV TYNOISS3iOdd GIENWNAD GANDISSY Ad GI.L3IdINOS 38 OL
QavI0uO SV OAHSLSINIINGY Juv SNOLLVOIG3IAN T1¥ JeNSN3 OL LSIMOFH NOLLWOICIA

6I-TI-S el 740 1M
JW CSIAWN S.IWNGIAICNI

MVS 70S

PAR

Qa/egfeQis TUE Lit 2g

‘aivd

‘Jivd

“WNOISSSIOUd GaldITYND
SJUNLLYNODIS S.AYOLISHIC TwlLNAGISaY

7

fon/s3A) {ON/s3a)
6T-£i-p JONIS UvRI
AllWd GaL0N 3INVN/G3LON | NO G2LON ONY
(alavorlddy i) SLNSIAIAIOD STWILINI S.45¥15 SHICYO MAAN | LNIWHND yIaYO

SIAN NOILYOIOIA

61T-ST-P OALV0 30d CNVTOCIN
YOLITULG TWILNIGISTY ONY TYNOISSAIJOUd GAITWND GANSISSY Ad GIL31d NOD 3s OL
G3y30H0 S¥ GSS LSINIINGY JV SNOLLVOIOSIA) TIV JYNSN3I OL 1SIAD9H3 NOLLVOIGAIA)

st-8t-s I) 40M
“JA UBIAYN S,TWNGIAIGNI

Qas2s/e2eNlLy TYE Li: 2G FAX VOL /Q0S

& Sew, Wotves

| FA x & ; Toa <mumbe ANA AWS SOIC

| Better Connections Inc

I Better Connections in
. | 315.6iftons Street |, “ | Name: AED hoary "nae
| Greenville, NC 27858 . ~ | Bax number 252- 689° 6013
.

 edehianigencabaudaiaminaetee |

N 252-814-2418

lone pate: “4 ~ ~My

Regarding: ~~? S C- Skee

Number of sheets including cover: Phone number for follow-up:

|

ee aS aK DAE
Comment:

; .
4 . i
| This email transmission and any attachments to it are may contain confidential
j information and is intended solely for the use of the individual or entity to which it |
| is addressed. If you are not the addressed recipient, be notified that your use, :
} ' forwarding, printing, storing dissemination, distribution or copying of this

| communication is.prohibited. If you received this communication in error, please
notify Better Gonnectians Inc., immediately by return email asd delete document [+

I contents from your computer.
I
q


raw_content:
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

MHL074-195

BETTER CONNECTION MIDLAND CT

A. BUILDING:

B. WING

STREET ADDRESS, CITY, STATE, ZIP CODE

3309 MIDLAND COURT
GREENVILLE, NC 27833

(X2) MULTIPLE CONSTRUCTION

PRINTED: 04/15/2019
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
04/11/2019

(X4) ID
PREFIX
TAG

SUMMARY STATEMENT OF DEFICIENCIES.
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

ID
PREFIX
TAG

PROVIDER'S PLAN OF CORRECTION (x5)
(EACH CORRECTIVE ACTION SHOULD BE COMPLETE

CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

V 000

Vv 118

INITIAL COMMENTS

An annual and follow-up survey was completed
on April 11, 2019. A deficiency was cited.

This facility is licensed for the following service
category: 10A NCAC 27G .5600F Supervised
Living/Alternative Family Living.

27G .0209 (C) Medication Requirements

10A NCAC 27G .0209 MEDICATION
REQUIREMENTS

(c) Medication administration:

(1) Prescription or non-prescription drugs shall
only be administered to a client on the written
order of a person authorized by law to prescribe
drugs.
(2) Medications shall be self-administered by
clients only when authorized in writing by the
client's physician.

(3) Medications, including injections, shall be
administered only by licensed persons, or by
unlicensed persons trained by a registered nurse,
pharmacist or other legally qualified person and
privileged to prepare and administer medications.
(4) A Medication Administration Record (MAR) of
all drugs administered to each client must be kept
current. Medications administered shall be
recorded immediately after administration. The
MAR is to include the following:

(A) client's name;

(B) name, strength, and quantity of the drug;

(C) instructions for administering the drug;

(D) date and time the drug is administered; and
(E) name or initials of person administering the
drug.

(5) Client requests for medication changes or
checks shall be recorded and kept with the MAR
file followed up by appointment or consultation
with a physician.

Division of Health Service Regulation
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

STATE FORM

V 000

V 118

6899

SVZZ11

TITLE (X6) DATE

If continuation sheet 1 of 3

PRINTED: 04/15/2019
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
R
MHL074-195 B. WING _____ 04/11/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

3309 MIDLAND COURT

BETTER CONNECTION MIDLAND CT GREENVILLE, NC 27833

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118] Continued From page 1 V 118

This Rule is not met as evidenced by:

Based on record review, observation and
interview, the facility failed to administer
medications on the written order of a physician
and failed to keep the MARs current affecting one
of two clients (#1). The findings are:

Review on 04/10/19 of client #1's record
revealed:

- 47 year old male.

- Admission date of 12/07/16.

- Diagnoses of Autism, Intermittent Explosive
Disorder, Moderate Intellectual Developmental
Disability and Acid Reflux.

Review on 04/10/19 of a signed Nurse
Practitioner order dated 03/14/19 revealed:

- Vitamin D (treats vitamin D deficiency)
50,000units - take one by mouth twice a week on
Monday and Thursday for 8 weeks.

Review on 04/10/19 of client #1's March 2019
and April 2019 MARs revealed:

- No transcribed entry for Vitamin D.

- No staff initials to indicate the Vitamin D was
administered as ordered.

Observation on 04/10/19 at approximately
3:00pm of client #1's medications revealed no
Vitamin D available for administration.

Interview on 04/10/19 the Clinical Director stated:
- Client #1's health care provider had prescribed
the Vitamin D and the order was supposed to
have been faxed to the pharmacy.

Division of Health Service Regulation

STATE FORM 6899 SVZZ11 If continuation sheet 2 of 3

PRINTED: 04/15/2019

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHLO074-195 B. WING 04/11/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

3309 MIDLAND COURT

BETTER CONNECTION MIDLAND CT GREENVILLE, NC 27833

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)
V 118| Continued From page 2 V 118

- The pharmacy had not filled the Vitamin D.
- She would follow up to ensure medications were
administered as ordered.

[This deficiency constitutes a re-cited deficiency
and must be corrected with 30 days.]

Division of Health Service Regulation
STATE FORM 6899 SVZZ11 If continuation sheet 3 of 3


raw_content:
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

MHL074-195

BETTER CONNECTION MIDLAND CT

A. BUILDING:

B. WING

STREET ADDRESS, CITY, STATE, ZIP CODE

3309 MIDLAND COURT
GREENVILLE, NC 27833

(X2) MULTIPLE CONSTRUCTION

PRINTED: 03/29/2018
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
03/28/2018

(X4) ID
PREFIX
TAG

SUMMARY STATEMENT OF DEFICIENCIES.
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

ID
PREFIX
TAG

PROVIDER'S PLAN OF CORRECTION (x5)
(EACH CORRECTIVE ACTION SHOULD BE COMPLETE

CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

V 000

Vv 118

INITIAL COMMENTS

An annual and follow up survey was completed
on March 28, 2018. A deficiency was cited.

This facility is licensed for the following service
category: 10A NCAC 27G .5600F, Supervised
Living/Alternative Family Living.

27G .0209 (C) Medication Requirements

10A NCAC 27G .0209 MEDICATION
REQUIREMENTS

(c) Medication administration:

(1) Prescription or non-prescription drugs shall
only be administered to a client on the written
order of a person authorized by law to prescribe
drugs.
(2) Medications shall be self-administered by
clients only when authorized in writing by the
client's physician.

(3) Medications, including injections, shall be
administered only by licensed persons, or by
unlicensed persons trained by a registered nurse,
pharmacist or other legally qualified person and
privileged to prepare and administer medications.
(4) A Medication Administration Record (MAR) of
all drugs administered to each client must be kept
current. Medications administered shall be
recorded immediately after administration. The
MAR is to include the following:

(A) client's name;

(B) name, strength, and quantity of the drug;

(C) instructions for administering the drug;

(D) date and time the drug is administered; and
(E) name or initials of person administering the
drug.

(5) Client requests for medication changes or
checks shall be recorded and kept with the MAR
file followed up by appointment or consultation
with a physician.

Division of Health Service Regulation
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

STATE FORM

V 000

V 118

6899

SK6P11

TITLE (X6) DATE

If continuation sheet 1 of 4

PRINTED: 03/29/2018
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
R
MHL074-195 B. WING _____ 03/28/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

3309 MIDLAND COURT

BETTER CONNECTION MIDLAND CT GREENVILLE, NC 27833

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)
V 118] Continued From page 1 V 118

This Rule is not met as evidenced by:

Based on record review, observation, and
interview the facility failed to administer
medications as ordered by a physician and failed
to keep MARs current affecting one of two
audited clients (#2) the findings are:

Review on 3/28/18 of Client #2's record revealed:
- 22 year old male admitted to the facility 6/03/13.
- Diagnoses included Asperger's Syndrome,
Oppositional Defiant Disorder, Mood Disorder,
Borderline Intellectual Functioning, Asthma,
Seasonal Allergies.

- Physician's orders, signed 11/20/17, for
Trazodone (used to treat depression, anxiety, and
insomnia), 100 mg (milligrams) at bedtime, and
Montelukast (generic for Singulair, used to treat
allergies and prevent asthma attacks), 10 mg, 1
tablet every evening "during allergy season."

- "Consultation Form" signed by physician 3/20/18
with order to increase Trazodone to 150 mg at

bedtime.
- "Consultation Form" signed by physician
11/20/17 ". . . Patient can take medications when

he wishes in regard to timing."
- No documentation by the physician to clarify
“allergy season."

Review on 3/28/18 of Client #2's MAR for March
2018 revealed no transcribed entry for
Trazodone, 150 mg at bedtime.

Review on 3/28/18 of Client #2's MAR's for
January - March 2018 revealed:

- Transcribed entry for Trazodone, 100 mg, 1
Division of Health Service Regulation

STATE FORM 6899 SK6P11 If continuation sheet 2 of 4

PRINTED: 03/29/2018
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
R
MHL074-195 B. WING _____ 03/28/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

3309 MIDLAND COURT

BETTER CONNECTION MIDLAND CT GREENVILLE, NC 27833

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)
V 118| Continued From page 2 V 118

tablet every evening..

- Transcribed entry for Montelukast 10 mg 1
tablet every evening; no staff initials to indicate
Montelukast had been administered.

Observation on 3/28/18 at approximately 10:00
am of Client #2's medications revealed:

- Blister card with pharmacy label Trazodone 100
mg, 1 tablet by mouth every evening, dispensed
2/26/18.

- No Trazodone 150 mg on hand.

- Montelukast 10 mg, one tablet every evening.

Interview on 3/28/18 Staff #1 stated:

- He would take Client #2 to his doctors’
appointments and would wait in the lobby while
Client #2 was with the doctor.

- Client #2 would give him the "consultation form"
completed by the physician after his
appointments.

- If the doctor made changes to Client #2's
medication regimen, he would make sure the
pharmacy received the new order, make copies
of the consultation form for the Residential
Director and the Qualified Professional, and
make sure the new order was transcribed onto
he MAR.

- He did not see the change to Client #2's
Trazodone on the consultation form dated
3/20/18.

- He would contact the pharmacy to make sure
hey received the updated order.

- Client #2 would take his Montelukast when he
elt allergy symptoms, it was supposed to be
laken as needed.

- He would ask the physician to clarify "allergy
eason" and the medication order.

i)

nterview on 3/28/18 the Residential Director
stated:

Division of Health Service Regulation

STATE FORM 6899 SK6P11 If continuation sheet 3 of 4

PRINTED: 03/29/2018

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHLO074-195 B. WING 03/28/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

3309 MIDLAND COURT

BETTER CONNECTION MIDLAND CT GREENVILLE, NC 27833

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118| Continued From page 3 V 118

- He completely missed the medication change
when he reviewed the consultation form dated
3/20/18.

- The pharmacy had been contacted and had
received the physician's order for Trazodone 150
mg, but had not delivered the new medication to
the facility.

- Trazodone 150 mg would be delivered to the
facility by the end of the business day 3/28/18.

Division of Health Service Regulation
STATE FORM 6899 SK6P11 If continuation sheet 4 of 4


facility_name: Alexander Youth Network - Charlotte Day Treatment

summary: Statement of Deficiency - MHLCS Follow-up

raw_content:
PRINTED: 07/07/2025

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL060968 B. WING 06/30/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE CHARLOTTE, NC 28211

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)
{V 000}| INITIAL COMMENTS {V 000}

A follow up survey was completed on June 30,
2025. No deficiencies were cited.

This facility is licensed for the following service
category: 10A NCAC 1400 Day Treatment For
Children And Adolescents With Emotional Or
Behavioral Disturbances.

This facility has a current census of 34.

Division of Health Service Regulation
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

STATE FORM 6899 KUZIN2 If continuation sheet 1 of 1

inspection_type: MHLCS Follow-up


summary: Statement of Deficiency - MHLCS Complaint

raw_content:
PRINTED: 06/09/2025

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL060968 06/03/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1
CHARLOTTE, NC 28211
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000} INITIAL COMMENTS V 000

Acomplaint survey was completed on 6-3-25.
The complaint was unsubstantiated (Intake
#NC00230794). No deficiencies were cited.

This facility is licensed for the following service
category: 10ANCAC 1400 Day Treatment For
Children And Adolescents With Emotional Or
Behavioral Disturbances.

This facility has a current census of 34. The
survey sample consisted of audits of 1 former
client.

Division of Health Service Regulation
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

STATE FORM

6899

YDZ911

TITLE (X6) DATE

If continuation sheet 1 of 1

inspection_type: MHLCS Complaint