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:

MHL001-149

1710 SYK'

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

A. BUILDING:

B. WING

STREET ADDRESS, CITY, STATE, ZIP CODE

ES STREET

(X2) MULTIPLE CONSTRUCTION

PRINTED: 12/13/2021
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
12/10/2021

(X4) ID
PREFIX
TAG

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

ID
PREFIX
TAG

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

(x5)
COMPLETE
DATE

V 000

V 364

INITIAL COMMENTS

Acomplaint survey was completed on December
10, 2021. The complaint was substantiated
(intake #NC00183147). Deficiencies were cited.

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

The survey sample consisted of audits of 2
current clients, 2 former clients.

G.S. 122C- 62 Additional Rights in 24 Hour
Facilities

§ 122C-62. Additional Rights in 24-Hour
Facilities.

(a) In addition to the rights enumerated in G.S.
122C-51 through G.S. 122C-61, each adult client
who is receiving treatment or habilitation in a
24-hour facility keeps the right to:

(1) Send and receive sealed mail and have
access to writing material, postage, and staff
assistance when necessary;

(2) Contact and consult with, at his own expense
and at no cost to the facility, legal counsel, private
physicians, and private mental health,
developmental disabilities, or substance abuse
professionals of his choice; and

(3) Contact and consult with a client advocate if
there is a client advocate.

The rights specified in this subsection may not be
restricted by the facility and each adult client may
exercise these rights at all reasonable times.

(b) Except as provided in subsections (e) and (h)
of this section, each adult client who is receiving
treatment or habilitation in a 24-hour facility at all
times keeps the right to:

(1) Make and receive confidential telephone

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

STATE FORM

V 000

V 364

6899

HNG411

TITLE (X6) DATE

If continuation sheet 1 of 9

PRINTED: 12/13/2021
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
c
MHL001-149 B. WING _____ 12/10/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

(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 364] Continued From page 1 V 364

calls. All long distance calls shall be paid for by
the client at the time of making the call or made
collect to the receiving party;

(2) Receive visitors between the hours of 8:00
a.m. and 9:00 p.m. for a period of at least six
hours daily, two hours of which shall be after 6:00
p.m.; however visiting shall not take precedence
over therapies;

(3) Communicate and meet under appropriate
supervision with individuals of his own choice
upon the consent of the individuals;

(4) Make visits outside the custody of the facility
unless:

a. Commitment proceedings were initiated as
the result of the client's being charged with a
violent crime, including a crime involving an
assault with a deadly weapon, and the
respondent was found not guilty by reason of
insanity or incapable of proceeding;

b. The client was voluntarily admitted or
committed to the facility while under order of
commitment to a correctional facility of the
Division of Adult Correction of the Department of
Public Safety; or

c. The client is being held to determine capacity
to proceed pursuant to G.S. 15A-1002;

A court order may expressly authorize visits
otherwise prohibited by the existence of the
conditions prescribed by this subdivision;

(5) Be out of doors daily and have access to
facilities and equipment for physical exercise
several times a week;

(6) Except as prohibited by law, keep and use
personal clothing and possessions, unless the
client is being held to determine capacity to
proceed pursuant to G.S. 15A-1002;

(7) Participate in religious worship;

(8) Keep and spend a reasonable sum of his
own money;

Division of Health Service Regulation
STATE FORM 6899 HNG411 If continuation sheet 2 of 9

PRINTED: 12/13/2021
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
c
MHL001-149 B. WING _____ 12/10/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

(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 364] Continued From page 2 V 364

(9) Retain a driver's license, unless otherwise
prohibited by Chapter 20 of the General Statutes;
and

(10)Have access to individual storage space for
his private use.

(c) In addition to the rights enumerated in G.S.
122C-51 through G.S. 122C-57 and G.S.
122C-59 through G.S. 122C-61, each minor client
who is receiving treatment or habilitation in a
24-hour facility has the right to have access to
proper adult supervision and guidance. In
recognition of the minor's status as a developing
individual, the minor shall be provided
opportunities to enable him to mature physically,
emotionally, intellectually, socially, and
vocationally. In view of the physical, emotional,
and intellectual immaturity of the minor, the
24-hour facility shall provide appropriate
structure, supervision and control consistent with
the rights given to the minor pursuant to this Part.
The facility shall also, where practical, make
reasonable efforts to ensure that each minor
client receives treatment apart and separate from
adult clients unless the treatment needs of the
minor client dictate otherwise.

Each minor client who is receiving treatment or
habilitation from a 24-hour facility has the right to:
(1) Communicate and consult with his parents or
guardian or the agency or individual having legal
custody of him;

(2) Contact and consult with, at his own expense
or that of his legally responsible person and at no
cost to the facility, legal counsel, private
physicians, private mental health, developmental
disabilities, or substance abuse professionals, of
his or his legally responsible person's choice; and
(3) Contact and consult with a client advocate, if
there is a client advocate.

The rights specified in this subsection may not be

Division of Health Service Regulation
STATE FORM 6899 HNG411 If continuation sheet 3 of 9

PRINTED: 12/13/2021

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL001-149 B. WING 12/10/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1710 SYKES STREET
JUST IN TIME YOUTH SERVICES
BURLINGTON, NC 27215
(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 364] Continued From page 3 V 364

restricted by the facility and each minor client
may exercise these rights at all reasonable times.
(d) Except as provided in subsections (e) and (h)
of this section, each minor client who is receiving
treatment or habilitation in a 24-hour facility has
the right to:

(1) Make and receive telephone calls. All long
distance calls shall be paid for by the client at the
time of making the call or made collect to the
receiving party;

(2) Send and receive mail and have access to
writing materials, postage, and staff assistance
when necessary;

(3) Under appropriate supervision, receive
visitors between the hours of 8:00 a.m. and 9:00
p.m. for a period of at least six hours daily, two
hours of which shall be after 6:00 p.m.; however
visiting shall not take precedence over school or
therapies;

(4) Receive special education and vocational
training in accordance with federal and State law;
(5) Be out of doors daily and participate in play,
recreation, and physical exercise on a regular
basis in accordance with his needs;

(6) Except as prohibited by law, keep and use
personal clothing and possessions under
appropriate supervision, unless the client is being
held to determine capacity to proceed pursuant to
G.S. 15A-1002;

(7) Participate in religious worship;

(8) Have access to individual storage space for
the safekeeping of personal belongings;

(9) Have access to and spend a reasonable sum
of his own money; and

(10)Retain a driver's license, unless otherwise
prohibited by Chapter 20 of the General Statutes.
(e) No right enumerated in subsections (b) or (d)
of this section may be limited or restricted except
by the qualified professional responsible for the

Division of Health Service Regulation
STATE FORM 6899 HNG411 If continuation sheet 4 of 9

PRINTED: 12/13/2021

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL001-149 B. WING 12/10/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1710 SYKES STREET
JUST IN TIME YOUTH SERVICES
BURLINGTON, NC 27215
(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 364] Continued From page 4 V 364

formulation of the client's treatment or habilitation
plan. Awritten statement shall be placed in the
client's record that indicates the detailed reason
for the restriction. The restriction shall be
reasonable and related to the client's treatment or
habilitation needs. A restriction is effective for a
period not to exceed 30 days. An evaluation of
each restriction shall be conducted by the
qualified professional at least every seven days,
at which time the restriction may be removed.
Each evaluation of a restriction shall be
documented in the client's record. Restrictions on
rights may be renewed only by a written
statement entered by the qualified professional in
the client's record that states the reason for the
renewal of the restriction. In the case of an adult
client who has not been adjudicated incompetent,
in each instance of an initial restriction or renewal
of a restriction of rights, an individual designated
by the client shall, upon the consent of the client,
be notified of the restriction and of the reason for
it. In the case of a minor client or an incompetent
adult client, the legally responsible person shall
be notified of each instance of an initial restriction
or renewal of a restriction of rights and of the
reason for it. Notification of the designated
individual or legally responsible person shall be
documented in writing in the client's record.

This Rule is not met as evidenced by:

Based on record reviews and interviews, facility
staff failed to ensure clients could make and
receive confidential telephone calls affecting two
of two current clients (#1 and #2) and two of two
former clients (FC#3 and FC#4). The findings
Division of Health Service Regulation

STATE FORM 6899 HNG411 If continuation sheet 5 of 9

PRINTED: 12/13/2021

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL001-149 B. WING 12/10/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1710 SYKES STREET
JUST IN TIME YOUTH SERVICES
BURLINGTON, NC 27215
(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 364] Continued From page 5 V 364
are:

a. Review on 12/8/21 of client #1's record
revealed:

-Admission date 4/29/21.

-Diagnoses of Disruptive Mood Dysregulation
Disorder, Mild Intellectual Disability, Autism,
Attention Deficit Hyperactivity Disorder and Post
Traumatic Stress Disorder.

-He was 11 years old.

-There was no documentation in his record to
indicate staff could monitor his phone calls.

b. Review on 12/8/21 of client #2's record
revealed:

-Admission date 6/17/21.

-Diagnoses of Autism Spectrum Disorder,
Attention Deficit Hyperactivity Disorder,
Schizophrenia and Mild Intellectual Disability.
-He was 13 years old.

-There was no documentation in his record to
indicate staff could monitor his phone calls.

c. Review on 12/8/21 of FC #3's record revealed:
-Admission date 12/28/20.

Diagnoses of Mild Intellectual Disability,
Oppositional Defiant Disorder, Attention Deficit
Hyperactivity Disorder, Fetal Alcohol Syndrome
and Learning Disorder.

-He was 14 years old.

-He was discharged on 11/25/21.

-There was no documentation in his record to
indicate staff could monitor his phone calls.

d. Review on 12/8/21 of FC #4's record revealed:
‘Admission date 10/18/21.

-Diagnoses of Attention Deficit Hyperactivity
Disorder, Disruptive Mood Dysregulation Disorder
and Autism Spectrum Disorder.

He was 17 years old.

Division of Health Service Regulation

STATE FORM 6899 HNG411 If continuation sheet 6 of 9

PRINTED: 12/13/2021

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL001-149 B. WING 12/10/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1710 SYKES STREET
JUST IN TIME YOUTH SERVICES
BURLINGTON, NC 27215
(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 364] Continued From page 6 V 364

-He was discharged on 11/3/21.
-There was no documentation in his record to
indicate staff could monitor his phone calls.

Interview on 12/8/21 with client #1 revealed:
-He talked to his mother on the phone.

-Staff monitored his phone calls with his mother
all of the time.

-When he talked to his mother he had to put the
phone on speaker.

nterview on 12/8/21 with client #2 revealed:
-He didn't talk on the phone often. When he
lalked on the phone staff monitored his phone
calls with his father.

-He had to put the phone on speaker while he
talked to his father.

-He was not sure why the calls had to be
monitored.

nterview on 12/8/21 with FC #3 revealed:
-When he lived at the Level III home staff
monitored his phone calls whenever he talked on
he phone.

-If they make a phone call they must put the call
on speaker.

-He had an issue with that because he wanted to
have a private conversation with his mother
sometimes.

-He asked why the calls had to be monitored and
staff said it was the rules of the group home.

Interview on 12/9/21 with FC #4 revealed:

-He had an issue with staff monitoring their phone
calls when he lived at the group home.

‘Whenever he would call his family, he had to put
the phone on speaker.

-He could never have a private conversation.

-All of the other clients also had to put the phone
on speaker when they talked with their family.
Division of Health Service Regulation

STATE FORM 6899 HNG411 If continuation sheet 7 of 9

PRINTED: 12/13/2021
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
c
MHL001-149 B. WING _____ 12/10/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

(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 364] Continued From page 7 V 364

Interview with staff #1 on 12/9/21 revealed:
-They don't monitor phone calls for all of the
clients.

-They only monitor phone calls for client #1. They
had to put the phone on speaker whenever client
#1 talked with his mother.

-He confirmed facility staff failed to ensure clients
could make and receive confidential telephone
calls.

Interview with staff #2 on 12/9/21 revealed:
-They monitored calls for all of the clients
whenever they are on the phone.

-Client #1 actually had to put the phone on
speaker when he talked with his mother.

-He confirmed facility staff failed to ensure clients
could make and receive confidential telephone
calls.

Interviews with the Home Manager on 12/8/21
and 12/9/21 revealed:

-The clients in this home had privacy when they
talked on the phone.

-None of these clients calls had to be monitored
other than client #1.

-Client #1's grandmother was his guardian. She
had requested his telephone calls with his mother
be monitored by staff.

-She confirmed facility staff failed to ensure
clients could make and receive confidential
telephone calls.

Interview with the Program Director on 12/8/21
revealed:

-He knew staff monitored client #1's phone calls
with his mother.

-He thought the other clients in this home had
privacy when they talked on the phone.

-None of the other clients calls had to be

Division of Health Service Regulation

STATE FORM 6899 HNG411 If continuation sheet 8 of 9

PRINTED: 12/13/2021

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL001-149 B. WING 12/10/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

(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 364] Continued From page 8 V 364
monitored.

-He confirmed facility staff failed to ensure clients
could make and receive confidential telephone
calls.

Interview with the Qualified Professional/Licensee
on 12/9/21 revealed:

-Staff did monitor clients phone calls.

-They had to monitor client #1's phones calls if he
was on the phone with his mother.

-His grandmother was his guardian and she does
not want client #1 talking with his mother on the
phone unsupervised.

-She knew staff had client #1 put his phone calls
with his mother on speaker phone.

-She did not know staff had the other clients put
the phone on speaker during their calls.

-She confirmed facility staff failed to ensure
clients could make and receive confidential
telephone calls.

Division of Health Service Regulation
STATE FORM 6899 HNG411 If continuation sheet 9 of 9


state: NC

facility_name: Just In Time Youth Services

summary: Plan of Correction - MHLCS Annual and Complaint

raw_content:
Division of Health Service Regulation

STATEMENT

OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA,

AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

PRINTED: 11/08/2021

FORM APPROVED
(X2)MULTIPLE = CONSTRUCTION (X3) DATE SURVEY
A.BUILDING: COMPLETED

11/04/2021

MHL001-149,8:WING

JUST IN TI

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET
BURLINGTON, NC 27215

IME YOUTH SERVICES

(x4) ID
PREFIX
TAG

V 000)

V 500)

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

INITIAL COMMENTS

An annual and complaint survey was completed
on 11/4/21. The complaint was unsubstantiated
(intake #+NC00182002). Deficiencies were cited.

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

27D .0101(a-e) Client Rights - Policy on Rights

10A NCAC 27D .0101 POLICY ON RIGHTS
RESTRICTIONS AND INTERVENTIONS

(a) The governing body shall develop policy
that assures the implementation of G.S. 122C-
59, G.S. 122C-65, and G.S. 122C-66.

(b) The governing body shall develop

and implement policy to assure that:

(1) all instances of alleged or suspected
abuse, neglect or exploitation of clients are
reported to the County Department of Social
Services as specified in G.S. 108A, Article 6
or G.S. 7A, Article 44; and

(2) procedures and safeguards are
instituted in accordance with sound medical
practice when a medication that is known to
present serious risk to the client is prescribed.
Particular attention shall be given to the use of
neuroleptic medications.

(c) In addition to those procedures prohibited in
10A NCAC 27E .0102(1), the governing body
of each facility shall develop and implement
policy that identifies:

(1) any restrictive intervention that is
prohibited from use within the facility; and
(2) in a 24-hour facility, the circumstances

under which staff are prohibited from restricting
the rights of a client.
(d) If the governing body allows the use of

ID
PREFIX
TAG

V 000

V 500

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

During the next JITYS clients rights
committee meeting. Policy on
Rights Restrictions and
Interventions will be discussed
pertaining to locks on closets, while
clients are out of the facility, and
procedures staff and clients for
unlocking the closets when they
return to the facility, whether it’s
from school, group home outings, or
home visits.

(x5)
COMPLETE
DATE

Division of Heal

Ith Service Regulation

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

STATE FORM

6899

DTGL11 If continu

ation sheet 1 of 4

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA,

AND PLAN OF CORRECTION

IDENTIFICATION NUMBER:

PRINTED: 11/08/2021

FORM APPROVED
(X2)MULTIPLE = CONSTRUCTION (X3) DATE SURVEY
A.BUILDING: COMPLETED
11/04/2021

MHL001-149,8-WING

NAME OF PROVIDER OR SUPPLIER

JUST IN TIME YOUTH SERVICES

STREET ADDRESS, CITY, STATE, ZIP CODE
1710 SYKES STREET

BURLINGTON, NC 27215

(x4) ID
PREFIX
TAG

V 500

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

Continued From page 1

restrictive interventions or if, in a 24-hour facility,
the restrictions of client rights specified in G.S.
122C-62(b) and (d) are allowed, the policy shall
identify:

(1) the permitted restrictive interventions or
allowed restrictions;

(2) the individual responsible for informing
the client; and

(3) the due process procedures for

an involuntary client who refuses the use

of restrictive interventions.

(e) If restrictive interventions are allowed for
use within the facility, the governing body shall
develop and implement policy that assures
compliance with Subchapter 27E, Section
.0100, which includes:

(1) the designation of an individual, who
has been trained and who has demonstrated
competence to use restrictive interventions, to
provide written authorization for the use of
restrictive interventions when the original order
is renewed for up to a total of 24 hours in
accordance with the time limits specified in 10A
NCAC 27E .0104(e)(10)(E);

(2) the designation of an individual to be
responsible for reviews of the use of restrictive
interventions; and

(3) the establishment of a process for
appeal for the resolution of any disagreement
over the planned use of a restrictive intervention.

This Rule is not met as evidenced by:

Based on observation, record review and
interviews, the facility failed to implement
interventions to address behaviors which did not
restrict the rights for one of three clients (#1).
The findings are:

ID
PREFIX
TAG

V 500

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

(x8)
COMPLETE
DATE

Division of Health Service Regulation

STATE FORM

6899

DTGL11

If continuation sheet 2 of 4

PRINTED: 11/08/2021

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A.BUILDING: COMPLETED
MHL001-149, 8-WING 11/04/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1710 SYKES STREET
JUST IN TIME YOUTH SERVICES
BURLINGTON, NC 27215
(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 500 | Continued From page 2 Vv 500

Observation of facility on 11/3/21 at approximately
2:35 pm revealed:

-Client #1 and client #2's bedroom-There was a
lock on client #1's closet. Client #1's clothing was
in the locked closet.

Review on 11/3/21 of General Statue 122C-62
revealed "A written statement shall be placed in
the client's record that indicates the detailed
reason for the restriction. The restriction shall be
reasonable and related to the client's treatment
or habilitation needs. A restriction is effective for
a period not to exceed 30 days. An evaluation of
each restriction shall be conducted by the
qualified professional (QP) at least every seven
days, at which time the restriction may be
removed. Each evaluation of a restriction shall
be documented in the client's records."

Review on 11/3/21 of client #1's record revealed:
-Admission date 4/29/21.

-Diagnoses of Disruptive Mood Dysregulation
Disorder, Mild Intellectual Disability, Autism,
Attention Deficit Hyperactivity Disorder and
Post Traumatic Stress Disorder.

-Date of birth was 11/30/10.

-There was no evidence of a written statement
for client #1 detailing restrictions of personal
possessions or evidence of an evaluation of
each restriction reviewed at least every seven
days by the Qualified Professional.

Interview on 11/3/21 with the Home Manager
revealed:

-Client #1's closet was locked because he would
smear feces on his clothing.

-She thought client #1 was admitted to the facility
earlier this year.

-They started locking his closet as soon as he

Division of Health Service Regulation
STATE FORM

6899 DTGL11

If continuation sheet 3 of 4

Division of Health Service Regulation

PRINTED: 11/08/2021
FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A.BUILDING COMPLETED
MHL001-149, &-WING 11/04/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1710 SYKES STREET
JUST IN TIME YOUTH SERVICES
BURLINGTON, NC 27215
(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 500] Continued From page 3 V 500

was admitted around March or April 2021. -
She did not realize locking client #1's clothes
in the closet was considered a rights
restriction. -She confirmed client #1's rights
were being restricted.

Interview on 11/4/21 with the Program
Director revealed:

-The agency had been
personal items for a while.
-The agency did not meet with the human
rights committee prior to locking up client #1's
clothing. -He confirmed client #1's rights were
being restricted.

locking up clients

Division of Health Service Regulation

STATE FORM

6899 DTGL11

If continuation sheet 4 of 4

inspection_type: MHLCS Annual and Complaint

document_type: Plan of Correction


summary: Statement of Deficiency - MHLCS Annual and Complaint

raw_content:
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
MHLO001-149
NAME OF PROVIDER OR SUPPLIER
1710 SYKI

JUST IN TIME YOUTH SERVICES

B. WING

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 11/08/2021
FORM APPROVED

11/04/2021

STREET ADDRESS, CITY, STATE, ZIP CODE
ES STREET

BURLINGTON, NC 27215

(X3) DATE SURVEY
COMPLETED

10A NCAC 27D .0101 POLICY ON RIGHTS
RESTRICTIONS AND INTERVENTIONS

(a) The governing body shall develop policy that
assures the implementation of G.S. 122C-59,
G.S. 122C-65, and G.S. 122C-66.

(b) The governing body shall develop and
implement policy to assure that:

(1) all instances of alleged or suspected
abuse, neglect or exploitation of clients are
reported to the County Department of Social
Services as specified in G.S. 108A, Article 6 or
G.S. 7A, Article 44; and

(2) procedures and safeguards are
instituted in accordance with sound medical
practice when a medication that is known to
present serious risk to the client is prescribed.
Particular attention shall be given to the use of
neuroleptic medications.

(c) In addition to those procedures prohibited in
10A NCAC 27E .0102(1), the governing body of
each facility shall develop and implement policy
that identifies:

(1) any restrictive intervention that is
prohibited from use within the facility; and
(2) in a 24-hour facility, the circumstances

under which staff are prohibited from restricting
the rights of a client.
(d) If the governing body allows the use of

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

STATE FORM

6899

(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 11/4/21. The complaint was unsubstantiated
(intake #NC00182002). Deficiencies were cited.
This facility is licensed for the following service
category: 10A NCAC 27G .1700 Residential
Treatment Staff Secure for Children or
Adolescents.
V 500} 27D .0101(a-e) Client Rights - Policy on Rights Vv 500

TITLE

(X6) DATE

DTGL11 If continuation sheet 1 of 4

PRINTED: 11/08/2021
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
MHL001-149 B. WING ____ 11/04/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

(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 500} Continued From page 1 Vv 500

restrictive interventions or if, in a 24-hour facility,
the restrictions of client rights specified in G.S.
122C-62(b) and (d) are allowed, the policy shall
identify:

(1) the permitted restrictive interventions or
allowed restrictions;

(2) the individual responsible for informing
the client; and

(3) the due process procedures for an
involuntary client who refuses the use of
restrictive interventions.

(e) If restrictive interventions are allowed for use
within the facility, the governing body shall
develop and implement policy that assures
compliance with Subchapter 27E, Section .0100,
which includes:

(1) the designation of an individual, who
has been trained and who has demonstrated
competence to use restrictive interventions, to
provide written authorization for the use of
restrictive interventions when the original order is
renewed for up to a total of 24 hours in
accordance with the time limits specified in 10A
NCAC 27E .0104(e)(10)(E);

(2) the designation of an individual to be
responsible for reviews of the use of restrictive
interventions; and

(3) the establishment of a process for
appeal for the resolution of any disagreement
over the planned use of a restrictive intervention.

This Rule is not met as evidenced by:

Based on observation, record review and
interviews, the facility failed to implement
interventions to address behaviors which did not
restrict the rights for one of three clients (#1). The
findings are:

Division of Health Service Regulation

STATE FORM 6899 DTGL11 If continuation sheet 2 of 4

PRINTED: 11/08/2021

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL001-149 B. WING 11/04/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1710 SYKES STREET
JUST IN TIME YOUTH SERVICES
BURLINGTON, NC 27215
(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 500} Continued From page 2 V 500

Observation of facility on 11/3/21 at approximately
2:35 pm revealed:

-Client #1 and client #2's bedroom-There was a
lock on client #1's closet. Client #1's clothing was
in the locked closet.

Review on 11/3/21 of General Statue 122C-62
revealed "A written statement shall be placed in
the client's record that indicates the detailed
reason for the restriction. The restriction shall be
reasonable and related to the client's treatment or
habilitation needs. A restriction is effective for a
period not to exceed 30 days. An evaluation of
each restriction shall be conducted by the
qualified professional (QP) at least every seven
days, at which time the restriction may be
removed. Each evaluation of a restriction shall be
documented in the client's records."

Review on 11/3/21 of client #1's record revealed:
-Admission date 4/29/21.

-Diagnoses of Disruptive Mood Dysregulation
Disorder, Mild Intellectual Disability, Autism,
Attention Deficit Hyperactivity Disorder and Post
Traumatic Stress Disorder.

-Date of birth was 11/30/10.

-There was no evidence of a written statement for
client #1 detailing restrictions of personal
possessions or evidence of an evaluation of each
restriction reviewed at least every seven days by
the Qualified Professional.

Interview on 11/3/21 with the Home Manager
revealed:

-Client #1's closet was locked because he would
smear feces on his clothing.

-She thought client #1 was admitted to the facility
earlier this year.

-They started locking his closet as soon as he
Division of Health Service Regulation

STATE FORM 6899 DTGL11 If continuation sheet 3 of 4

PRINTED: 11/08/2021
FORM APPROVED

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL001-149 B. WING ____ 11/04/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1710 SYKES STREET
JUST IN TIME YOUTH SERVICES
BURLINGTON, NC 27215
(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 500} Continued From page 3 V 500

was admitted around March or April 2021.

-She did not realize locking client #1's clothes in
the closet was considered a rights restriction.
-She confirmed client #1's rights were being
restricted.

Interview on 11/4/21 with the Program Director
revealed:

-The agency had been locking up clients personal
items for a while.

-The agency did not meet with the human rights
committee prior to locking up client #1's clothing.
-He confirmed client #1's rights were being
restricted.

Division of Health Service Regulation

STATE FORM 6899 DTGL11 If continuation sheet 4 of 4

document_type: Statement of Deficiency


raw_content:
PRINTED: 11/08/2021

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES AND | (X1) PROVIDER/SUPPLIERICLIA} (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
B. WING
MHL001-149 11/04/2021

NAME OF PROVIDER OR SUPPLIER

STREET AD
1710 SYK'

JUST IN TIME YOUTH SERVICES

ES STREET

DRESS, CITY, STATE, ZIP CODE

BURLINGTON, NC 27215

(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) V 000
INITIAL COMMENTS
An annual and complaint survey was completed
on 11/4/21. The complaint was unsubstantiated
(intake #NCO00182002). Deficiencies were cited.
This facility is licensed for the following service
category: 10A NCAC 27G .1700 Residential
Treatment Staff Secure for Children or
Adolescents.
V 500) V 500

27D .0101(a-e) Client Rights - Policy on Rights
10A NCAC 27D .0101 POLICY ON RIGHTS
RESTRICTIONS AND INTERVENTIONS

(a) The governing body shall develop policy
that assures the implementation of G.S. 122C-59,
G.S. 122C-65, and G.S. 122C-66.
(b) The governing body shall develop and
implement policy to assure that:
(1) all instances of alleged or suspected
abuse, neglect or exploitation of clients are
reported to the County Department of Social
Services as specified in G.S. 108A, Article 6 or
G.S. 7A, Article 44; and
(2) procedures and safeguards are instituted
in accordance with sound medical practice when
a medication that is known to present serious risk
to the client is prescribed. Particular attention
shall be given to the use of neuroleptic
medications.

(c) In addition to those procedures prohibited in
10A NCAC 27E .0102(1), the governing body of
each facility shall develop and implement policy
that identifies:

(1) any restrictive intervention that is
prohibited from use within the facility; and

(2) in a 24-hour facility, the circumstances
under which staff are prohibited from restricting
the rights of a client.

(d) If the governing body allows the use of

The clients rights committee will meet
quarterly to discuss restrictive
interventions related to all clients in the
group home. During the meeting the
committee will discuss all options of
interventions that could vary due to
certain client behaviors, as well as
securing their personal property that locks
on closets are an option, and that client
will have access to a key to their closet, if
locks on the closets are chosen to be
acceptable by the committee.

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

TITLE

(X6) DATE

PRINTED: 11/08/2021
FORM APPROVED

Division of Health Service Regulation

STATE FORM 6899 DTGL11 If continuation sheet 1 of 4

STATEMENT OF DEFICIENCIES AND
PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA|
IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

B. WING

MHL001-149 11/04/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES
BURLINGTON, NC 27215

(x4) ID
PREFIX
TAG

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

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

(x5)
COMPLETE
DATE

Division of Health Service Regulation
STATE FORM 6899 DTGL11 If continuation sheet 2 of 5

PRINTED: 11/08/2021
FORM APPROVED

Division of Health Service Regulation
V 500) Continued From page 1 V 500

restrictive interventions or if, in a 24-hour facility,
the restrictions of client rights specified in G.S.
122C-62(b) and (d) are allowed, the policy shall
identify:

(1) the permitted restrictive interventions or
allowed restrictions;

(2) the individual responsible for informing
the client; and

(3) the due process procedures for an
involuntary client who refuses the use of
restrictive interventions.

(e) If restrictive interventions are allowed for use
within the facility, the governing body shal
develop and implement policy that assures
compliance with Subchapter 27E, Section .0100,
which includes:
(1) the designation of an individual, who has
been trained and who has demonstrated
competence to use restrictive interventions, to
provide written authorization for the use o
restrictive interventions when the original order is
renewed for up to a total of 24 hours in
accordance with the time limits specified in 10A
NCAC 27E .0104(e)(10)(E);
(2) the designation of an individual to be
responsible for reviews of the use of restrictive
interventions; and
(3) the establishment of a process for appeal
for the resolution of any disagreement over the
planned use of a restrictive intervention.

This Rule is not met as evidenced by: Based on
observation, record review and interviews, the
facility failed to implement interventions to
address behaviors which did not restrict the
rights for one of three clients (#1). The findings
are:

STATEMENT OF DEFICIENCIES AND | (X1) PROVIDER/SUPPLIER/CLIA] (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
B. WING
MHLO001-149 11/04/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET
JUST IN TIME YOUTH SERVICES
BURLINGTON, NC 27215

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5)
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)

Division of Health Service Regulation
STATE FORM 6899 DTGL11 If continuation sheet 3 of 5

PRINTED: 11/08/2021
FORM APPROVED

Division of Health Service Regulation
V 500) Continued From page 2 V 500

Observation of facility on 11/3/21 at approximatel
2:35 pm revealed:

-Client #1 and client #2's bedroom-There was a
lock on client #1's closet. Client #1's clothing was
in the locked closet.

Review on 11/3/21 of General Statue 122C-62
revealed "A written statement shall be placed in
the client's record that indicates the detailed
reason for the restriction. The restriction shall be
reasonable and related to the client's treatment or
habilitation needs. A restriction is effective for a
period not to exceed 30 days. An evaluation of
each restriction shall be conducted by the
qualified professional (QP) at least every seven
days, at which time the restriction may be
removed. Each evaluation of a restriction shall be
documented in the client's records."

Review on 11/3/21 of client #1's record revealed:
-Admission date 4/29/21.

-Diagnoses of Disruptive Mood Dysregulation
Disorder, Mild Intellectual Disability, Autism,
Attention Deficit Hyperactivity Disorder and Post
Traumatic Stress Disorder.

-Date of birth was 11/30/10.

-There was no evidence of a written statement for
client #1 detailing restrictions of personal
possessions or evidence of an evaluation of each
restriction reviewed at least every seven days by
the Qualified Professional.

Interview on 11/3/21 with the Home Manager
revealed:

-Client #1's closet was locked because he would
smear feces on his clothing.

-She thought client #1 was admitted to the facility
earlier this year.

-They started locking his closet as soon as he

STATEMENT OF DEFICIENCIES AND | (X1) PROVIDER/SUPPLIERI/CLIA} (X2) MULTIPLE CONSTRUCTION, (X3) DATE SURVEY
PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
B. WING
MHLO001-149 11/04/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET
JUST IN TIME YOUTH SERVICES
BURLINGTON, NC 27215

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5)
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)

Division of Health Service Regulation
STATE FORM 6899 DTGL11 If continuation sheet 4 of 5

PRINTED: 11/08/2021
FORM APPROVED

Division of Health Service Regulation

V 500) Continued From page 3 was admitted around V 500
March or April 2021. -She did not realize
locking client #1's clothes in the closet was
considered a rights restriction. -She confirmed
client #1's rights were being restricted.

Interview on 11/4/21 with the Program Director
revealed:

-The agency had been locking up clients personal
items for a while.

-The agency did not meet with the human rights
committee prior to locking up client #1's clothing. -
He confirmed client #1's rights were being
restricted.

Division of Health Service Regulation
STATE FORM 6899 DTGL11 If continuation sheet 5 of 5


summary: Statement of Deficiency - MHLCS Complaint

raw_content:
PRINTED: 01/25/2021

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHLO001-149 B. WING 01/25/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1710 SYKES STREET

JUST IN TIME YOUTH SERVICES

BURLINGTON, NC 27215

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000) INITIAL COMMENTS V 000
Acomplaint survey was completed on January
25, 2021. The complaint was unsubstantiated
(Intake #NC00173379). No deficiencies were
cited.
This facility is licensed for the following service:
10A NCAC 27G .1700 Residential Treatment
Staff Secure for Children and Adolescents.
Division of Health Service Regulation
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

STATE FORM

6899

HTJ011 If continuation sheet 1 of 1

inspection_type: MHLCS Complaint


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

raw_content:
Division of Health Service Regulation

JUST IN TIME YOUTH SERVICES

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
MHLO001-149
NAME OF PROVIDER OR SUPPLIER
1710 SYKI

A. BUILDING:

B. WING

ES STREET

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/22/2020
FORM APPROVED

10/22/2020

STREET ADDRESS, CITY, STATE, ZIP CODE

BURLINGTON, NC 27215

(X3) DATE SURVEY
COMPLETED

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000) INITIAL COMMENTS V 000
Acomplaint and follow up survey was completed
on 10/22/20. The complaint was unsubstantiated
(intake #NC00170300). No deficiencies were
cited.
This facility is licensed for the following service
10A NCAC 27G.1700 Residential Treatment Staff
Secure for Children and Adolescents.
Division of Health Service Regulation
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
STATE FORM 6899 OHDH11 If continuation sheet 1 of 1

inspection_type: MHLCS Complaint and Follow-up


summary: Statement of Deficiency - MHLCS 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:

MHL001-149

1710 SYK'

JUST IN TIME YOUTH SERVICES

BURLINGTON, NC 27215

A. BUILDING:

B. WING

STREET ADDRESS, CITY, STATE, ZIP CODE

ES STREET

(X2) MULTIPLE CONSTRUCTION

PRINTED: 06/28/2019
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
06/27/2019

(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
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

(x5)
COMPLETE
DATE

{V 000}

{V 536}

NITIAL COMMENTS

A limited follow up survey for the Type A1 and
Type A2 was completed 6/27/19. This was a
imited follow up survey, only 10A NCAC 27G
.0205 Assessment and Treatment or Services
Plan (V112) and 10A NCAC 27G .0209
Medication Requirements (V118) were reviewed
‘or compliance. The following were brought back
into compliance: 10A NCAC 27G .0205
Assessment and Treatment or Services Plan
(V112) and 10A NCAC 27G .0209 Medication
Requirements (V118). No deficiencies were cited.

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

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

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

(d) The training shall be competency-based,

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

STATE FORM

{V 000}

{V 536}

6899

Ewsu12

TITLE (X6) DATE

If continuation sheet 1 of 8

PRINTED: 06/28/2019
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
MHL001-149 B. WING _____ 06/27/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

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

DEFICIENCY)
{V 536}] Continued From page 1 {V 536}

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
assisting in the person's involvement in making
decisions about their life;

(7) skills in assessing individual risk for
escalating behavior;

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

(9) positive behavioral supports (providing

means for people with disabilities to choose
activities which directly oppose or replace
behaviors which are unsafe).

(h) Service providers shall maintain

Division of Health Service Regulation
STATE FORM 6899 Ewsu12 If continuation sheet 2 of 8

PRINTED: 06/28/2019
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
MHL001-149 B. WING _____ 06/27/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

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

DEFICIENCY)
{V 536}| Continued From page 2 {V 536}

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

(1) Documentation shall include:

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

(B) when and where they attended; and
(C) instructor's name;

(2) The Division of MH/DD/SAS may

review/request this documentation at any time.

(i) Instructor Qualifications and Training
Requirements:

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

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

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

(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
course;

(C) methods for evaluating trainee
performance; and

(D) documentation procedures.

(6) Trainers shall have coached experience

teaching a training program aimed at preventing,
reducing and eliminating the need for restrictive

Division of Health Service Regulation
STATE FORM 6899 Ewsu12 If continuation sheet 3 of 8

PRINTED: 06/28/2019

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
MHL001-149 B. WING 06/27/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1710 SYKES STREET
JUST IN TIME YOUTH SERVICES
BURLINGTON, NC 27215
(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

{V 536}| Continued From page 3 {V 536}

interventions at least one time, with positive
review by the coach.

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

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

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

(1) Documentation shall include:

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

(B) when and where attended; and

(C) instructor's name.

(2) The Division of MH/DD/SAS may
request and review this documentation any time.
(k) Qualifications of Coaches:

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

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

(3) Coaches shall demonstrate

competence by completion of coaching or
train-the-trainer instruction.

(l) Documentation shall be the same preparation
as for trainers.

This Rule is not met as evidenced by:

Division of Health Service Regulation
STATE FORM 6899 Ewsu12 If continuation sheet 4 of 8

PRINTED: 06/28/2019
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
MHL001-149 B. WING _____ 06/27/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

(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 537}| Continued From page 4 {V 537}
{V 537}, 27E .0108 Client Rights - Training in Sec Rest & | {V 537}
ITO

10A NCAC 27E .0108 TRAINING IN
SECLUSION, PHYSICAL RESTRAINT AND
ISOLATION TIME-OUT

(a) Seclusion, physical restraint and isolation
time-out may be employed only by staff who have
been trained and have demonstrated
competence in the proper use of and alternatives
to these procedures. Facilities shall ensure that
staff authorized to employ and terminate these
procedures are retrained and have demonstrated
competence at least annually.

(b) Prior to providing direct care to people with
disabilities whose treatment/habilitation plan
includes restrictive interventions, staff including
service providers, employees, students or
volunteers shall complete training in the use of
seclusion, physical restraint and isolation time-out
and shall not use these interventions until the
training is completed and competence is
demonstrated.

(c) Apre-requisite for taking this training is
demonstrating competence by completion of
training in preventing, reducing and eliminating
the need for restrictive interventions.

(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 plans to employ must be approved by
the Division of MH/DD/SAS pursuant to

Division of Health Service Regulation
STATE FORM 6899 Ewsu12 If continuation sheet 5 of 8

PRINTED: 06/28/2019
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
MHL001-149 B. WING _____ 06/27/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

(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 537}| Continued From page 5 {V 537}

Paragraph (g) of this Rule.
(g) Acceptable training programs shall include,
but are not limited to, presentation of:

(1) refresher information on alternatives to
the use of restrictive interventions;

(2) guidelines on when to intervene
(understanding imminent danger to self and
others);

(3) emphasis on safety and respect for the

rights and dignity of all persons involved (using
concepts of least restrictive interventions and
incremental steps in an intervention);

(4) strategies for the safe implementation
of restrictive interventions;
(5) the use of emergency safety

interventions which include continuous
assessment and monitoring of the physical and
psychological well-being of the client and the safe
use of restraint throughout the duration of the
restrictive intervention;

(6) prohibited procedures;

(7) debriefing strategies, including their
importance and purpose; and

(8) documentation methods/procedures.

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

(1) Documentation shall include:

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

(B) when and where they attended; and
(C) instructor's name.

(2) The Division of MH/DD/SAS may

review/request this documentation at any time.

(i) Instructor Qualification and Training
Requirements:

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

Division of Health Service Regulation
STATE FORM 6899 Ewsu12 If continuation sheet 6 of 8

PRINTED: 06/28/2019

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
MHL001-149 B. WING 06/27/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

(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 537}| Continued From page 6 {V 537}
need for restrictive interventions.
(2) Trainers shall demonstrate competence

by scoring 100% on testing in a training program
teaching the use of seclusion, physical restraint
and isolation time-out.

(3) Trainers shall demonstrate competence
by scoring a passing grade on testing in an
instructor training program.

(4) 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.

(5) 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 (j)(6) of this Rule.

(6) Acceptable instructor training programs
shall include, but not be limited to, presentation
of:

(A) understanding the adult learner;

(B) methods for teaching content of the
course;

(C) evaluation of trainee performance; and
(D) documentation procedures.

(7) Trainers shall be retrained at least

annually and demonstrate competence in the use
of seclusion, physical restraint and isolation
time-out, as specified in Paragraph (a) of this

Rule.

(8) Trainers shall be currently trained in
CPR.

(9) Trainers shall have coached experience

in teaching the use of restrictive interventions at
least two times with a positive review by the
coach.
(10) Trainers shall teach a program on the
use of restrictive interventions at least once

Division of Health Service Regulation
STATE FORM 6899 Ewsu12 If continuation sheet 7 of 8

PRINTED: 06/28/2019

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
MHL001-149 B. WING 06/27/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1710 SYKES STREET
JUST IN TIME YOUTH SERVICES
BURLINGTON, NC 27215
(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 537}| Continued From page 7 {V 537}
annually.
(11) Trainers shall complete a refresher

instructor training at least every two years.

(k) 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
outcome (pass/fail);

(B) when and where they attended; and
(C) instructor's name.

(2) The Division of MH/DD/SAS may
review/request this documentation at any time.
(1) Qualifications of Coaches:

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

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

(3) Coaches shall demonstrate

competence by completion of coaching or
train-the-trainer instruction.

(m) Documentation shall be the same
preparation as for trainers.

This Rule is not met as evidenced by:

Division of Health Service Regulation
STATE FORM 6899 Ewsu12 If continuation sheet 8 of 8

inspection_type: MHLCS Follow-up