summary: Plan of Correction - MHLCS Annual

raw_content:
PRINTED: 01/04/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X38) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED

346303 B.WING_ 12/19/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD
CHARLOTTE, NC 28212

(X4) 10 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL. (GACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE. DATE

DEFICIENCY)

MONROE ROAD

STAFF TREATMENT OF CLIENTS W153 2/17/2019
CFR(s): 483.420(d)(2)
RHA Health Services, LLC will ensure 3
The facility must ensure that all allegations of staff are in-service trained on the Incide!
mistreatment, neglect or abuse, as well as Reporting policy and are completing
injuries of unknown source, are reported incident reports for all individuals supported
immediately to the administrator or to other as needed when reportable incidents occur.
officials in accordance with State law through RHA will ensure all incident
established procedures. reports are reviewed and needed follow+
up completed for each individual by the
LPN and QP in a timely manner.
All incident reports and follow-up care are
reviewed monthly by the Regional
Administrator. This process is monitored
monthly by the Safety and CQI team
meetings.

it

This STANDARD is not met as evidenced by:
Based on observation, record review and
interviews, the facility failed to ensure an injury
was reported to the administrator immediately for
1 of 3 sampled clients (#3). The finding is:

Observations conducted in the group home on
12/18/18 at 4:50 PM revealed client #3 had an
open, excoriated area approximately 1/2 inch in
diameter on her left hand near the base of her
thumb. Interview conducted with direct care staff
at that time revealed no knowledge of how or
when the injury to client #3's left hand occurred.

Review of incident/accident reports for client #3,
conducted on 12/19/18, revealed the most recent
incident involving injury to client #3 was dated
5/11/48 and documented client #3 was scratched
on the arm by another client on that date.
Interviews conducted with the qualified intellectual
disabilities professional (QIDP) and the nurse
revealed the injury to client #3's hand had not
been reported to the QIDP or the nurse and no
treatment treatment had been documented as
having been completed. Further interview with
the nurse verified the injury to client #3's hand
should have been reported to the nurse and the
QIDP immediately.

NURSING SERVICES

ww
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mba
ea
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TITLE (X6) DATE,
Regional Administrator 41/9/2019

‘Any deficionayatétertent ghding with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide Sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided, For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued
program participation,

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID; SP2H11 Facility 1D: 924961 If continuation sheet Page 1 of 6

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

34G303
NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

(x4) 10 SUMMARY STATEMENT OF DEFICIENCIES
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL
TAG REGULATORY OR LSC IDENTIFYING INFORMATION)

Continued From page 1
CFR(s): 483.460(c)

The facility must provide clients with nursing
services in accordance with their needs.

This STANDARD is not met as evidenced by:
Nursing services failed to provide services in
accordance with client needs relative to ensuring
staff are properly trained in the administration of
medications procedures for 4 of 4 clients
observed during medication administration (#2,
#3, #5 and #6) as evidenced by observations and
interviews. The findings are:

A. Nursing services failed to ensure staff was
knowledgeable of the appropriate procedures for
administering medications relative to sanitation,
client participation, and client teaching for client
#3. For example:

Observations of the medication administration for
client #3 on 12/19/18 at 7:11 AM revealed client
#8 to receive Cymbalta 30 mg, Cymbalta 60 mg,
Vitamin D, and Claritin. Further observation
revealed staff to punch medications into her
ungloved hand and subsequently into a med cup,
after she had used her ungloved hand to cover
her mouth from her cough. Continued
observations revealed staff did not provide
teaching to client #3 about the medications, their
purpose, or possible side effects. Further
observations revealed staff did not encourage
client #3's participation in the med administration
except for the pouring of client #3's water with
which to swallow her medications. Further
observations revealed staff to use a plastic spoon
to scrape medications out of the med cup for

client #3 after client #3 put the med cup to her
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: SP2H11

PRINTED: 01/04/2019
FORM APPROVED
OMB NO. 0938-0391

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
A. BUILDING COMPLETED

Be AING 12/19/2018
STREET ADDRESS, CITY, STATE, ZIP CODE.
7621 MONROE ROAD
CHARLOTTE, NC 28212
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE

CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

W 331

RHA Health Services, LLC will ensure
all Medication Administration policies wi
be followed by Direct Care staff when
administering medications AEB:

1) In-servicing direct care staff to wash
hands and put on clean gloves prior to
punching medications for administration
2) In-servicing direct care staff to stop
the medication pass and wash hands and
reapply clean gloves if they cough into
their hands.

3) In-servicing direct care staff to educate
all individuals on the purpose of and
possible side effects of all medications
during the medication pass.

4) In-servicing direct care staff to avoid
cross contamination after using utensils
to administer medications to the
individual(s) by ensuring the used utens
is washed appropriately before placing
in storage with clean utensils.

5) In-servicing direct care staff to ensure
the privacy of the individuals during the
medication pass by knocking on their
bedroom door prior to entering their root
and closing the bedroom door to avoid

others from overhearing HIPPA informat
6) In-servicing direct care staff to ensure’
any dropped or broken medications are
reported to the On Call Nurse and disposed
of appropriately and not administered.
7) In-servicing direct care staff to ensure!
they communicate appropriately with all
individuals during the medication pass
including sign language when needed.
Con't pg

Facility 1D; 924981 if continuation sheet Page 2 of 6

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

346303
NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL
TAG REGULATORY OR LSC IDENTIFYING INFORMATION)

Continued From page 2

mouth. Subsequent observation revealed the staff
to return the contaminated spoon to the large
container of clean spoons.

Interview with the facility nurse on 12/19/18
confirmed staff should have used gloved/clean
hands and thrown away the contaminated spoon
to prevent the spread of germs. Continued
interview with the facility nurse conformed staff
should have provided teaching to client #3 about
her medications, their purpose and possible side
effects, and encouraged participation at each
step of the medication pass for client #3.

B. Nursing services failed to ensure staff was
knowledgeable of the appropriate procedures for
administering medications relative to privacy,
sanitation, client participation, and client teaching
for client #2. For example:

Observations of the medication administration for
client #2 on 12/19/18 at 6:08 AM revealed staff to
enter client #2's room without knocking and
proceeded to administer medications, leaving the
door open as other clients passed by. Further
observation revealed client #2 sitting on her bed
in her room where she remained during the
medication pass. Continued observation
revealed #2 to receive Inhospitable 500 mg,
Abilify 2 mg, Zyrtec 10 mg, Zoloft 100 mg,
Synthroid 137 mg and Vit D. Continued
observations revealed staff to punch all
medications into her ungloved hand, later
transferring them into a medication cup. Further
observations revealed staff broke a medication
which fell onto a used bubble pack, which she
proceeded to add to the medication cup and
administer to client #2. Continued observations
revealed staff did not provide teaching about the

FORM CMS-2567(02-9) Previous Versions Obsolete Event ID: SP2H14

PRINTED: 01/04/2019
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING.

B. WING 12/19/2018

STREET ADDRESS, CITY, STATE, ZIP CODE.
7621 MONROE ROAD
CHARLOTTE, NC 28212
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE

CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

Con't from pg 2:

8) In-servicing staff to allow and
encourage all individuals

fo participate in each medication pass
based on their abilities and preferences.
RHA Health Services, LLC will ensure
compliance with these policies and practices
by completing at least two (2) Medicatio:
Observation Assessments each week
for 60 days by the Group Home Supervisor,
Habilitation Specialist, QP and LPN. Thi
process will be monitored ongoing
through required Medication Observatio!
each month and reviewed at the Safety
and CQI team meetings each month.

Facility ID; 924981 If continuation sheet Page 3 of 6

PRINTED: 01/04/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES (%1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X38) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED

346303 B.WING 12/19/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

MONROE ROAD 7621 MONROE ROAD
CHARLOTTE, NC 28212
(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION Ks)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 331 | Continued From page 3 W331

medications, their use or side effects to client #2.
Subsequent observations revealed staff did not
encourage client #2's participation in the med
administration except for the pouring of client #2's
water for administration of medications, which
client #2 did independently.

Interview with the facility nurse confirmed staff
should have provided privacy, used gloved
hands, provided teaching to client #2 about her
medications their purpose and possible side
effects, and encouraged participation at each
step of the medication pass for client #2.

C. Nursing services failed fo ensure staff was
knowledgeable of the appropriate procedures for
administering medications relative to privacy,
sanitation, client participation, and client teaching
for client #5. For example:

Observations of the medication administration for
client #5 on 12/19/18 at 6:18 AM revealed client
#5 to be seated at the breakfast table preparing
to eat breakfast. Continued observations revealed
staff to enter client #5's room without knocking or
permission, pulling the medication cart with her.
Further observations revealed staff to request
client #5 to come to her room to take her
medication, which she did. Continued
observations revealed client #5 to receive Oscal
for her morning medication. Further observation
revealed staff to punch the medication into her
ungloved hand, later transferring the medication
into a medication cup. Further observations
revealed staff did not engage client #5 in sign
language or participation in the med pass.
Further observations revealed staff did not
provide teaching about the medications, their use
or side effects to client #5. Subsequent

FORM CMS-2567(02-98) Pravious Versions Obsolete Event ID: SP2H11 Facility ID; 924981 {f continuation sheet Page 4 of 6

PRINTED: 01/04/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES (%1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION |(X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING. COMPLETED

34G303 8. WING —_____§£ i 12/19/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD
CHARLOTTE, NC 28212

(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE

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

MONROE ROAD

Continued From page 4

observations revealed staff did not encourage
client #5's participation in the med administration
except for the pouring of client #5's water for
administration of medications, which client #5
accomlished with hand over hand assistance
from staff.

Interview with the facility nurse on 12/19/18
confirmed staff should utilize sign lanuage with
client #5 for her med pass. Continued interview
with the facilty nurse confirmed staff should have
provided teaching to client #5 about her
medications, their purpose and possible side
effects, along with encouraging participation at
each step of the medication pass for client #5.

D. Nursing services failed to ensure staff was
knowledgeable of the appropriate procedures for
administering medications relative to sanitation,
client participation, and client teaching for client
#6. For example:

Observations of the medication administration for
client #6 at 6:30 AM on 12/19/18 at revealed
client #6 to be sitting on her bed in her bedroom.
Continued observations revealed client #6 to
receive Colase 50 mg, Keppra 500mg, and
Lactalose 15 cc. Further observations revealed
staff to punch all medications into her ungloved
hand, later transferring them into a medication
cup. Continued observations revealed staff did
not provide teaching about the medications or
their use or side effecis to client #6. Subsequent
observations revealed staff did not encourage
client #6's participation in the med administration
except for the pouring of client #6's water for
administration of medications, which client #6 did
with assistance from staff.

FORM CMS-2567 (02-98) Previous Versions Obsolete Event 1D: SP2H11 Facility 1D; 824981 If continuation sheet Page 5 of 6

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES (X41) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

346303
NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL
TAG REGULATORY OR LSC IDENTIFYING INFORMATION)

Continued From page 5

Interview with the facility nurse confirmed staff
should have used gloved hands, provided
teaching to client #6 about her medications, their
purpose and possible side effects, and
encouraged participation at each step of the
medication pass for client #6.

FORM CMS-2567(02-99) Pravious Versions Obsolete

Event (iD: SP2H11

(X2) MULTIPLE CONSTRUCTION

A. BUILDING,

B. WING.

PRINTED: 01/04/2019
FORM APPROVED
OMB NO. 0938-0391

(X3} DATE SURVEY
COMPLETED

12/19/2018

STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD
CHARLOTTE, NC 28212

io

TAG

a ooo

Facility 1D: 924981

PROVIDER'S PLAN OF CORRECTION xs)
(EACH CORRECTIVE ACTION SHOULD BE COMPLETION
CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

If continuation sheet Page 6 of 6


state: NC

facility_name: Smith Care LLC

summary: Plan of Correction - MHLCS Annual

raw_content:
PRINTED: 04/01/2019

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: COMPLETED
A. BUILDING
MHLO13-195 8. WING ______________ 03/27/2019
NAME OF PROVIDER OR SUPPLIER, STREET ADDRESS, CITY, STATE, ZIP CODE

9167 HYDRANGEA DRIVE

SMITH HOME
HARRISBURG, NC 28075
(4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (x5)
E COMPLETE

PREFIX (GACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

V 000) INITIAL COMMENTS Vv 000

| An annual survey was completed on 3/27/19.
Deficiencies were cited.

This facility is licensed for the folllowing service
category: 10A NCAC 27G .5600F Alternative

ale i DHSR - Mental Health
V 108) 27G .0202 (F-I) Personne! Requirements Vv 108 APR 1 5 2019

410A NCAC 27G .0202 PERSONNEL
REQUIREMENTS : :

(f) Continuing education shall be documented. Lic. & Cert. Section
(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 Hgaith Service Regulation
LABORATORY DIRECTOR'S OR PROYIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE (x6) DATE

Ahh ~_ Bhsr00/ Kesolenbat, ] Paral Aya Lf DolG_

STATE FORM COFL11 Teontinuaton shoot 4 of

PRINTED: 04/01/2019
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: re EB COMPLETED
.. BUILDING:
MHLO13-195 8. WING _£____W— 03/27/2019
NAME OF PROVIDER OR SUPPLIER, STREET ADDRESS, CITY, STATE, ZIP CODE
9167 HYDRANGEA DRIVE
‘SMITH HOME
HARRISBURG, NC 28075
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES iD PROVIDER'S PLAN OF CORRECTION os)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (ACH 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 Vil08 V108 27G ~=.0202. (F-I)_ Personnel
clients. Requirements
10A NCAC 27G. 0202 PERSONNEL!
REQUIREMENTS
Correction: Support Staff is scheduled to
This Rule is not met as evidenced by: receive FA/CPR on April 9, 2019. Client
Based on interviews, observations and record Specific training will be provided once all
reviews, the facility failed to ensure all staff required trainings are competed.

completed trainings in general organizational
orientation, training in client rights and

confidentiality, training to meet the mh/dd/sa Prevention: TSG will ensure all Back-up
needs of the client as specified in the | staff are trained on Personnel Requirements
treatment/habilitation plan, training in infectious to ensure individuals served are healthy and
diseases and bloodborne pathogens and the safe.
facility also failed to ensure at least one staff |
member trained in basic first aid including seizure Who Will Monitor: The Office Manager
management, currently trained to provide | will verify and monitor that requirements are
cardiopulmonary resuscitation and trained in the completed and current.
Heimlich maneuver or other first aid techniques |
| was available in the facility at all times when The QP and/or the monitoring specialist will
clients were present affecting 2 of 2 clients (#1, monitor if new Back-up staff is identified to
| #2) The findings are:

ensure requirements are fulfilled before
support is provided. Monitoring to be

Observation on 3/25/19 at 3:00pm revealed a conducted monthly or as needed.

male adult in the facility with staff #1.

Review on 3/22/19 of client #1's record revealed:
-admission date of 11/10/14 with diagnoses of
COPD, Encephalopathy, Osteoarthritis, Asthma,
Schizoaffective Disorder, Depressive Disorder,

| Borderline Personality Disorder and Intellectual
Developmental Disabilities(IDD)-Moderate.

Review on 3/22/19 of client #2's record revealed.
-admission date of 4/5/18 with diagnoses of
PTSD, Personality Disorder, Bipolar Disorder,
Psychosis Disorder, Depression, Acid Reflux,
Hypothyroidism, Obesity, Anxiety, IDD-Moderate,
Migraines and Adjustment Disorder.

Division of Health Service Regulation

STATE FORM an COFLI1 If continuation sheet 2 of 18

Division of Health Service Regulation

PRINTED: 04/01/2019

FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

MHLO13-195

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

B. WING

(X3) DATE SURVEY

COMPLETED

03/27/2019

NAME OF PROVIDER OR SUPPLIER

SMITH HOME

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

(x4) 1D
PREFIX
TAG

STREET ADDRESS, CITY, STATE, ZIP CODE.

9167 HYDRANGEA DRIVE
HARRISBURG, NC 28075

| ID

PREFIX
TAG

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

(x5)
COMPLETE
DATE

V 108

Continued From page 2

Interview on 3/25/19 with client #1 revealed when
staff #1 goes places, "[the adult male] watches
them sometimes.”

Interview on 3/25/19 with client #2 revealed if staff
#1 has to run an errand, “[the adult male]
watches them."

Interview with staff #1 revealed the adult male
was her boyfriend and watched client #1 and #2
sometimes if she has to run a quick errand.

Request on 3/27/19 to review the personnel
record and trainings of the adult male in the
facility providing care for clients #1 and #2 was
unsuccessful as there was not a personnel record
| or trainings to review.

Interview on 3/27/19 with the Residential Director
revealed:

-staff #1's boyfriend does not live in the facility;
-he only visits from time to time;

-considered a "natural support,"

-can watch clients #1 and #2 up to three hours
per their policy and no training required;

-this policy was created by a former administrator
regarding an issue at another facility;

-do not have a personnel record on the adult
male in the facility;

-the adult male in the facility does not have any
completed trainings.

V 118 27G .0209 (C) Medication Requirements

10A NCAC 27G .0209 MEDICATION
REQUIREMENTS

(c) Medication administration:

| (1) Prescription or non-prescription drugs shall

Division of Health Service Regulation
STATE FORM

Vv 108

Vv 118

COFL11

if continuation sheet 3 of 18

PRINTED: 04/01/2019

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
MHLO13-195 BAWING 03/27/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
9167 HYDRANGEA DRIVE
‘SMITH HOME
HARRISBURG, NC 28075
(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES | 10 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)
Vv 118| Continued From page 3 Vv 118

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 shal! 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 records review, observation and
interviews, the facility failed to ensure
medications were administered as ordered
affecting 1 of 2 clients (#1). The findings are:

Review on 3/22/19 of client #1's record revealed:
-admission date of 11/10/14 with diagnoses of
COPD, Encephalopathy, Osteoarthritis, Asthma,

Division of Health Service Regulation

STATE FORM

699

COFL11

If continuation sheet 4 of 18

Division of Health Service Regulation

PRINTED: 04/01/2019
FORM APPROVED

Division of Health Service Regulation

STATE FORM

sacs

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 7 COMPLETED
A. BUILDING:
MHL013-195 B.WING ——— 03/27/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
9167 HYDRANGEA DRIVE
h IE
SMITH HOM HARRISBURG, NC 28075
(%4) 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 4 V 118 |
|
Schizoaffective Disorder, Depressive Disorder, | |
Borderline Personality Disorder and Intellectual Vi18 =27G_=— 0209. (C)_—— Medication
Developmental Disabilities-Moderate; Requirements |
-physicians' orders dated 1/9/19 for
Triamcinolone ointment apply twice daily to groin 10 NCAC 27G .0209 MEDICATION
and Ketoconazole cream apply once daily to right REQUIREMENTS
groin
Observation on 3/25/19 at 2:58pm of client #1's
medications on site revealed: Correction: Medications sited Triamcinolone
-Triamcinolone ointment apply twice daily to groin ointment and Ketoconazole cream is available
not on site: in the home. Medication listed above is now
-Ketoconazole cream apply once daily to right added to the Medication Administration
groin not on site. Record,
Review on 3/22/19 and 3/25/19 of client #1's
MARS from 1/1/19-3/22/19 revealed: — .
-Triamcinolone ointment apply twice daily and Prevention: TSG will CRSUES: the AFL Staff
Ketoconazole cream apply once daily not listed kecp medication current in the home. Along
| on MARs for 1/2019, 2/2019 and 3/2019; with all current prescriptions, orders, and
-no documentation on the 1/2019, 2/2019 and discontinue orders. TSG will ensure all AFL
3/2019 MARs Triamcinolone ointment apply twice Staff are trained on Medication management
daily and Ketoconazole cream apply once daily including ensuring all Medication is added to
was administered. the MAR accurately.
Interview on 3/25/19 with client #1 revealed she
was not aware of any missed medications.
Who Will Monitor: The On-Site Nurse will
Interview on 3/27/19 with the Nurse revealed: monitor and observe Medication, Orders and
-not sure why medications were not on MARs; MAR’s Monthly or as needed to ensure
-not sure why medications were not administered; —
5 . pliance.
-will ensure correct medications were listed on
| MARS and medications administered as
prescribed.
V 131) G.S. 134-256 (D2) HCPR - Prior Employment Vv 131
Verification
G.S. §131E-256 HEALTH CARE PERSONNEL |

COFL11

If continuation sheet 5 of 18

PRINTED: 04/01/2019

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
MHL013-195 Brine 03/27/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
9167 HYDRANGEA DRIVE
SMITH HOME
HARRISBURG, NG 28075
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (GACH 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 131] Continued From page 5 Vv 131

REGISTRY

(d2) Before hiring health care personnel into a
health care facility or service, every employer at a
health care facility shall access the Health Care
Personnel Registry and shall note each incident
of access in the appropriate business files.

This Rule is not met as evidenced by:
Based on records review, observations and

| interviews, the facility failed to access the

HCPR(Health Care Personnel Registry). The
findings are:

Observation on 3/25/19 at 3:00pm revealed a
male adult in the facility with staff #1.

Review on 3/22/19 of client #1's record revealed:
-admission date of 11/10/14 with diagnoses of
COPD, Encephalopathy, Osteoarthritis, Asthma,
Schizoaffective Disorder, Depressive Disorder,
Borderline Personality Disorder and Intellectual
Developmental Disabilities(IDD)-Moderate.

Review on 3/22/19 of client #2's record revealed
-admission date of 4/5/18 with diagnoses of
PTSD, Personality Disorder, Bipolar Disorder,
Psychosis Disorder, Depression, Acid Reflux,
Hypothyroidism, Obesity, Anxiety, |DD-Moderate,
Migraines and Adjustment Disorder.

Interview on 3/25/19 with client #1 revealed when
staff #1 goes places, "[the adult male] watches
them sometimes."

Interview on 3/25/19 with client #2 revealed if staff

V 131 G.S. 131E-256 (D2) HCPR Prior
Employment Verification

| GS. 131E-256 (D2) HEALTH CARE
PERSONNEL REGISTRY

Correction: Therapeutic Services Group
(TSG) retrieved a Health Care Personnel
Registry (HCPR).

Prevention: TSG will ensure a HCPR be
accessed and results documented for each
back-up staff prior to providing support for
the AFL Contractor.

Who Will Monitor: The Office Manager
will verify and monitor that requirements are
completed and current annually.

‘The QP and/or the monitoring specialist will
monitor if new Back-up staff is identified to
ensure requirements are fulfilled before
support is provided. Monitoring to be
conducted monthly or as needed.

Division of Health Service Regulation

STATE FORM

COFL11

If continuation sheet 6 of 18

(x4) 1D
PREFIX
TAG

Vv 131

V 133)

Division of Health Service Regulation

‘STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

SMITH HOME

PRINTED: 04/01/2019
FORM APPROVED

(X1) PROVIDERYSUPPLIERYCLIA
IDENTIFICATION NUMBER:

MHL013-195

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

B. WING

A. BUILDING:

9167 HYDRANGEA DRIVE

HARRISBU!

IRG, NC 28075

COMPLETED

03/27/2019

STREET ADDRESS, CITY, STATE, ZIP CODE

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

1D
PREFIX
TAG

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

CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

Continued From page 6

#1 has to run anerrand, "[the adult male]
watches them."

Interview with staff #1 revealed the adult male
was her boyfriend and watched client #1 and #2
sometimes if she has to run a quick errand.

Request on 3/27/19 to review the personnel
record and HCPR check of the adult male in the
facility providing care to clients #1 and #2 was
unsuccessful as there was not a personnel record
or HCPR check to review.

Interview on 3/27/19 with the Residential Director
revealed:

-staff #1's boyfriend does not live in the facility;
-he only visits from time to time;

-considered a "natural support;"

-can watch clients #1 and #2 up to three hours
per their policy;

-this policy was created by a former administrator
regarding an issue at another facility;

-do not have a personnel record on the adult
male in the facility;

-the adult male in the facility does not have a
HCPR check since he does not reside in the
facility.

G.S. 122C-80 Criminal History Record Check

G.S. §122C-80 CRIMINAL HISTORY RECORD
CHECK REQUIRED FOR CERTAIN
APPLICANTS FOR EMPLOYMENT.

(a) Definition. - As used in this section, the term
"provider" applies to an area authority/county
program and any provider of mental health,
developmental disability, and substance abuse

| services that is licensable under Article 2 of this

Chapter.

V 131

V 133

Division of Health Service Regulation

STATE FORM

338

COFL11

if continuation sheet 7 of 18

Division of Health Service Regulation

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FORM APPROVED

(b) Requirement. - An offer of employment by a
provider licensed under this Chapter to an
applicant to fill a position that does not require the
applicant to have an occupational license is
conditioned on consent to a State and national
criminal history record check of the applicant. If
the applicant has been a resident of this State for
less than five years, then the offer of employment
is conditioned on consent to a State and national
criminal history record check of the applicant. The
national criminal history record check shall
include a check of the applicant's fingerprints. If
the applicant has been a resident of this State for
five years or more, then the offer is conditioned
on consent to a State criminal history record
check of the applicant. A provider shall not
employ an applicant who refuses to consent to a
criminal history record check required by this
section. Except as otherwise provided in this
subsection, within five business days of making
the conditional offer of employment, a provider
shall submit a request to the Department of

| Justice under G.S. 114-19.10 to conduct a
criminal history record check required by this
section or shall submit a request to a private
entity to conduct a State criminal history record
check required by this section. Notwithstanding
GS. 114-19.10, the Department of Justice shall
return the results of national criminal history

| record checks for employment positions not
covered by Public Law 105-277 to the
Department of Health and Human Services,
Criminal Records Check Unit. Within five
business days of receipt of the national criminal
history of the person, the Department of Health
and Human Services, Criminal Records Check
Unit, shall notify the provider as to whether the
information received may affect the employability
of the applicant. In no case shall the results of the

STATEMENT OF DEFICIENCIES (X1) PROVIDER/ISUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING. COMPLETED
MHL013-195 EWING 03/27/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
9167 HYDRANGEA DRIVE
SMITH HOME
HARRISBURG, NC 28075
(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 133} Continued From page 7 V 133

Division of Health Service Regulation
STATE FORM

6809

COFLI1

lf continuation sheet 8 of 18

Division of Health Service Regulation

PRINTED: 04/01/2019
FORM APPROVED.

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(Xt) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

MHL013-195

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
A. BUILDING:

COMPLETED

03/27/2019

STREET ADDRESS, CITY, STATE, ZIP CODE

9167 HYDRANGEA DRIVE

national criminal history record check be shared
with the provider. Providers shall make available
upon request verification that a criminal history
check has been completed on any staff covered
by this section. A county that has adopted an
appropriate local ordinance and has access to
the Division of Criminal Information data bank
may conduct on behalf of a provider a State
criminal history record check required by this
section without the provider having to submit a
request to the Department of Justice. In such a
case, the county shall commence with the State
criminal history record check required by this
section within five business days of the
conditional offer of employment by the provider.
All criminal history information received by the
provider is confidential and may not be disclosed,
except to the applicant as provided in subsection
(c) of this section. For purposes of this
subsection, the term "private entity" means a
business regularly engaged in conducting
criminal history record checks utilizing public
records obtained from a State agency.

(c) Action. - If an applicant's criminal history
record check reveals one or more convictions of

| arelevant offense, the provider shall consider all

of the following factors in determining whether to
hire the applicant:

(1) The level and seriousness of the crime.

(2) The date of the crime.

| (3) The age of the person at the time of the

conviction.

(4) The circumstances surrounding the
commission of the crime, if known:

(5) The nexus between the criminal conduct of
the person and the job duties of the position to be
filled

(6) The prison, jail, probation, parole,
rehabilitation, and employment records of the

SMITH HOME
HARRISBURG, NC 28075
(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 133] Continued From page 8 V 133

Division of Health Service Regulation

STATE FORM

e039

COFL11

if continuation sheet 9 of 18

Division of Health Service Regulation

PRINTED: 04/01/2019
FORM APPROVED

person since the date the crime was committed.
(7) The subsequent commission by the person of
a relevant offense.

The fact of conviction of a relevant offense alone
shall not be a bar to employment; however, the
listed factors shall be considered by the provider.
If the provider disqualifies an applicant after
consideration of the relevant factors, then the
provider may disclose information contained in
the criminal history record check that is relevant

| to the disqualification, but may not provide a copy

of the criminal history record check to the
applicant.

(d) Limited Immunity. - A provider and an officer
or employee of a provider that, in good faith,
complies with this section shall be immune from
civil liability for:

(1) The failure of the provider to employ an
individual on the basis of information provided in
the criminal history record check of the individual.
(2) Failure to check an employee's history of

| criminal offenses if the employee's criminal

history record check is requested and received in
compliance with this section.

(e) Relevant Offense. - As used in this section,
"relevant offense" means a county, state, or
federal criminal history of conviction or pending
indictment of a crime, whether a misdemeanor or
felony, that bears upon an individual's fitness to

| have responsibility for the safety and well-being of

persons needing mental health, developmental
disabilities, or substance abuse services. These

| crimes include the criminal offenses set forth in

any of the following Articles of Chapter 14 of the
General Statutes: Article 5, Counterfeiting and

| Issuing Monetary Substitutes; Article 5A,

Endangering Executive and Legislative Officers,
Article 6, Homicide; Article 7A, Rape and Other
Sex Offenses; Article 8, Assaults; Article 10,

STATEMENT OF DEFICIENCIES (Xt) PROVIDERISUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: er COMPLETED
. BUILDING:
MHL013-195 BSVNG. — 03/27/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
9167 HYDRANGEA DRIVE
SMITH HOME
HARRISBURG, NC 28075
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES iD PROVIDER'S PLAN OF CORRECTION | x6)
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 133} Continued From page 9 V 133

Division of Health Service Regulation

STATE FORM

“= COFL11

If continuation sheet 10 of 18

PRINTED: 04/01/2019
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: AB 7 COMPLETED
\. BUILDING:
MHL013-195 See 03/27/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
9167 HYDRANGEA DRIVE
SMITH HOME
HARRISBURG, NC 28075
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (xs)
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 133] Continued From page 10 V 133

Kidnapping and Abduction; Article 13, Malicious
Injury or Damage by Use of Explosive or
Incendiary Device or Material; Article 14, Burglary
and Other Housebreakings; Article 15, Arson and
Other Burnings; Article 16, Larceny; Article 17,
Robbery; Article 18, Embezzlement; Article 19,
False Pretenses and Cheats; Article 19A,
Obtaining Property or Services by False or
Fraudulent Use of Credit Device or Other Means;
Article 19B, Financial Transaction Card Crime
Act; Article 20, Frauds; Article 21, Forgery; Article
26, Offenses Against Public Morality and
Decency; Article 26A, Adult Establishments;
Article 27, Prostitution; Article 28, Perjury; Article
29, Bribery; Article 31, Misconduct in Public
Office; Article 35, Offenses Against the Public
Peace; Article 36A, Riots and Civil Disorders;
Article 39, Protection of Minors; Article 40,
Protection of the Family; Article 59, Public
Intoxication; and Article 60, Computer-Related
Crime. These crimes also include possession or
sale of drugs in violation of the North Carolina
Controlled Substances Act, Article 5 of Chapter
90 of the General Statutes, and alcohol-related
offenses such as sale to underage persons in
violation of G.S. 18B-302 or driving while
impaired in violation of G.S. 20-138.1 through
G.S. 20-138.5.

(f) Penalty for Furnishing False Information. - Any
applicant for employment who willfully furnishes,
supplies, or otherwise gives false information on
an employment application that is the basis for a
criminal history record check under this section
shall be guilty of a Class A1 misdemeanor.

(g) Conditional Employment. - A provider may
employ an applicant conditionally prior to
obtaining the results of a criminal history record

| check regarding the applicant if both of the
following requirements are met:

Division of Health Service Regulation

STATE FORM ess COFL11 If continuation sheet 11 of 18

PRINTED: 04/01/2019

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
MHL013-195 B WING __ 03/27/2019
NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE
eur Home 9167 HYDRANGEA DRIVE
HARRISBURG, NC 28075
(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 133] Continued From page 11 V 133 |

(1) The provider shall not employ an applicant
prior to obtaining the applicant's consent for
criminal history record check as required in
subsection (b) of this section or the completed
fingerprint cards as required in G.S. 114-19.10.
(2) The provider shall submit the request for a
criminal history record check not later than five
business days after the individual begins
conditional employment. (2000-154, s. 4;

| 2001-155, s. 1; 2004-124, ss. 10.19D(c), (h);
2005-4, ss. 1, 2, 3, 4, 5(a), 2007-444, s. 3.)

This Rule is not met as evidenced by:

Based on records review, observations and
interviews, the facility failed to request the
required criminal records check. The findings are:

| Observation on 3/25/19 at 3:00pm revealed a
male adult in the facility with staff #1

Review on 3/22/19 of client #1's record revealed:
-admission date of 11/10/14 with diagnoses of
COPD, Encephalopathy, Osteoarthritis, Asthma,
Schizoaffective Disorder, Depressive Disorder,
Borderline Personality Disorder and Intellectual
Developmental Disabilities(IDD)-Moderate.

Review on 3/22/19 of client #2's record revealed:
-admission date of 4/5/18 with diagnoses of
PTSD, Personality Disorder, Bipolar Disorder,

| Psychosis Disorder, Depression, Acid Reflux,
Hypothyroidism, Obesity, Anxiety, IDD-Moderate,
Migraines and Adjustment Disorder

|
Interview on 3/25/19 with client #1 revealed when
staff #1 goes places, "[the adult male] watches

|
V 133 G.S. 122C-80 Criminal History
Record Check

G.S. 122C-80 CRIMINAL HISTORY
RECORD CHECK REQUIRED FOR
CERTRAIN APPLICANTS FOR
EMPLOYMENT.

Correction: Therapeutic Services Group
(TSG) retrieved a Criminal History Record
Check.

Prevention: TSG will ensure a Criminal
History Record check be accessed and results |
documented for each back-up staff prior to |
providing support for the AFL Contractor.

Who Will Monitor: The Office Manager
will verify and monitor that requirements are
completed and current.

The QP and/or the monitoring specialist will
monitor if new Back- staff is identified to
ensure requirements are fulfilled before
support is provided. Monitoring to be
conducted monthly or as needed.

Division of Health Service Regulation

STATE FORM

e209 COFL11 I continuation sheet 12 of 18

PRINTED: 04/01/2019

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:
MHL013-195 03/27/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
9167 HYDRANGEA DRIVE
SMITH HOME
HARRISBURG, NC 28075
l wan | SUMMA 7
(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 133 | Continued From page 12 V 133
them sometimes."
Interview on 3/25/19 with client #2 revealed if staff

watches them.”

review.

revealed:

-he only visits from time to time;
-considered a "natural support,"

per their policy;

regarding an issue at another facility;

male in the facility;

in the facility.

Int.

410A NCAC 27E .0107
ALTERNATIVES TO RESTRICTIVE
INTERVENTIONS

i
Division of Health Service Regulation

STATE FORM

#1 has torun an errand, "[the adult male]

Interview with staff #1 revealed the adult male

| was her boyfriend and watched client #1 and #2
sometimes if she has to run a quick errand.
Request on 3/27/19 to review the personnel
record and criminal records check of the adult
male providing care to clients #1 and #2 in the
facility was unsuccessful as there was nota
personnel record or criminal records check to

Interview on 3/27/19 with the Residential Director

-staff #1's boyfriend does not live in the facility;

-can watch clients #1 and #2 up to three hours
-this policy was created by a former administrator
-do not have a personnel record on the adult

-the adult male in the facility does not have a
criminal records check since he does not reside

V 536 27E .0107 Client Rights - Training on Alt to Rest. V 536

TRAINING ON

| (a) Facilities shall implement policies and

oe COFLI1 Ifcontinuation sheet 13 of 18

PRINTED: 04/01/2019

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 COMPLETED
MHLO13-195 B. WING _________ 03/27/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
surraTOME 9167 HYDRANGEA DRIVE
HARRISBURG, NC 28075
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES: iD PROVIDER'S PLAN OF CORRECTION. (x8)
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 536| Continued From page 13 V 536

practices that emphasize the use of alternatives
to restrictive interventions.

(b) Prior to providing services to people with
disabilities, staff including service providers,
employees, students or volunteers, shall
demonstrate competence by successfully
completing training in communication skills and
other strategies for creating an environment in
which the likelihood of imminent danger of abuse
or injury to a person with disabilities or others or
property damage is prevented.

(c) Provider agencies shall establish training
based on state competencies, monitor for internal
compliance and demonstrate they acted on data
gathered.

(d) The training shall be competency-based,
include measurable learning objectives,
measurable testing (written and by observation of
behavior) on those objectives and measurable
methods to determine passing or failing the
course.

(e) Formal refresher training must be completed
by each service provider periodically (minimum
annually)

(f) Content of the training that the service
provider wishes to employ must be approved by
the Division of MH/DD/SAS pursuant to
Paragraph (g) of this Rule.

(g) Staff shall demonstrate competence in the
following core areas:

(1) knowledge and understanding of the
people being served;

(2) recognizing and interpreting human
behavior;

(3) recognizing the effect of internal and
external stressors that may affect people with
disabilities;

(4) strategies for building positive
relationships with persons with disabilities;

Division of Health Service Regulation

STATE FORM

= COFLI1

If continuation sheet 14 of 18

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA,
IDENTIFICATION NUMBER:

MHL013-195

PRINTED: 04/01/2019

FORM APPROVED

A. BUILDING:

5. WING

(X2) MULTIPLE CONSTRUCTION

(X3) DATE SURVEY
COMPLETED

03/27/2019

NAME OF PROVIDER OR SUPPLIER

SMITH HOME

9167 HYDRANGEA DRIVE

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES
PREFIX (BACH DEFICIENCY MUST BE PRECEDED BY FULL
TAG REGULATORY OR LSC IDENTIFYING INFORMATION)

V 536

Continued From page 14

(5) recognizing cultural, environmental and
organizational factors that may affect people with
disabilities;

(6) recognizing the importance of and
assisting in the person's involvement in making
decisions about their life;

(7) skills in assessing individual risk for

| escalating behavior;

(8) communication strategies for defusing
and de-escalating potentially dangerous behavior;
and

(9) positive behavioral supports (providing
means for people with disabilities to choose
activities which directly oppose or replace
behaviors which are unsafe).

(h) Service providers shall maintain
documentation of initial and refresher training for
at least three years.

(1) Documentation shall include:

(A) who participated in the training and the
outcomes (pass/fail);

(B) when and where they attended; and
(C) instructor's name;
(2) The Division of MH/DD/SAS may

review/request this documentation at any time.

(i) Instructor Qualifications and Training
Requirements:

(1) Trainers shall demonstrate competence
by scoring 100% on testing in a training program
aimed at preventing, reducing and eliminating the
need for restrictive interventions.

(2) Trainers shall demonstrate competence
by scoring a passing grade on testing in an

| instructor training program.

(3) The training shall be

| competency-based, include measurable learning

objectives, measurable testing (written and by
observation of behavior) on those objectives and
measurable methods to determine passing or

HARRISBU!

RG, NC 28076

STREET ADDRESS, CITY, STATE, ZIP CODE

1D
PREFIX
TAG

V 536

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

5)
COMPLETE
DATE

Division of Health Service Regulation

STATE FORM

6039

COFL11

Ifcontinuation sheet 15 of 18

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA

(X2) MULTIPLE CONSTRUCTION

PRINTED: 04/01/2019
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
B. WING
MHLO013-195 03/27/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
aniniitiowe 9167 HYDRANGEA DRIVE
HARRISBURG, NC 28075
(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)
|
¥: 536 | Continued From page 15 V 536

failing the course.
(4) The content of the instructor training the
service provider plans to employ shall be
approved by the Division of MH/DD/SAS pursuant
| to Subparagraph (i)(5) of this Rule.
| (6) Acceptable instructor training programs
shall include but are not limited to presentation of:

| (A) understanding the adult learner;

| (B) methods for teaching content of the
course;

| (C) methods for evaluating trainee

performance; and

(D) documentation procedures.

(6) Trainers shall have coached experience
teaching a training program aimed at preventing,
reducing and eliminating the need for restrictive
interventions at least one time, with positive
review by the coach.

(7) Trainers shall teach a training program
aimed at preventing, reducing and eliminating the
need for restrictive interventions at least once
annually.

(8) Trainers shall complete a refresher
instructor training at least every two years.

(j) Service providers shall maintain

| documentation of initial and refresher instructor
training for at least three years.

(1) Documentation shall include:

(A) who participated in the training and the
outcomes (pass/fail);

(B) when and where attended; and
(C) instructor's name.
(2) The Division of MH/DD/SAS may

request and review this documentation any time.
(k) Qualifications of Coaches:

(1) Coaches shall meet all preparation
requirements as a trainer.

(2) Coaches shall teach at least three times
the course which is being coached.

Division of Health Service Regulation
STATE FORM

a9

COFL11

If continuation sheet 16 of 18

Division of Health Service Regulation

PRINTED: 04/01/2019
FORM APPROVED.

STATEMENT OF DEFICIENCIES (Xt) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: "As BUNLDINNG: COMPLETED
MHL013-195 03/27/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
SMITH HOME 9167 HYDRANGEA DRIVE
HARRISBURG, NC 28075
(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 536 | Continued From page 16 V 536
(3) Coaches shall demonstrate
competence by completion of coaching or
train-the-trainer instruction.
(!) Documentation shal! be the same preparation V536 27E .0107 Client Rights- Training on
as for trainers. Alt to Rest. Int.
10A NCAC 27E .0107 TRAINING ON
ALTERNATIVES TO RESTRICTIVE
INTERVENTIONS
Correction: Staff is scheduled to receive
AIM/Alternative to restrictive intervention on
This Rule is not met as evidenced by: April 10" to support AFL staff as a Back-up.
Based on records review, observations and
interviews, the facility failed to ensure prior to
providing services, staff demonstrated Prevention: TSG will ensure individuals |
competence by successfully completing training providing Back-up are trained on Personnel
in alternatives to restrictive interventions. The Requirements prior to supporting the AFL
findings are: Contractor to ensure individuals served are
healthy and safe.
Observation on 3/25/19 at 3:00pm revealed a |
male adult in the facility with staff #1.
pene ° ee sl dy ll ie Bika Who Will Monitor: The Office Manager
-admission date o with diagnoses 0} 1 ‘ : .
oe will verify and itor that
COPD, Encephalopathy, Osteoarthritis, Asthma, someleicl ond avert: a i are
Schizoaffective Disorder, Depressive Disorder. | P ‘urrent annually.
Borderline Personality Disorder and Intellectual The QP and/or the monitoring specialist will
Developmental Disabilities(IDD)-Moderate. = ne .
monitor if new Back-up staff is identified to
Review on 3/22/19 of client #2's record revealed: Sasure requirements are fulfilled before
-admission date of 4/5/18 with diagnoses of support is provided. Monitoring to be
PTSD, Personality Disorder, Bipolar Disorder, conducted monthly or as needed.
Psychosis Disorder, Depression, Acid Reflux, |
Hypothyroidism, Obesity, Anxiety, IDD-Moderate, |
Migraines and Adjustment Disorder.
|
Interview on 3/25/19 with client #1 revealed when
staff #1 goes places, "[the adult male] watches
them sometimes."
Division of Health Service Regulation
STATE FORM 6899 COFL11 If continuation sheet 17 of 18

PRINTED: 04/01/2019

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
MHL013-195 B WINS 03/27/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
9167 HYDRANGEA DRIVE
SMITH HOME
HARRISBURG, NC 28075
(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 536 | Continued From page 17 V 536

Interview on 3/25/19 with client #2 revealed if staff
#1 has to run an errand, "[the adult male]
watches them."

Interview with staff #1 revealed the adult male
was her boyfriend and watched client #1 and #2
sometimes if she has to run a quick errand.

Request on 3/27/19 to review the personnel
record and completed training in alternatives to
restrictive interventions of the adult male in the
facility was unsuccessful as there was not a
personnel record or any trainings to review.

Interview on 3/27/19 with the Residential Director
revealed:

-staff #1's boyfriend does not live in the facility;
-he only visits from time to time;

-considered a "natural support;"

-can watch clients #1 and #2 up to three hours
per their policy;

| -this policy was created by a former administrator
regarding an issue at another facility;

-do not have a personnel record on the adult
male in the facility;

-the adult male in the facility does not have a any
completed trainings since he does not reside in
the facility.

Division of Health Service Regulation
STATE FORM

609

COFL11

If continuation sheet 18 of 18

x rs I Therapeutic Services Group, LLC

April 10, 2019

NCDHHS DHSR - Mental Health
Division of Health Service Regulation

Mental Health Licensure and Certification Section APR 15 2019
Attn: Gina McLain

Facility Compliance Consultant I Lic. & Cert. Section

Re: — Annual Survey completed March 27, 2019
Smith Home, 9167 Hydrangea Drive, Harrisburg, NC 28075
MHL # 013-195

Dear Ms. McLain,

Thank you for the services you rendered on 3/27/19 located at the Smith Home. You noted an
areas of deficiency that was in need of correction and we have responded expeditiously. Please
find enclosed a copy of your letter to ensure correct identification. The summary state of
deficiencies and the plan of correction.

We believe that this will conclude all necessary corrections. However, if you find that there is
something else that needs our attention, Please do not hesitate to call me at 704-321-1635.

Sincerely,
ob tl Adah

Natara Williams
Director of Residential Services

5309 Idlewild Rd North - Mint Hill, NC 28227 - 704.321.1635 - Fax: 704.332.2987

e% NC DEPARTMENT OF ROY COOPER + Governor
I FR ALTH AND Es MANDY COHEN, MD, MPH * Secretary
Ay) MARK PAYNE ~ Director, Division of Health Service Regulation

Eau we

April 2, 2019

Natara Williams, Regional Director
Therapeutic Services Group, LLC
5309 Idlewild Road North
Charlotte, NC 28227

Re: Annual Survey completed 3/27/19
Smith Home, 9167 Hydrangea Drive, Harrisburg, NC 28075
MHL # 013-195
E-mail Address: natara.wiliams@asmallmiraclellc.com

Dear Ms. Williams:

Thank you for the cooperation and courtesy extended during the annual survey completed March 27,
2019. Deficiencies were cited.

Enclosed you will find all deficiencies cited listed on the Statement of Deficiencies Form. The purpose of
the Statement of Deficiencies is to provide you with specific details of the practice that does not comply
with state regulations. You must develop one Plan of Correction that addresses each deficiency listed on
the State Form, and return it to our office within ten days of receipt of this letter. Below you will find
details of the type of deficiencies found, the time frames for compliance plus what to include in the Plan of
Correction.

Type of Deficiencies Found

e Standard level deficiencies were cited.

Time Frames for Compliance
e The standard level deficiencies must be corrected within 60 days from the exit date of the survey,

which is May 26, 2019.

What to include in the Plan of Correction :

e Indicate what measures will be put in place to correct the deficient area of practice (i.e. changes
in policy and procedure, staff training, changes in staffing patterns, etc.).
Indicate what measures will be put in place to prevent the problem from occurring again.
Indicate who will monitor the situation to ensure it will not occur again.
Indicate how often the monitoring will take place.
Sign and date the bottom of the first page of the State Form.

Make a copy of the Statement of Deficiencies with the Plan of Correction to retain for your records.
Please do not include confidential information in your plan of correction and please remember
never to send confidential information (protected health information) via email.

NC DEPARTMENT OF HEALTH AND HUMAN SERVICES « DIVISION OF HEALTH SERVICE REGULATION

LOCATION: 1800 Umstead Drive, Williams Building, Raleigh, NC 27603
MAILING ADDRESS: 2718 Mail Service Center, Raleigh, NC 27699-2718
www.ncdhhs.gov/dhsr + TEL: 919-855-3795 + FAX: 919-715-8078

AN EQUAL OPPORTUNITY / AFFIRMATIVE ACTION EMPLOYER

April 2, 2019
Natara Williams
Therapeutic Services Group, LLC

Send the original completed form to our office at the following address within 10 days of receipt of this
letter.

Mental Health Licensure and Certification Section
NC Division of Health Service Regulation
2718 Mail Service Center
Raleigh, NC 27699-2718

A follow up visit will be conducted to verify all violations have been corrected. If we can be of further
assistance, please call Lynn Grier at (704)596-4072.

Sincerely,

Gina McLain

Facility Compliance Consultant |

Mental Health Licensure & Certification Section

Enclosures

CC: qmemail@cardinalinnovations.org

inspection_type: MHLCS Annual

document_type: Plan of Correction