raw_content:
PRINTED: 12/11/2023
FORM APPROVED
Division of Health Service Regulation

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

(X3) DATE SURVEY

(X2} MULTIPLE CONSTRUCTION
COMPLETED

A. BUILDING:

R
41/30/2023

MHL012-142 B. WING ___

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
5741 FISH HATCHERY ROAD

LAKE JAMES ALTERNATIVE FAMILY LIVING MORGANTON, NC 28655

(X4) 1D 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 _vooo | *i8

An annual and follow Up’sulvey was completed | The natural supports for these members
on 11/30/23. Deficiencies were cited. ' will receive training in CPR, First Aid, 12/30/2023
| _ client rights, confidentiality, and MH/DD
This facility is licensed for the following service needs of clients.
| category: 10A NCAC 27G .5600F Supervised
Living for Individuals of all Disability

Groups/Alternative Family Living.

Policies will be updated to ensure that any
| Natural supports that provides these

| supports inside the facility, must receive
training to ensure member safety.

This facility is licensed for 3 and currently has a
census of 3. The survey sample consisted of an _ '
audit of 3 current clients. /

| V536
V 108 27G .0202 (F-I) Personnel Requirements | Vv108 | |
i | The natura! supports for these members will |
10A NCAC 27G 0202 PERSONNEL | receive training in alternatives to restrictive 12/30/2023
: intervention
REQUIREMENTS i
(f) Continuing education shall be documented. | rollcies will De upeatey eerste, that any if
provided and, at a minimum, shall consist of the | ensure member safety.
following: |
(1) general organizational orientation; |
(2) training on client rights and confidentiality as |
delineated in 10A NCAC 27C, 27D, 27E, 27F and | -V736
10A NCAC 26B;
(3) training te mee! the mhidd/sa needs of the | | Rabies documentation will be required for all
aha aoceenes in the treatment/habilitation i | dogs on the premises and updated as required. 12/30/2023
plan; ani | i
(4) training in infectious diseases and | | Policies will be updated to reflect that all dogs,

| | cats, and/or ferrets on the premises of a licensed
bloodborne pathogens. | | facility shall have rabies vaccination. This is to
(h) Except as permitted under 10a NCAC 27G / "ensure member safety.

-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 | RECEIVED
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 DHSR-MH Licensure Sect

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

Aimee Smith, COO 12/15/2023

STATE FORM 6899 D2T111 If continuation sheet 1 of &

PRINTED: 12/11/2023

FORM APPROVED

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X41) PROVIDER/SUPPLIER/CLIA

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED
R
MHL012-142 BLWING .. 14/30/2023

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
5741 FISH HATCHERY ROAD

LAKE JAMES ALTERNATIVE FAMILY LIVING MORGANTON, NC 28655

(x4) 1D 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 108) Continued From page 1 V 108 |

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
clients. |

This Rule is not met as evidenced by:
Based on record reviews and interviews, the |
facility failed to ensure one of three audited staff |
(Staff #2) had training in Cardiopulmonary
Resuscitation (CPR) and First Aid, MH/DD/SAS
needs of clients, client rights and confidentiality

| and training to meet the needs of the clients as |
| specified in the treatment/habilitation plan. The
findings are:

Record review on for Staff #2 revealed:
-Date of hire-no date of hire as considered natural |
support. |
-Criminal Background was conducted on 9/18/17. |
-HCPR (health care personnel registry) was |
conducted on 7/17/17. |
-There was no training in first aid, CPR,
medication administration, client rights,
confidentiality, client specific training.

Interview on 11/28/23 with Staff #2 revealed: |
-He lived on site and was there if the clients | |
needed him. |
-He did not pass medications.

d

Interview on 11/29/23 with Staff #1 revealed:
-She worked a full time job during the week away
from the facility.
Division of Health Service Regulation
STATE FORM 6898 pzT111 Ifcontinuation sheet 2 of 8

PRINTED: 12/11/2023
FORM APPROVED
Division of Health Service Requlation

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

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION

A. BUILDING:

R
11/30/2023

B. WING

MHL012-142

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
5741 FISH HATCHERY ROAD

LAKE JAMES ALTERNATIVE FAMILY LIVING MORGANTON, NC 28655

(X4) 1D 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)
———
Vv 108 Continued From page 2 V 108

-Staff #2 was her son and had always been
considered a natural support for the clients. i
-Staff #2 lived on the property and provided |
supervision and/or assistance for the clients as
needed when she was not there. |
-He prepared lunch during the week for the |
clients when they did not attend their day i
Program,

Interview on with the Qualified Professional
revealed:

-All 3 clients in the facility were fairly independent
and didn't require eyes on supervision. |
-Client #1 and Client #2 chose not to attend their |
PSR (psychosocial rehabilitation) program on |
Tuesdays and Thursdays. Staff #1's son and
daughter were always on the property if the

clients needed assistance. i
-Had considered Staff #2 a natural support and |
did not provide supervision or training for Staff #2.

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

10A NCAC 27E .0107 TRAINING ON
ALTERNATIVES TO RESTRICTIVE
INTERVENTIONS
(a) Facilities shall implement policies and
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. | /
i

Division of Health Service Regulation
STATE FORM seo8 DZT111 If continuation sheet 3 of 8

PRINTED: 12/41/2023

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

MHL012-142 8. WING ______H— 11/30/2023

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

5741 FISH HATCHERY ROAD

LAKE JAMES ALTERNATIVE FAMILY LIVING MORGANTON, NC 28655

(x4) 1D ] SUMMARY STATEMENT OF DEFICIENCIES 1D 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 3 _ V536

| |
|
| (c) Provider agencies shall establish training i |
| 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;
| (5) recognizing cultural, environmental and
| organizational factors that may affect people with |
| disabilities; | |
| (6) recognizing the importance of and i
| 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 i

Division of Health Service Regulation

STATE FORM bas D2ZT111 If continuation sheet 4 of 8

PRINTED: 12/11/2023
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
MHL012-142 B. WING 11/30/2023

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE

LAKE JAMES ALTERNATIVE FAMILY LIVING 5741 FISH HATCHERY ROAD

MORGANTON, NC 28655 _|
(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
ji DEFICIENCY)
| T
V 536 Continued From page 4 V5360
(9) positive behavioral supports (providing

means for people with disabilities to choose
activities which directly oppose or replace

behaviors which are unsafe). i
(h) Service providers shall maintain
documentation of initial and refresher training for |
at least three years.

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 shail 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 i
measurable methods to determine passing or |
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.

(1) Documentation shall include: /
(A) who participated in the training and the |
outcomes (pass/fail); ‘ | |
(B) when and where they attended; and i
(C) instructor's name; | i
(2) The Division of MH/DD/SAS may |

/

(5) 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 i
course; /
(C) methods for evaluating trainee |

Division of Health Service Regulation
STATE FORM Sse: DZT111 It continuation sheet 5 of 8

PRINTED: 12/11/2023
FORM APPROVED
Division of Health Service Regulation

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY.
COMPLETED

R
11/30/2023

MHLO012-142 B.WING __

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

5741 FISH HATCHERY ROAD

LAKE JAMES ALTERNATIVE FAMILY LIVING MORGANTON, NC 28655

(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)

Continued From page 5 V 536

performance; and |
(D) documentation procedures. | i
(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: |
(A) Coaches shall meet all preparation | |
requirements as a trainer. |
(2) Coaches shail teach at least three times | |
the course which is being coached. |
(3) Coaches shall demonstrate |
competence by completion of coaching or
train-the-trainer instruction. |
| (1) Documentation shall be the same preparation _
as for trainers. | |

Division of Health Service Regulation
STATE FORM 6899 DzT111 if continuation sheet 6 of 8

PRINTED: 12/11/2023
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
MHL012-142 B. WING 11/30/2023

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
5741 FISH HATCHERY ROAD
MORGANTON, NC 28655

Le JAMES ALTERNATIVE FAMILY LIVING

(X4) 1D 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

i DEFICIENCY)
1 i
V 536 Continued From page 6 | ¥ 536

This Rule is not met as evidenced by:

Based on personnel record review and staff
interviews, the facility failed to ensure that all staff
completed training in alternatives to restrictive
intervention annually for 1 of 3 audited staff (Staff
#2). The findings are:

Record review on for Staff #2 revealed:
-Date of hire-no date of hire as considered natural i
support. |
-There was no documentation of de-escalation |
training. ' |

Interview on with the Qualified Professional
revealed:

-Had considered Staff #2 a natural support and
did not provide supervision or training for Staff #2.

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 shail be kept free from offensive
odor.

This Rule is not met as evidenced by:

Based on record review and interviews, the i
facility was not maintained in a safe manner. The |

findings are: |

Attempted review on 11/28/23 of vaccination
| papers for the facility dogs (both indoor and

outdoor) were unsuccessful. Copies of the

documents were requested from the Human

Division of Health Service Regulation
STATE FORM 6808 DZT111 lf continuation sheet 7 of 8

PRINTED: 12/11/2023
FORM APPROVED
Division of Health Service Regulation

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

(X2) MULTIPLE CONSTRUCTION.
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

R
14/30/2023

MHL012-142 B. WING ______

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

5741 FISH HATCHERY ROAD

LAKE JAMES ALTERNATIVE FAMILY LIVING MORGANTON, NC 28655

(x4) ID Ty 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
j DEFICIENCY)
V¥ 736 Continued From page 7 V 736

|

Resources Assistant (HRA), but no documents |
were provided prior to exit. |
|

|

|

Observation on 11/28/23 of facility at

| approximately 10am revealed a large white Great
Pyrenees dog and a small long haired black and

| gray dog outside the facility. Upon entering the |

facility was another small black and gray dog

| along with a blue gray bulldog. Staff #2 entered | |

the facility approximately 10:45am with his 2 large

| Berna- doodles. All animals had a pleasant |

| demeaner and got along well with each other and | |

both clients.

Interview on 11/28/23 with Client #1 revealed:
-Minnie was his dog. She slept in a kennel in his ©
room and he took care of her.

-He was not aware of her vaccination status.

Interview on 11/28/23 with the HRA revealed:

-She would contact Staff #1 but did not have any
tabies certificates in her file.

-Was not aware all indoor and outdoor dogs were |
required to be vaccinated.

Division of Health Service Regulation
STATE FORM od DZT111 if continuation sheet 8 of 8


state: NC

facility_name: Lake James Alternative Family Living

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

raw_content:
PRINTED: 12/30/2019
FORM APPROVED

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X3) DATE SURVEY
COMPLETED.

R
12/09/2019

(X2) MULTIPLE CONSTRUCTION
A, BUILDING a

B, WING

MHL012-142

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

§741 FISH HATCHERY ROAD
LAKE JAMES ALTERNATIVE FAMILY LIVING MORGANTON, NC 28655

(X4) 1D SUMMARY STATEMENT OF DEFICIENCIES 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)

INITIAL COMMENTS

An annual and follow up survey was completed
on 12-9-19. Deficiencies were cited.

This facility is licensed for the following service
category 10A NCAC 27G .5600F Supervised
Living for Individuals of all Disability
Groups/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 DHSR - Mental h ealth
unlicensed persons trained by a registered nurse,
pharmacist or other legally qualified person and JAN 10 2020
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

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

: )

Lic. & Cert. Sedtion

1

STATE FORM 6899 G8Qo011 'f continuation sheet 4 of 3

PRINTED: 12/30/2019
FORM APPROVED

Division of Health Service Regulation.

STATEMENT OF DEFICIENCIES (x1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

COMPLETED

A.BUWOING:

R
12/09/2019

B. WING

MHL012-142

STREET ADDRESS, CITY, STATE, ZIP CODE

5741 FISH HATCHERY ROAD
MORGANTON, NC 28655

NAME OF PROVIDER OR SUPPLIER

LAKE JAMES ALTERNATIVE FAMILY LIVING

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D 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)

Continued From page 1

with a physician.

This Rule is not met as evidenced by:
Based on record reviews and interviews the
facility failed to ensure MAR's were kept current
for 1 of 3 clients (Client #3). The findings are:

Review of Client #3's record on 12-9-19 revealed:
-Date of admission: 1-21-19;

-Diagnoses: Borderline Intellectual Functioning,
Language Disorder, Schizoaffective Disorder,
Chronic Kidney disease, Hyperlipidemia and
Hypothyroidism;

-Physician's orders for the following medications:
-lamotrigine 100 milligram (mg) 4 tablet by
mouth each evening and fluoxetine hydrochloride
20 mg 1 capsule by mouth daily dated 2-1-19; |

-omeprazole 20 mg 1 capsule by mouth daily
dated 3-28-19;

-buspirone hydrochloride 5 mg 1 tablet by
mouth three times daily as needed for anxiety
dated 7-19-19;

-lisinopril 10 mg 1 tablet by mouth daily dated
8-22-19;

-aripiprazole 30 mg 1 tablet by mouth at
bedtime and divalproex sodium extended release
500 mg 1 tablet by each morning and 2 tablets by
mouth each evening dated 10-8-19;

-Physician's order allowing client to
self-administer his medications dated 2-1-19;
-No MAR was on file in the client's record from
the date of admission.

Interview with Client #3 on 12-9-19 revealed:
-He self-administered his medications,
-Staff #1 ensured he was compliant with tal
Division of Health Service Regulation

STATE FORM od G8aoit If continuation sheet 2 of 3

king

PRINTED: 12/30/2019
FORM APPROVED

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X3) DATE SURVEY
COMPLETED

R
12/09/2019

(X2) MULTIPLE CONSTRUCTION

A. BUILDING:

B. WING

MHL012-142

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

5741 FISH HATCHERY ROAD
LAKE JAMES ALTERNATIVE FAMILY LIVING MORGANTON, NC 28665

(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION 5)
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)
Continued From page 2 vig fy Y2\\ a BY comeckec|

MACS Fr alienk #% with
Gurpenk qedioAays

his medications as prescribed.

Ingeeaie with Staff #1 on 12-6-19 revealed: On 124\- 1G OY net © +Le AFL, N

-Client #3 did not have a MAR; A +e, NaS

-She was told by the Qualified Professional (QP) CEN’ BA, Dfedery ke

that Client #3 did not require a MAR since he had OP Liplain-ed 4. aepeiiellie

an order to self-administer his medications. iar:
He reason WP geare,N

Interview with the QP on 12-9-19 revealed: in PIAGe», y ne

| She was unaware that a MAR was needed for on

clients who self-administered their medications; PDN ide his Nand- Yer INGaa

-AMAR would be prepared this week for Client eerie ig eee Hing? +0

#3; Ay pt Sages - Client 2

-The use of the MAR for Client #3 would be

implemented immediately. Creu to eae |
Ache is copy OF ALL

This deficiency constitutes a re-cited deficiency

| and must be corrected within 30 days. MALS ONS wrRn +
Aneoe’s OF dar fy Client

Ab aif- AAMIMster HIS
NA GAYONS TNS Oda will
bt Updated U2AIY >, epk \
Client Cecord :

Meo 16 PYAChe dae DUPE!
Nok Fr VEG, indéceri 1 Ai
tle MAR's woe ‘presented

Nhis dale - ‘
OP wi) Monitor te APL 3

MA's menehy,

Division of Health Service Regulation
STATE FORM see. G8aQo11 If continuation sheet 3 of 3

Month/Year:

Community Companion Home Care, LLC.
Medication Administration Record

None cos: Sex:__M. Record Li

Allergies:_NKA
[ Name Initials Name Initials
A. Put initials in appropriate box when medication is given.
B. State reason for refusal / omission on back of form. |
C. PRN Medications: Reason given and results must be noted on back of form.
D. Legend: $= School; H = Home visit; W = Work —
Medication be rag Per (ea EO Pe Ld ee RO GL SS Pee BS eB 23 [24 [2 [ee] 27] we] wl sO
Omeprazole 20 mg DR

CAP |
1 cap PO once daily |

Lamotrigine 100 mg
1 tab PO each morning

Member Self Administers

All Medications
Divalproex SOD ER |
500 mg TA
1 tab PO each morning & 2 |

tabs each evening

‘Fluoxetine HCL 20 mg
Take 1 cap PO once daily

Lamotrigine 100 mg
1 tab PO each evening

Month/Year:
Name Initials PRN Result Instructions Name Initials
1) Condition Improved
2) Condition not Improved (Please contact QP) |
3) Condition worsened (Contact QP)
4) If condition becomes critical, please contact 911 and QP
ees Noted | _initicts |
Date Time Given Medication & Dosage Reason Results Time Noted Initials

Month/Year:

Community Companion Home Care, LLC.
Medication Administration Record

None cos: Sex:__M. Record ol

Allergies:___NKA

Name Initials Name Initials
A. Put initials in appropriate box when medication is given.
B. State reason for refusal / omission on back of form.
C. PRN Medications: Reason given and results must be noted on back of form.
~ D. Legend: S$ = School; H = Home visit; W= Work
Medication Hour |1 |2 [3 [4 [5 [6 [7 [8 | 9 | 10] 1) 142) 13] 44 15 | 16 [17 [18 [49 | 20] 24 | 22 | 23 | 24 | 25] 26] a] oe] 2] a0] aT]
| Lisinopril 10 mg
| 1 tab PO once daily
A il {
Divalproex SOD ER 500 Member Self-Administers
mg MG TA All Medications
ltab
Aripiprazole 30 mg
1 tab PO @ bedtime =
Buspirone HCL 5 mg
1 tab PO 3X’s as needed for
anxiety PRN
Ibuprofen 600 mg
Take | tab PO Q8 hours
PRN with food

Month/Year:
Name Initials PRN Result Instructions Name Initials
1) Condition Improved
2) Condition not Improved (Please contact QP)
TF 3) Condition worsened (Contact QP)
4) If condition becomes critical, please contact 911 and QP
Date Time Given Medication & Dosage Reason Results Time Noted Initials

Month/Year: |

Community Companion Home Care, LLC.
Medication Administration Record

Name: | ti*@d vos: Sex:_M. Record lO

Allergies: NKA

Name Initials Name Initials
A. Put initials in appropriate box when medication is given.
B. State reason for refusal / omission on back of form.
C. PRN Medications: Reason given and results must be noted on back of form.
D. Legend: S$ = School; H = Home visit; W = Work
Medication Lage EO WY sd Os We RE YB Ba ELM epee ees pe 24 | 25 | 26 | 27 | 28 | 2 | 30] af

Depakote ER 500 mg |

Take | tab PO in AM & 2 |

tabs in PM |

Member Self-Administers

All Medications

Month/Year:
Name Initials PRN Result Instructions Name Initials
1) Condition Improved
2) Condition not Improved (Please contact QP)
3) Condition worsened (Contact QP)
4) If condition becomes critical, please contact 911 and QP
Date Time Given Medication & Dosage Reason Results Time Noted Initials

Community Family Healthcare
2:19 A Avery Ave Morganton, NC 28655
Alan M. Hicks, DNP, FNP-C
Board Certified Nurse Practitioner (AANP)

SS a

Orders
Name: _ ___ Age/DOB:
Address:
Date: ;
ss -—— = _

seas j
Diagnosis: ~ ~
Notes:

Alan M. Hicks, DNP, FNP-C

DEA: MH4442074 LIC#: 5009756 NPI: 1720503972,

EMERGENCY / AFTER HOURS LINE: 828-439-4057 or 828-260-4125
~ 219 A Avery Ave Morganton, NC 28655

sek: (828)391-83264 / Fax: (828)391-1972

1/2/2020

Supervision Note

Sraitn, tal

| Demoat

Employee First Name baure

Date Caner)

Communication
Crisis Prevention and Intervention
Confidentiatity

Person-Centered Thinking

Service Definitions

Incident Reporting
C Client Specitic Behavioral fssues
Client. Support Needs
t Positive Behavior Supports
Home/Envioramental Modifications
s Employee Counseling

Employee Evatuation

| Comments:

OnTarget

Community Companion Home Care, LLC
Supervision Notes

Employee Last Name Seth

Time 3:45 pm Location

Topics Discussed

Therapeutic Relationships
Client Rights

Abuse and Neglect
Philosophy of Services
Documentation

Client Specific Medical Issues
Diagnoses

Planaing Needs/ Progress on Goals
Natural Supports

Employee Support Needs
Training Updates

Other

QP returned to Laura's home this PMA to deliver her new licensure & the updated MAR’s for 2 of her

members. Laura tumed in her MAR for member DH for Oct.2019, Laura will provide copy of her fire
inspection once she receives from the inspector

Gate Employ

https //otb.ontargetclinical.com/nome.jsp#/employees

Home

4

inspection_type: MHLCS Annual and Follow-up

document_type: Plan of Correction


summary: Statement of Deficiency - 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:

MHL012-142

LAKE JAMES ALTERNATIVE FAMILY LIVING

A. BUILDING:

B. WING

STREET ADDRESS, CITY, STATE, ZIP CODE

5741 FISH HATCHERY ROAD
MORGANTON, NC 28655

(X2) MULTIPLE CONSTRUCTION

PRINTED: 12/30/2019
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
12/09/2019

(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 12-9-19. Deficiencies were cited.

This facility is licensed for the following service
category 10A NCAC 27G .5600F Supervised
Living for Individuals of all Disability
Groups/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

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

STATE FORM

V 000

V 118

6899

G8Qo11

TITLE (X6) DATE

If continuation sheet 1 of 3

PRINTED: 12/30/2019
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
MHL012-142 B. WING _____ 12/09/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

5741 FISH HATCHERY ROAD

LAKE JAMES ALTERNATIVE FAMILY LIVING MORGANTON, NC 28655

(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

with a physician.

This Rule is not met as evidenced by:

Based on record reviews and interviews the
facility failed to ensure MAR's were kept current
for 1 of 3 clients (Client #3). The findings are:

Review of Client #3's record on 12-9-19 revealed:
-Date of admission: 1-21-19;

-Diagnoses: Borderline Intellectual Functioning,
Language Disorder, Schizoaffective Disorder,
Chronic Kidney disease, Hyperlipidemia and
Hypothyroidism;

-Physician's orders for the following medications:
-lamotrigine 100 milligram (mg) 1 tablet by
mouth each evening and fluoxetine hydrochloride
20 mg 1 capsule by mouth daily dated 2-1-19;
omeprazole 20 mg 1 capsule by mouth daily
dated 3-28-19;

buspirone hydrochloride 5 mg 1 tablet by
mouth three times daily as needed for anxiety
dated 7-19-19;

isinopril 10 mg 1 tablet by mouth daily dated
8-22-19;

-aripiprazole 30 mg 1 tablet by mouth at
bedtime and divalproex sodium extended release
500 mg 1 tablet by each morning and 2 tablets by
mouth each evening dated 10-8-19;

-Physician's order allowing client to
self-administer his medications dated 2-1-19;
-No MAR was on file in the client's record from
the date of admission.

Interview with Client #3 on 12-9-19 revealed:
-He self-administered his medications;

-Staff #1 ensured he was compliant with taking
Division of Health Service Regulation

STATE FORM 6899 G8Q011 If continuation sheet 2 of 3

PRINTED: 12/30/2019

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
MHL012-142 B. WING ____ 12/09/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
5741 FISH HATCHERY ROAD
LAKE JAMES ALTERNATIVE FAMILY LIVING
MORGANTON, NC 28655
(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

his medications as prescribed.

Interview with Staff #1 on 12-6-19 revealed:
-Client #3 did not have a MAR;

-She was told by the Qualified Professional (QP)
that Client #3 did not require a MAR since he had
an order to self-administer his medications.

Interview with the QP on 12-9-19 revealed:
-She was unaware that a MAR was needed for
clients who self-administered their medications;
-A MAR would be prepared this week for Client
#3;

-The use of the MAR for Client #3 would be
implemented immediately.

This deficiency constitutes a re-cited deficiency
and must be corrected within 30 days.

Division of Health Service Regulation
STATE FORM 6899 G8Q011 If continuation sheet 3 of 3

document_type: Statement of Deficiency


summary: Plan of Correction - MHLCS Annual

raw_content:
Division of Health Service Regulation

PRINTED: 10/01/2018
FORM APPROVED.

‘STATEMENT OF DEFICIENCIES Q1) PROVIDER/SUPPLIER/CLIA

(X2) MULTIPLE CONSTRUCTION

(%3) DATE SURVEY
COMPLETED

V 118) 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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER ALBULDING:
I MHL012-142 8 WINS 09/26/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
5741 FISH HATCHERY ROAD
LAKE JAMES ALTERNATIVE FAMILY LIVING
MORGANTON, NC 28655
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES 10 | 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 000 INITIAL COMMENTS V 000 |
| An annual survey was completed on September |
26, 2018. A deficiency was cited
| | |
| This facility is licensed for the following service |
| category: 10A NCAC 27G .5600F Supervised
Living/Alternative Family Living.
|
Vv 118 |

DHSR - Mental Health |
| OCT 192018

Lic. & Cert. Section

Division of Health Service Regulation

LABORATORY,

(X6) DATE

LIS [18

TITLE

ye

ECTOR'S OR PROVIDERASUPPLIER REPRESENTATIVE'S SIGNATURE
A ~ \ « \
c

STATE FORM

98

xYIV14 lf continuation sheet 1 of 3

NAME OF PROVIDER OR SUPPLIER

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER

MHLO012-142

PRINTED: 10/01/2018
FORM APPROVED

(X2) MULTIPLE CONSTRUCTION

A. BUILDING

(X3) DATE SURVEY

COMPLETED

09/26/2018

STREET ADDRESS CITY, STATE, ZIP CODE

5741 FISH HATCHERY ROAD

LAKE JAMES ALTERNATIVE FAMILY LIVING

MORGANTON, NC 28655

| SUMMARY STATEMENT OF DEFICIENCIES

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

(xa) 1D 1D
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL | PREFIX
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG
V 118] Continued From page 1 V118

This Rule is not met as evidenced by:

Based on observation, record review and
interviews, the facility failed to administer
medications based on the written order of a
person authorized to prescribe medications and
failed to keep the MARs complete and current
affecting 1 of 2 clients (Client #2). The findings
| are:

| Observations of Client #2's medication box and 2
of his medications on 9/26/18 from 2:55PM
through 3:45PM revealed

| - lorazepam (anti-anxiety) 0.5mg %-1 tablet QD
(daily) dispensed 8/24/18 with 11 doses out of 30
missing from the bottle

- Prazosin (anti-anxiety) 1mg QHS (each
bedtime) dispensed 8/24/18

Review on 9/26/18 of Client #2's record revealed:
- Admission date: 6/15/18

- Diagnoses: Mild Mental Retardation (MR);
Oppositional Defiant Disorder (ODD); Attention
Deficit Hyperactive Disorder, Combined

- Medication Orders: No physician's order for
Client #2's lorazepam or Prazosin

Review on 9/26/18 of Client #2's MARs revealed
| the lorazepam and Prazosin had not been written
on the MARs for July, August and September

Interview on 9/26/18 with Staff #1 revealed:

- She was unsure why Client #2's lorazepam and
| Prazosin had not been written on the MARs,

- Staff #1 acknowledged Client #2 had been
| administered the aforementioned medications.

iv ~ Copies of prys cian’ s
Forder fr Client #2's

| Lorazepam and Proarasin af
adechecl fo tis apoct Be
revierd. Copies alse Placed in
tient 42's ce cords (Chart -

ahehh 1 cetrained of
Nwdieation Admins strahed . |
Copy of traning Cer thfarte
iahachedl fo this copert for

Yevilw

Measures taken 4 peever |

future proolem Occurring, 15
sbef erraiaing and Close’
Moniteriag Super rive |
BP WW monrtow His sitwahon
ak \eask once a month te
[ensure Compl ane’ 5

(x5)
COMPLETE
DATE

Division of He:
STATE FORM

alth Service Regulation

XY¥IV11

If continuation sheet 2 of 3

Division of Health Service Regulation

PRINTED: 10/01/2018
FORM APPROVED

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

MHL012-142

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

B. WING

(X3) DATE SURVEY
COMPLETED

09/26/2018

NAME OF PROVIDER OR SUPPLIER

LAKE JAMES ALTERNATIVE FAMILY LIVING

STREET ADDRESS, CITY, STATE, ZIP CODE

5741 FISH HATCHERY ROAD
MORGANTON, NC 28655

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

V 118 Continued From page 2

Interview on 9/26/18 with the Qualified
Professional (QP) revealed:
- She acknowledged written medication orders
had not been obtained for Client #2's lorazepam
and Prazosin;
- The QP stated she would ensure Staff #1 was
re-trained in medication administration and

| licensure rule requirements.

] ID
| PREFIX
TAG

$$$

Vv 118

| PROVIDER'S PLAN OF CORRECTION x5)
(EACH CORRECTIVE ACTION SHOULD BE COMPLETE
CROSS-REFERENCED TO THE APPROPRIATE, | DATE
DEFICIENCY) |
- ———}

Division of Health Service Regulation
STATE FORM

338

XYIV11 If continuation sheet 3 of 3

Certificate of Completion
te herby granted to:

49_A State Street
Marion, NC 28752

Date:

Alan Hicks, NP
Community Family HealthCare, PLLC
219-A Avery Avenue
Morganton, NC 28655
Phone: 828.391.8364 Fax: 828-391-1972
DEA# MH4442074 NPI# 1720503972
PRESCRIPTION

PATIENT DEMO.

Allergies: penicillin, mixed grass pollens allergen extract

"MEDICATION: Sn ae ATE:
LORazepam 0.5 mg oral tablet bie 2018
SIG:

Take 0.5 to 1 pills by mouth QD (Daily) As Needed
collab md nr mauney

DISPENSE: **(30) Thirty** REFILLS: **(1) One**

atin HE (-c

Dispense As Written Substitution Permitted

Below is a micro print signature line visible under
high magnification and illegible when copied.

Amazing Charts Security Prescription _ ; Lee
“his prescription has the following security features: (1) Micro print signature fine legible at 5x or higher magnification and
legible when copied. (2) Asterisks (**) on both sides of dispense amount and refills allowed. The information on this page is
SONFIDENTIAL. Any release of this information requires the expressed written authorization of the patient listed above. For
uestions regarding this prescription, please contact the practice.

Alan Hicks, NP
Community Family HealthCare, PLLC
219-A Avery Avenue
Morganton, NC 28655
Phone: 828-391-8364 Fax: 828-391-1972
DEA# MH4442074 NPI# 1720503972

PRESCRIPTION

PATIENT DEMOGRAPHICS

Allergies: penicillin, mixed grass pollens allergen extract

| MEDICATION: ; eee DATE:
prazosin 1 mg oral capsule Sep 26, 2018
SIG:

| Take 1 pill by mouth QHS (nightly) X 1 Month (30d)
| collab md nr mauney

DISPENSE: **(30) Thirty** REFILLS: **(3) Three**
po eA rote fob
i Dispense As Written Substitution Permitted

Below is a micro print signature line visible under
high magnification and illegible when copied.

Amazing Charts Security Prescription _
This prescription has the following security features: (1) Micro print signature line legible at 5x or higher magnification and
illegible when copied. (2) Asterisks (**) on both sides of dispense amount and refills allowed. The information on this page is
CONFIDENTIAL. Any release of this information requires the expressed written authorization of the patient listed above. For
questions regarding this prescription, please contact the practice.

NC DEPARTMENT OF ROY COOPER « Governor
; OMAN CERO IrEE MANDY COHEN, MD, MPH = Secretary
MARK PAYNE «» Director, Division of Health Service Regulation

October 8, 2018

Tamora Cook, CEO

Community Companion Home Care, LLC
49-A State Street,

Marion, NC 28752

Re: Annual Survey completed September 26, 2018
Lake James Alternative Family Living, 5741 Fish Hatchery Road, Morganton, NC 28655
MHL # 012-142
E-mail Address

Dear Ms. Cook:

Thank you for the cooperation and courtesy extended during the annual survey completed September 26,
2018.

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 The tag cited is a standard level deficiency.

Time Frames for Compliance
e Standard level deficiencies must be corrected within 60 days from the exit of the survey, which
is November 25, 2018.

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.).
e 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.
e Indicate how often the monitoring will take place.
e Sign and date the bottom of the first page of the State Form.

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.nedhhs.gov/dhsr » TEL: 919-855-3795 + FAX: 919-715-8078

AN EQUAL OPPORTUNITY / AFFIRMATIVE ACTION EMPLOYER

October 8, 2018
Community Companion Home Care, LLC
Tamora Cook, CEO

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.

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 Robin Sulfridge, Branch Manager at 336-861-7342.

Sincerely,
N

Vou og

Dolly Van Wy, BA, ADN, RN
Facility Nurse Consultant |
Mental Health Licensure & Certification Section

Enclosures

Ce: W. Rhett Melton, Director, Partners Behavioral Healthcare LME/MCO
Selenna Moss, Quality Management Director, Partners Behavioral Healthcare LME/MCO
File

inspection_type: MHLCS Annual


summary: Statement of Deficiency - MHLCS Annual

raw_content:
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHL012-142

PRINTED: 10/01/2018

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

STREET ADDRESS, CITY, STATE, ZIP CODE

5741 FISH HATCHERY ROAD
MORGANTON, NC 28655

LAKE JAMES ALTERNATIVE FAMILY LIVING

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

09/26/2018

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

TITLE

6808 XYIV11

(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 survey was completed on September
26, 2018. A deficiency was cited.
This facility is licensed for the following service
category: 10A NCAC 27G .5600F Supervised
Living/Alternative Family Living.
V 118| 27G .0209 (C) Medication Requirements Vv 118

(X6) DATE

If continuation sheet 1 of 3

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL012-142

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

5741 FISH HATCHERY ROAD
MORGANTON, NC 28655

LAKE JAMES ALTERNATIVE FAMILY LIVING

PRINTED: 10/01/2018

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

09/26/2018

This Rule is not met as evidenced by:

Based on observation, record review and
interviews, the facility failed to administer
medications based on the written order of a
person authorized to prescribe medications and
failed to keep the MARs complete and current
affecting 1 of 2 clients (Client #2). The findings
are:

Observations of Client #2's medication box and 2
of his medications on 9/26/18 from 2:55PM
through 3:45PM revealed:

- lorazepam (anti-anxiety) 0.5mg %2-1 tablet QD
(daily) dispensed 8/24/18 with 11 doses out of 30
missing from the bottle

- Prazosin (anti-anxiety) 1mg QHS (each
bedtime) dispensed 8/24/18

Review on 9/26/18 of Client #2's record revealed:
- Admission date: 6/15/18

- Diagnoses: Mild Mental Retardation (MR);
Oppositional Defiant Disorder (ODD); Attention
Deficit Hyperactive Disorder, Combined

- Medication Orders: No physician's order for
Client #2's lorazepam or Prazosin

Review on 9/26/18 of Client #2's MARs revealed
the lorazepam and Prazosin had not been written
on the MARs for July, August and September.

Interview on 9/26/18 with Staff #1 revealed:

- She was unsure why Client #2's lorazepam and
Prazosin had not been written on the MARs;

- Staff #1 acknowledged Client #2 had been
administered the aforementioned medications.

Division of Health Service Regulation
STATE FORM

6809

XYIV11

(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 Vv 118

If continuation sheet 2 of 3

Division of Health Service Regulation

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

MHL012-142

NAME OF PROVIDER OR SUPPLIER

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

5741 FISH HATCHERY ROAD
MORGANTON, NC 28655

LAKE JAMES ALTERNATIVE FAMILY LIVING

PRINTED: 10/01/2018

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

09/26/2018

(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 Vv 118

Interview on 9/26/18 with the Qualified
Professional (QP) revealed:

- She acknowledged written medication orders
had not been obtained for Client #2's lorazepam
and Prazosin;

- The QP stated she would ensure Staff #1 was
re-trained in medication administration and
licensure rule requirements.

Division of Health Service Regulation
STATE FORM

6809

XYIV11

If continuation sheet 3 of 3


facility_name: Tournament Street

summary: Plan of Correction - MHLCS Annual

raw_content:
PRINTED: 05/12/2025
FORM APPROVED.
Division of Health Service Regulation

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

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

COMPLETED

A.BUILDING:

04/28/2025

MHL013-090 EWING

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1508 LANE STREET
KANNAPOLIS, NC 28083

TOURNAMENT STREET

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION («5)
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)

} INITIAL COMMENTS

An annual survey was completed on April 28,
2025. Adeficiency was cited.

This facility is licensed for the following service
category: 10A NCAC 27G .1700 Residential
Treatment Staff Secure for Children and
Adolescents.

This facility is licensed for 4 and has a current
census of 4. The survey sample consisted of
audits of 3 current clients.

27G .0304(b)(4) Hot Water Temperatures

10A NCAC 27G .0304 FACILITY DESIGN AND
EQUIPMENT

(b) Safety: Each facility shall be designed,
constructed and equipped in a manner that
ensures the physical safety of clients, staff and
visitors.

(4) In areas of the facility where clients are
exposed to hot water, the temperature of the
water shall be maintained between 100-116
degrees Fahrenheit.

This Rule is not met as evidenced by: We have adjusted the water temperature to a! | 04/28/25

Based on interviews and observation the facility lower temp. We are going to check it at least
failed to ensure the hot water temperature was 3 times a week. We will keep a water temp log
maintained between 100-116 degrees Fahrenheit. for the next 60 days. We will ensure the

The findings are: client's safety.

Observation on 4/23/25 at approximately 1:15 PM
revealed:

- the hot water temperature was 122 degrees
Fahrenheit at the sink in the hall bathroom

Interview with Client #1 on 4/23/25 revealed:
-had no issues with the water temperature
Division of Health Service Regulation

l TORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
—_ 5
rr Tay! reSedevl S14 25
STATE FORM sled 7T1H11 If continuation sheet 1 of 2

RECEIVED

DHSR-MH Licensure Sect

PRINTED: 05/12/2025
FORM APPROVED

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES. (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (3) DATE SURVEY.
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING: COMPLETED

MHL013-090 5. WING 04/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1508 LANE STREET

TOURNAMENT STREET KANNAPOLIS, NC 28083

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

Continued From page 1

-took showers in the hall bathroom

Interview with Client #2 on 4/23/25 revealed:
-had no issues with the water temperature
-took showers in the hall bathroom

Interview with Client #3 on 4/23/25 revealed:
-had no issues with the water temperature
-took showers in the hall bathroom

Interview with the Qualified Professional on
4/24/25 revealed.

-the clients had not complained about the water
being too hot

-he was not aware the hot water temperature was
above the required range

Interview with the Executive Director/Licensee on
4/23/25 revealed:

-the clients had not complained about the water
being too hot

-was not aware the hot water temperature was
above the required range

Division of Health Service Regulation
STATE FORM bad 7T1H11 If continuation sheet 2 of 2


summary: Statement of Deficiency - MHLCS Annual

raw_content:
Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA
AND PLAN OF CORRECTION

IDENTIFICATION NUMBER:

MHLO013-090

A. BUILDING:

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 05/12/2025

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

04/28/2025

10A NCAC 27G .0304 FACILITY DESIGN AND
EQUIPMENT

(b) Safety: Each facility shall be designed,
constructed and equipped in a manner that
ensures the physical safety of clients, staff and
visitors.

(4) In areas of the facility where clients are
exposed to hot water, the temperature of the
water shall be maintained between 100-116
degrees Fahrenheit.

This Rule is not met as evidenced by:

Based on interviews and observation the facility
failed to ensure the hot water temperature was
maintained between 100-116 degrees Fahrenheit.
The findings are:

Observation on 4/23/25 at approximately 1:15 PM
revealed:

- the hot water temperature was 122 degrees
Fahrenheit at the sink in the hall bathroom

Interview with Client #1 on 4/23/25 revealed:
-had no issues with the water temperature

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

STATE FORM

6899

771H11

TITLE

1508 LANE STREET
TOURNAMENT STREET
KANNAPOLIS, NC 28083
(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 survey was completed on April 28,
2025. A deficiency was cited.
This facility is licensed for the following service
category: 10A NCAC 27G .1700 Residential
Treatment Staff Secure for Children and
Adolescents.
This facility is licensed for 4 and has a current
census of 4. The survey sample consisted of
audits of 3 current clients.
V 752) 27G .0304(b)(4) Hot Water Temperatures V 752

(X6) DATE

If continuation sheet 1 of 2

Division of Health Service Re

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

NAME OF PROVIDER OR SUPPLIER

MHLO013-090

A. BUILDING:

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/12/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

04/28/2025

-took showers in the hall bathroom

Interview with Client #2 on 4/23/25 revealed:
-had no issues with the water temperature
-took showers in the hall bathroom

Interview with Client #3 on 4/23/25 revealed:
-had no issues with the water temperature
-took showers in the hall bathroom

Interview with the Qualified Professional on
4/24/25 revealed:

-the clients had not complained about the water
being too hot

-he was not aware the hot water temperature was
above the required range

Interview with the Executive Director/Licensee on
4/23/25 revealed:

-the clients had not complained about the water
being too hot

-was not aware the hot water temperature was
above the required range

Division of Health Service Regulation
STATE FORM

6809

771H11

1508 LANE STREET
TOURNAMENT STREET
KANNAPOLIS, NC 28083
(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 752| Continued From page 1 V 752

If continuation sheet 2 of 2


summary: Plan of Correction - MHLCS Annual and Complaint

raw_content:
To:

Page: 2 of 9 2023-09-21 17:13:00 GMT 17049195983 From: RICKY Taylor

PRINTED: 09/15/2023
FORM APPROVED

Division of Health Service Regulation
STATEMENT Of DEFICIENCIES (41) PROVIDER/SUPPLIERICLIA
AND PLAN OF GORRECTION IDENTIFICATION NUMBER:

(2) MULTIPLE CONSTRUCTION (3) OATE SURVEY
A, BUILDING: COMPLETED

c
8, WANG —______— 08/48/2023

STREET ADORESS. CITY, STATE, ZIP CODE

1508 LANE STREET
KANNAPOLIS, NC 28083

MHLO13-096

NAME OF PROVIDER OR SUPPLIER

TOURNAMENT STREET

4) 10 SUMMARY STATEMENT OF DEFICIENCIES PROMIDER'S PLAN OF CORRECTION
PREFIX (BACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EAGH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAS CROSS-REFERENCED TO THE APPROPRIATE, DATE
DEFICIENCY}

V 000 INITIAL COMMENTS
| An annual and complaint survey was completed
on 8-18-23. The complaints were
unsubstantiated (Intake #'s NC 00203897 and NC
| 00203666}. Deficiencies were cited.

This facility is licensed for the following service
category: TOA NCAC 27G .1700 Residential
Treatment Staff Secure for Children or
Adolescents

This facility is licensed for 4 and currently has a
census of 4. The survey sample consisted of
_ audits of 2 current clients and 1 former client.

V 118 27G .0204 Training/Supervision V 110
_ Paraprofessionals

_ TOA NCAC 27G .0204 COMPETENCIES AND
SUPERVISION OF PARAPROFESSIONALS

(a) There shall be no privileging requirements for
paraprofessionals.

(b) Paraprofessionals shall be supervised by an
associate professional or by a qualified
professional as specified in Rule .0104 of this
Subchapter.

(e) Paraprofessionats shall demonstrate
knowledge, skills and abilities required by the

| population served.

| @d) At such time as a competency-based

_ employment system is established by rulemaking,
| then qualified professionals and associate
professionals shall demonstrate competence.

{e} Competence shail be demonstrated by
exhibiting core skills including:

(1) technical knowledge:

(2) cultural awareness;

| G3} analytical skilis;
(4) decision-making
(5) interpersonal skills;
Division of Health Service Raguiation

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVES 5: E FALE 06 DATE
ae Pras. get one fer

STATE FORM cena OuB Itt Weantinuation sheet 1 of 8

To:

Page: 3 of 9 2023-09-21 17:13:00 GMT 17049195983 From: RICKY Taylor

PRINTED: 09/15/2020

FORM APPROVED

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES G1) PROVIDER/SUPPLIERICLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(<2) MULTIPLE CONSTRUCTION
A. BUILDING:

(3) DATE SURVEY
COMFEETED

c
08/18/2023

MHL013-080 6 WING

STREET ADDRESS, CITY. STATE, ZIP CODE
1508 LANE STREET
KANNAPOLIS, NC 28083

SUMMARY STATEMENT OF DEFICIENCIES: iD PROVIDER'S PLAN OF CORRECTION £88}
PREFIX {EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE:
REGULATORY OR LSC IDENTIFYING INFORMATION) GROSS-REFERENCED TO THE APPROPRIATE Gate
DEFICIENCY)

NAME OF PROVIDER OR SUPPLIER

TOURNAMENT STREET

Continued From page t

(8) communication skills; and
(7) clinical skills.

() The governing body for each facility shall
develop and implement policies and procadures
for the initiation of the individualized supervision
plan upon hiring each paraprofessional.

The agency has corrected the issue of staff 07/25/2023)
competence by giving them supervision.
Staff was negligent in his behavior and we
will continue to increase the supervision on
a weekly basis in order to bring the staff up
to speed. Staff #2 is no longer working
with the consumers in the facility.

This Rule is not met as evidenced by:
Based on record reviews and interviews, the
facility failed to ensure 1 of 3 audited staff (staff
#2) demonstrated the knowledge, skills, and
abilities required by the population served, The
findings are:

Review on 7-20-23 of former client (FC) #5's
record revealed:
-Date of admission: 3-17-23.
-Date of Discharge: 7-9-23.
-Age: 16.
-Diagnoses: Attention Deficit Hyperactivity
, Disorder (ADHD), combined, Conduct Disorder
childhood onset, Post-Traumatic Stress Disorder
(PTSD).

-Review on 7-18-23 of staff #2's personnel record
tevealed:

-Date of Hire: 6-19-2014.

-Tile: direct support professional,

Review on 7-17-23 of facility records revealed,
-Documentation of an internal investigation
(6-18-23) regarding allegations that staff #2
pointed a gun and threatened FC #5

-Email from FC #5's Department of Social
Division of Health Service Regulation

STATE FORM ine ousitt Heortinvation sham 2 of B

Page: 4 of 9 2023-09-21 17:13:00 GMT 17049195983 From: RICKY Taylor

PRINTED: 09/15/2023
FORM APPROVED
Division of Heaith Service Regulation
STATEMENT OF DEFICIENCIES (1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(2) MULTIPLE CONSTRUCTION
A. BUILDING!

(X3) DATE BURVEY
COMPLETED

c
08/18/2023

MHLO13-090

NAME OF PROVIDER OR SUPPLIER STREET ADORESS, CITY, STATE. ZIP COUE
4608 LANE STREET
KANNAPOLIS, NC 28083

TOURNAMENT STREET

&X4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION et
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (GACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE CATE

DEFICIENCY!
Continued From page 2

Services Social Worker to the Executive Director
(ED) dated 6-18-23 titled "[FC #5] concems" in
which the Social Worker revealed:

~"E had gotten wind that he (FC #8) claimed a staff
pulled a gun on him (which he admitted was a lie
by Spm same day)."

TFC #3] claims that he just made the claim

about the weapon because he wanted to avoid

, Consequences for his actions. He said he

| understands he was wrong.”

| Interview on &-3-23 with staff #2 revealed:

-"E didn’t bring the qun to the house (facllity)."

~" Lam a licensed gun owner. | had been at the
gun range the day before and had put the gun in
one of my bags. | usually have several bags
because Igo to schesl, and have a couple of
different things going an and | cary a couple
different bags with mea."

~"l usually work overnights, | came in the house
and sat the bags down. [FC #5] was in the room
with me, | opened the bag to look for my
computer and saw the gun. | panicked. [FC #5]
was standing right beside me. [Client #3] was
coming to the living room from his room. 1
wrapped it (the gun) up in a cloth, put i back in
the bag, took the bag to my car and locked it in
my trunk.“

-'| called [QP] he was already on his way in. As
soon as he came | told him | had to run a quick
errand. | took the gun home."

-"I did not tell anyone about the gun. | never took
it out, | didn’t show if to anyone. [FC #5] didn't
say anything to me about the gun, | wasn't sure if
he even seen the gun but thought he had to have
seen it cause he was standing right beside me
when | opened the bag."

Interview on 7-17-23 with client #1 revealed:
-He did nat see the gun. L
Division of Health Service Regulation
STATE FORM 20

ON51T if cortinuation shset 3 of 8

To:

NAME OF PROVIDER OR SUPPLIER

Page: 5 of 9 2023-09-21 17:13:00 GMT

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES:
AND PLAN OF CORRECTION

OC) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHLO13-090

082) MULTIPLE
A, BUILDING:

17049195983

CONSTRUCTION

BLAMING

4508 LANE STREET

TOURNAMENT STREET

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

Continued From page 3

-He had never seen a weapon of any kind in the
facility.

Interview on 7-17-23 with client #2 revealed:
-He did not see the gun.

-He had never seen a weapon of any kind in the
facility.

Interview on 7-17-23 with client #3 revealed:
-He dic not see the gun.

-He had never seen a weapon of any kind in the
facility.

Interview on 7-17-23 with client #4 reveaied:
-He dic not see a gun.

-FC #6 told him about the gun.

-While he and FC #5 were AWOL (absent without
leave), FC #5 told him that staff #2 had pulled a
gun on him and threatened him.

"I found out that he lied about all of that, he (FC
#5) admitted he lied. He just told ma that to
scare me so | would run with him,”

~"I never saw a gun. The staff here are goad to
us.”

Interview on 7-20-23 with FC #5 revealed:

-"No, [never saw a gun."

-"| saw the gun but he (staff #2) never pointed it
at me or anything.”

"I don’t know why } said that (staff #2 pointed a
gun at him and threatened him)}.°

Interview on 7-17-23 with the ED revealed:

-He was informed by the Qualified Professional
(QP) on 6-15-23 of the allegations (staff #2
threatened FC #5 with a gun).

-"[FC #5] immediately recanted the allegation."
-Compieted an internal investigation on 6-18-23
and concluded that staff #2 did not threaten FC
#5 with a gun, however staff #2 had brought a

Division of Health Service Regulation

STATE FORM

KANNAPOLIS, NC 28083

STREET ADDRESS, CITY, STATE, ZIP CODE

From: RICKY Taylor

PRINTED: 09/15/2023
FORM APPROVED

(3) DATE SURVEY
COMPLETED

c
GBB 2023

ib PROVIDER'S PLAN OF CORRECTION (x8)
PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE,
TAG CROSE-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
~
¥ 110

ne

Ou5411

Wt continuation sheet 4 of &

To:

£4) ID
PREFIX
TAS

V110

Vv 119)

Division of Heath Service Reguiation

STATE FORM

NAME OF PROVIDER OR SUPPLIER

TOURNAMENT STREET

Page: 6 of 9 2023-09-21 17:13:00 GMT

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(41) PROVIDER/SUPPLIERICLIA,
IDENTIFICATION NUMBER:

MHL013-099

(0X2) MULTIPLE CONSTRUCTION:

A. BUILDING:

B.WING

17049195983

From: RICKY Taylor

PRINTED: 09/15/2023

STREET ADDRESS, CITY, STATE, ZIP CODE
4608 LANE STREET
KANNAPOLIS, NC 28083

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

Continued From page 4

gun to the facility.

-Staff #2 did not inform him that he had
accidentally" brought a gun to the facility.
-Staff #2 was suspended on 6-18-23 due to
bringing @ gun to the facility.

-Staff #2 remained on suspension and no
decision regarding staff #2's status had been
made by survey exit date.

276 .0209 (D) Medication Requirements

410A NCAC 27G .0209 MEDICATION
REQUIREMENTS

(d} Medication disposal:

(1) All prescription and non-prescription
medication shail be disposed of in a manner that
guards against diversion or accidental ingestion.
(2) Non-controlled substances shail be disposed
of by incineration, flushing into septic or sewer
system, or by transfer to a local pharmacy for
destruction, A record of the medication disposal
shall be maintained by the program.
Documentation shall specify the client's name,
medication name, strength, quantity, disposal
date and method, the signature of the person
disposing of medication, and the person
witnessing destruction

(3) Controlied substances shall be disposed of in
accordance with the North Carolina Controlied
Substances Act, G.S. 90, Article 5, including any
subsequent amendments.

(4) Upon discharge of a patient or resident, the
remainder of his or her drug supply shall be
disposed of promptly unless it is reasonably
expected that the patient or resident shall return
to the facility and in such case, the remaining
drug supply shall not be held for more than 30
calendar days after the date of discharge.

Ls)
PREFIX
TAG

PROMIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
GROSS-REFERENCED TO THE APPROPRIATE,
DEFICIENCY)

Ojsttt

4X3) DATE SURVEY

FORM APPROVED

COMPLETED

Cc
08/18/2023

eS
COMPLETE
DATE

{f continuation sheet 6 of B

Page: 7 of 9 2023-09-21 17:13:00 GMT 17049195983 From: RICKY Taylor

PRINTED: 09/15/2023
FORM APPROVED:

(1) PROVIDER/SUPPLIER/CLIA. (%2)} MULTIPLE CONSTRUCTION (X3} DATE SURVEY
AND PLAN OF CORRECTION IOENTIFICATION NUMBER; A. BUILDING: COMPLETED

Cc
MHL013-090 B.VANG —— ——J_____ 03/48/2023

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1808 LANE STREET
KANNAPOLIS, NC 28083
SUMMARY STATEMENT OF DEFICIENCIES. iD I PROVIDER'S PLAN OF CORRECTION
{EACH DEFICIENGY MUST BE PRECEDED BY FULL PREFIX | {EACH CORRECTIVE ACTION SHOULD BE

REGULATORY OR LSC IDENTIFYING INFORMATION) TAG GCROSS-REFERENGED TG THE APPROPRIATE
DEFICIENCY}

TOURNAMENT STREET

V 419} Continued From page 5

| i
| This Rule is not met as evidenced by: As a result of the findings we have instituted | S7i20/2023

Based on record reviews, observation and an audit of medication and files every 30
© . ot a ge days by our nurse and the QP,
interviews, the facility failed to ensure medication
_ was disposed of in a manner that guarded
against diversion of accidental ingestion affecting
| 1 of 2 audited clients (client #1}. The findings
are:

Review on 7-17-23 of client #1's record revealed:
-Date of admission: 3-18-22.

-Age: 16.

~Diagnoses: Post-Traumatic Stress Syndrome,
Attention Deficit Hyperactivity Disorder, Enuresis,
Reactive Attachment Disorder, Oppositional
Defiant Disorder, Possible Borderline Fetal
Alcohol Syndrome.

-Physician’s order dated 6-12-23 for Benzoyl
Peroxide 6% Lotion (Acne) 10 oz (ounce), apply
gmail amount to affected area at bedtime.

Observation on 7-17-23 at approximately 2:30pm
of cilent #1's medications revealed: |
~Benzoyl Peroxide 5% Lotion 10 oz (ounce),
dispensed 2-9-22, expired 2-9-23,

Review on 7-17-23 of client #1's MAR revealed ‘| i
~Benzoy! Peroxide 5% Lotion 10 oz (ounce), apply i
1 "APP" small amount to affected area at bedtime }
documented as administered from 6-1-23 to |
7-16-23.

Interview on 7-17-23 with client #1 revealed:
"Yes." he was gatting his mediations daily.

Interview on 7-17-23 with the Qualified
Division of Health Service Regulation
STATE FORM Cd OUS114 continuation sheet Gof 8

To:

Page: 8 of 9 2023-09-21 17:13:00 GMT 17049195983 From: RICKY Taylor

PRINTED: 09/15/2023
FORM APPROVED
ulation
(At) PROVIDER/SUPPUIERCLIA,
IDENTIFICATION NUMBER:

Division of Heaith Service Reg

STATEMENT OF DEFICIENCIES:
AND PLAN OF CORRECTION

(2) MULTIPLE CONSTRUCTION
A. BUILDING:

4X3) DATE SURVEY
COMPLETED

Cc
98/18/2023

MHLO13-090 8. WING

STREET ADDRESS, CITY, STATE, ZIP CODE

1508 LANE STREET
KANNAPOLIS, NC 28083

MAME OF PROVIDER GR SUPPLIER

TOURNAMENT STREET

SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION
(EACH DEFICIENCY MUST BE PRECEDEO 8Y FULL PREFIX {EAGH CORRECTIVE ACTION SHOULD BE COMPLETE
REGULATORY OR LSG IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

¥ 118} Continued From page 6

Professional (QP) revealed:

| .The client was getting the medication daily at
i ‘i

} bedtime.

i -The expiration date was an oversight.

; "Tl call {the pharmacy) right new and get it

| (medication) ordered.”

V 782, 276 .0304(b)(4) Hot Water Temperatures

10A NCAC 27G .0304 FACILITY DESIGN AND
EQUIPMENT
ib) Safety: Each facility shall be designed,
constructed and equipped in a manner that

| ensures the physical safety of clients, staff and
visitors.

7c) In areas of the facility where clients are
exposed to hot water, the temperature of the

i water shall be maintained between 1066-115

| degrees Fahrenheit,
This Rule is not met as evidenced by: AS a result of the findings we have been doing 07/20/2024
Based on interviews and observation, the facility water temperature checks daily. We have
failed to ensure the hot water temperature was baen able to regulate the water temperatura.
maintained between 100 and 116 degrees The hot water heater has been turned all the
Fahrenheit. The findings are: way down.

Observation on 7-17-23 at approximately 1:30pm
revealed:

-Temperature in the kitchen sink was 120
degrees Fahrenheit.

-Tamperature in bathroom #1 located in the
hallway was 118 degrees in the sink and 116 in

| the shower.

| ‘Temperature in bathroom #2 located beside

, bedroom #4 was 120 degrees in the sink.

: Interview on 7-17-23 with client #1 revealed:
-No issues with the water temperature.

Division of Healt Service Regulation
STATE FORM Cad O5411 I comtinuates: sheet 7 of

To: Page: 9 of 9 2023-09-21 17:13:00 GMT 17049195983 From: RICKY Taylor

PRINTED: 09/15/2023
FORM APPROVED

Division of Health Service Reauiation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA &X2) MULTIPLE CONSTRUCTION: (x3) DATE SURVEY
AND PLAN OF GORRECTION IDENTIFICATION NUMBER: A BUILDING: COMPLETED

c
MHiLO13-090 Be YAN enn 05/18/2023

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1808 LANE STREET
TOURNAMENT STREET KANNAPOLIS, NC 28083

SUMMARY STATEMENT OF DEFICIENCIES: PROVIDER'S PLAN OF CORRECTIGN
(BACK DEFICIENCY MUST SE PRECEDED 8Y FULL (EACH CORRECTIVE ACTION SHOULD BE
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE
DEFIGIENCY)

"Continued From page 7
_ "Ethink they had it fixed last weex"

Interview on 7-17-23 with client #2 revealed:
| -No issues with the water temperature.
| "It’s fine (the water temperature).”

interview on 7-17-23 with client #3 revealed:
-No issues with the water temperature.

~¥ don't like taking cold showers, {like the water
hoi.”

interview on 7-17-23 with cliant #4 revealed:
No issues with the water temperature.
-"Yeah, it's good."

Interview on 7-17-23 with the Qualified

| Professional (QP) revealed:

| -"We've had issues with the water for a couple of
i weeks. [Executive Director/(ED)] had them
(maintenance) out here a couple of times working
on the water. The last time they were here they
turned it (temperature) down too low and they had
fo come back out and turn it up. I'll call him (ED)
tight now and have them come back out to tum it
down."

-There were no complaints from the residents
about the water.

i Interview on 7-17-23 with the ED revealed:
-"l've already called them (maintenance} to come
} out and fix the water. They will be here today.”

Division of Health Service Regulation
STATE FORM bead QUSTt If continuation sheer & ot 8

To:

Page: 1 of 9 2023-09-21 17:13:00 GMT 17049195983
FAX COVER SHEET
TO
COMPANY NC DHSR
FAXNUMBER 19197158078
FROM RICKY Taylor
DATE 2023-09-21 17:12:33 GMT
RE NewPath Youth Services
COVER MESSAGE

Plan ofcorrections for Compiaintinvestigation.

From: RICKY Taylor

inspection_type: MHLCS Annual and Complaint


summary: Statement of Deficiency - MHLCS Annual and Complaint

raw_content:
Division of Health Service Regulation

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

MHLO013-090

NAME OF PROVIDER OR SUPPLIER

A. BUILDING:

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/15/2023

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

Cc
08/18/2023

1508 LANE STREET
TOURNAMENT STREET
KANNAPOLIS, NC 28083
(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 complaint survey was completed
on 8-18-23. The complaints were
unsubstantiated (Intake #'s NC 00203897 and NC
00203666). Deficiencies were cited.
This facility is licensed for the following service
category: 10A NCAC 27G .1700 Residential
Treatment Staff Secure for Children or
Adolescents.
This facility is licensed for 4 and currently has a
census of 4. The survey sample consisted of
audits of 2 current clients and 1 former client.
V 110| 27G .0204 Training/Supervision Vv 110

Paraprofessionals

10A NCAC 27G .0204 COMPETENCIES AND
SUPERVISION OF PARAPROFESSIONALS

(a) There shall be no privileging requirements for
paraprofessionals.

(b) Paraprofessionals shall be supervised by an
associate professional or by a qualified
professional as specified in Rule .0104 of this
Subchapter.

(c) Paraprofessionals shall demonstrate
knowledge, skills and abilities required by the
population served.

(d) At such time as a competency-based
employment system is established by rulemaking,
then qualified professionals and associate
professionals shall demonstrate competence.

(e) Competence shall be demonstrated by
exhibiting core skills including:

(1) technical knowledge;

(2) cultural awareness;

(3) analytical skills;

(4) decision-making;
interpersonal skills;

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

STATE FORM

6899

0J5111

TITLE

(X6) DATE

If continuation sheet 1 of 8

Division of Health Service Regulation

PRINTED: 09/15/2023

FORM APPROVED

(6) communication skills; and

(7) clinical skills.

(f) The governing body for each facility shall
develop and implement policies and procedures
for the initiation of the individualized supervision
plan upon hiring each paraprofessional.

This Rule is not met as evidenced by:

Based on record reviews and interviews, the
facility failed to ensure 1 of 3 audited staff (staff
#2) demonstrated the knowledge, skills, and
abilities required by the population served. The
findings are:

Review on 7-20-23 of former client (FC) #5's
record revealed:

-Date of admission: 3-17-23.

-Date of Discharge: 7-9-23.

-Age: 16.

-Diagnoses: Attention Deficit Hyperactivity
Disorder (ADHD), combined, Conduct Disorder
childhood onset, Post-Traumatic Stress Disorder
(PTSD).

-Review on 7-18-23 of staff #2's personnel record
revealed:

-Date of Hire: 6-19-2014.

-Title: direct support professional.

Review on 7-17-23 of facility records revealed:
-Documentation of an internal investigation
(6-18-23) regarding allegations that staff #2
pointed a gun and threatened FC #5
-Email from FC #5's Department of Social
Division of Health Service Regulation

STATE FORM

6809

0J5111

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL013-090 08/18/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1508 LANE STREET
TOURNAMENT STREET
KANNAPOLIS, NC 28083
(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 110] Continued From page 1 Vv 110

If continuation sheet 2 of 8

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHLO013-090

A. BUILDING:

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/15/2023

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

Cc
08/18/2023

Services Social Worker to the Executive Director
(ED) dated 6-18-23 titled "[FC #5] concerns" in
which the Social Worker revealed:

-"| had gotten wind that he (FC #5) claimed a staff
pulled a gun on him (which he admitted was a lie
by 5pm same day)."

-"[FC #3] claims that he just made the claim

about the weapon because he wanted to avoid
consequences for his actions. He said he
understands he was wrong."

Interview on 8-3-23 with staff #2 revealed:

-"| didn't bring the gun to the house (facility)."
-"|am a licensed gun owner. | had been at the
gun range the day before and had put the gun in
one of my bags. | usually have several bags
because | go to school, and have a couple of
different things going on and | carry a couple
different bags with me."

-"| usually work overnights, | came in the house
and sat the bags down. [FC #5] was in the room
with me. | opened the bag to look for my
computer and saw the gun. | panicked. [FC #5]
was standing right beside me. [Client #3] was
coming to the living room from his room. |
wrapped it (the gun) up in a cloth, put it back in
the bag, took the bag to my car and locked it in
my trunk."

-"| called [QP] he was already on his way in. As
soon as he came | told him | had to run a quick
errand. | took the gun home."

-"| did not tell anyone about the gun. | never took
it out, | didn't show it to anyone. [FC #5] didn't
say anything to me about the gun, | wasn't sure if
he even seen the gun but thought he had to have
seen it cause he was standing right beside me
when | opened the bag."

Interview on 7-17-23 with client #1 revealed:
-He did not see the gun.

Division of Health Service Regulation

STATE FORM

6809

0J5111

1508 LANE STREET
TOURNAMENT STREET
KANNAPOLIS, NC 28083
(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 110) Continued From page 2 Vv 110

If continuation sheet 3 of 8

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHLO013-090

A. BUILDING:

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/15/2023

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

Cc
08/18/2023

-He had never seen a weapon of any kind in the
facility.

Interview on 7-17-23 with client #2 revealed:
-He did not see the gun.

-He had never seen a weapon of any kind in the
facility.

Interview on 7-17-23 with client #3 revealed:
-He did not see the gun.

-He had never seen a weapon of any kind in the
facility.

Interview on 7-17-23 with client #4 revealed:
-He did not see a gun.

-FC #5 told him about the gun.

-While he and FC #5 were AWOL (absent without
leave), FC #5 told him that staff #2 had pulled a
gun on him and threatened him.

-"| found out that he lied about all of that, he (FC
#5) admitted he lied. He just told me that to
scare me so | would run with him."

-"| never saw a gun. The staff here are good to
us."

Interview on 7-20-23 with FC #5 revealed:
-"No, | never saw a gun."

-"| saw the gun but he (staff #2) never pointed it
at me or anything."

-"| don't know why | said that (staff #2 pointed a
gun at him and threatened him)."

Interview on 7-17-23 with the ED revealed:
-He was informed by the Qualified Professional
(QP) on 6-15-23 of the allegations (staff #2
threatened FC #5 with a gun).

-"[FC #5] immediately recanted the allegation."
-Completed an internal investigation on 6-18-23
and concluded that staff #2 did not threaten FC
#5 with a gun, however staff #2 had brought a

Division of Health Service Regulation

STATE FORM

6809

0J5111

1508 LANE STREET
TOURNAMENT STREET
KANNAPOLIS, NC 28083
(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 110) Continued From page 3 Vv 110

If continuation sheet 4 of 8

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHLO013-090

PRINTED: 09/15/2023

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED
(X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
A. BUILDING: COMPLETED
Cc
08/18/2023

10A NCAC 27G .0209 MEDICATION
REQUIREMENTS

(d) Medication disposal:

(1) All prescription and non-prescription
medication shall be disposed of in a manner that
guards against diversion or accidental ingestion.
(2) Non-controlled substances shall be disposed
of by incineration, flushing into septic or sewer
system, or by transfer to a local pharmacy for
destruction. A record of the medication disposal
shall be maintained by the program.
Documentation shall specify the client's name,
medication name, strength, quantity, disposal
date and method, the signature of the person
disposing of medication, and the person
witnessing destruction.

(3) Controlled substances shall be disposed of in
accordance with the North Carolina Controlled
Substances Act, G.S. 90, Article 5, including any
subsequent amendments.

(4) Upon discharge of a patient or resident, the
remainder of his or her drug supply shall be
disposed of promptly unless it is reasonably
expected that the patient or resident shall return
to the facility and in such case, the remaining
drug supply shall not be held for more than 30
calendar days after the date of discharge.

Division of Health Service Regulation
STATE FORM

6809

0J5111

1508 LANE STREET
TOURNAMENT STREET
KANNAPOLIS, NC 28083
(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 110) Continued From page 4 Vv 110
gun to the facility.
-Staff #2 did not inform him that he had
"accidentally" brought a gun to the facility.
-Staff #2 was suspended on 6-18-23 due to
bringing a gun to the facility.
-Staff #2 remained on suspension and no
decision regarding staff #2's status had been
made by survey exit date.
V 119| 27G .0209 (D) Medication Requirements Vv 119

If continuation sheet 5 of 8

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHLO013-090

A. BUILDING:

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/15/2023

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

Cc
08/18/2023

This Rule is not met as evidenced by:

Based on record reviews, observation and
interviews, the facility failed to ensure medication
was disposed of in a manner that guarded
against diversion or accidental ingestion affecting
1 of 2 audited clients (client #1). The findings
are:

Review on 7-17-23 of client #1's record revealed:
-Date of admission: 3-18-22.

-Age: 16.

-Diagnoses: Post-Traumatic Stress Syndrome,
Attention Deficit Hyperactivity Disorder, Enuresis,
Reactive Attachment Disorder, Oppositional
Defiant Disorder, Possible Borderline Fetal
Alcohol Syndrome.

-Physician's order dated 6-12-23 for Benzoyl
Peroxide 5% Lotion (Acne) 10 oz (ounce), apply
small amount to affected area at bedtime.

Observation on 7-17-23 at approximately 2:30pm
of client #1's medications revealed:

-Benzoyl Peroxide 5% Lotion 10 oz (ounce),
dispensed 2-9-22, expired 2-9-23.

Review on 7-17-23 of client #1's MAR revealed:
-Benzoyl Peroxide 5% Lotion 10 oz (ounce), apply
1 "APP" small amount to affected area at bedtime
documented as administered from 6-1-23 to
7-16-23.

Interview on 7-17-23 with client #1 revealed:
-"Yes," he was getting his mediations daily.

Interview on 7-17-23 with the Qualified

1508 LANE STREET
TOURNAMENT STREET
KANNAPOLIS, NC 28083
(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 119] Continued From page 5 Vv 119

Division of Health Service Regulation
STATE FORM

6809

0J5111

If continuation sheet 6 of 8

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHLO013-090

A. BUILDING:

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/15/2023

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

Cc
08/18/2023

10A NCAC 27G .0304 FACILITY DESIGN AND
EQUIPMENT

(b) Safety: Each facility shall be designed,
constructed and equipped in a manner that
ensures the physical safety of clients, staff and
visitors.

(4) In areas of the facility where clients are
exposed to hot water, the temperature of the
water shall be maintained between 100-116
degrees Fahrenheit.

This Rule is not met as evidenced by:

Based on interviews and observation, the facility
failed to ensure the hot water temperature was
maintained between 100 and 116 degrees
Fahrenheit. The findings are:

Observation on 7-17-23 at approximately 1:30pm
revealed:

-Temperature in the kitchen sink was 120
degrees Fahrenheit.

-Temperature in bathroom #1 located in the
hallway was 118 degrees in the sink and 116 in
the shower.

-Temperature in bathroom #2 located beside
bedroom #4 was 120 degrees in the sink.

Interview on 7-17-23 with client #1 revealed:
-No issues with the water temperature.

Division of Health Service Regulation
STATE FORM

6809

0J5111

1508 LANE STREET
TOURNAMENT STREET
KANNAPOLIS, NC 28083
(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 119] Continued From page 6 Vv 119
Professional (QP) revealed:
-The client was getting the medication daily at
bedtime.
-The expiration date was an oversight.
-"I'll call (the pharmacy) right now and get it
(medication) ordered."
V 752) 27G .0304(b)(4) Hot Water Temperatures V 752

If continuation sheet 7 of 8

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHLO013-090

A. BUILDING:

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/15/2023

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

Cc
08/18/2023

-"| think they had it fixed last week"

Interview on 7-17-23 with client #2 revealed:
-No issues with the water temperature.
-"It's fine (the water temperature)."

Interview on 7-17-23 with client #3 revealed:
-No issues with the water temperature.

-"| don't like taking cold showers, | like the water
hot."

Interview on 7-17-23 with client #4 revealed:
-No issues with the water temperature.
-"Yeah, it's good."

Interview on 7-17-23 with the Qualified
Professional (QP) revealed:

-"We've had issues with the water for a couple of
weeks. [Executive Director/(ED)] had them
(maintenance) out here a couple of times working
on the water. The last time they were here they
turned it (temperature) down too low and they had
to come back out and turn it up. I'll call him (ED)
right now and have them come back out to turn it
down."

-There were no complaints from the residents
about the water.

Interview on 7-17-23 with the ED revealed:
-"I've already called them (maintenance) to come
out and fix the water. They will be here today."

Division of Health Service Regulation
STATE FORM

6809

0J5111

1508 LANE STREET
TOURNAMENT STREET
KANNAPOLIS, NC 28083
(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 752] Continued From page 7 V 752

If continuation sheet 8 of 8