summary: Plan of Correction - MHLCS Annual and Complaint

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FORM APPROVED

Division of Health Service Requiation

STATEMENT OF DEFICIENCIES (%1) PROVIDER/SUPPLIER/CUA (%2) MULTIPLE CONSTRUCTION {X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED

MHLO11-384 B. WING 10/26/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

450 MONFORD AVENUE
ASHEVILLE, NC 28801

SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIF YING INFORMATION)

MARY BENSON HOUSE

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

(x4) 10
PREFIX
TAG

¥00q INITIAL COMMENTS

An annual and complaint survey was completed
on 10/26/22. The complaint was unsubstantiated
(intake #NC00 192537). Deficiencies were cited.

This facility is licensed for the following service
category: 10A NCAC 27G 4100 Residential
Recovery Programs for individuals with
Substance Abuse Disorders and Their Children.

This facility is licensed for 12 and curently has a
census of 5. The survey sample consisted of
audits of 3 current clients.

V 104 27G .0201 (A) (8-18) (B) GOVERNING BODY

POLICIES

1O0ANCAC 27G .0201 GOVERNING BODY

POLICIES DHSR - Mental Health
(a) The governing body responsible for each

facility or service shall develop and implement nec 19 2022

written policies for the following:
(8) use of medications by clients in accordance
with the rules in this Section;

(8) reporting of any incident, unusual occurrence
or medication error;

(10) voluntary non-compensated work performed
by a client;

(11) clientfee assessment and collection
practices;

(12) medical preparedness plan to be utilized ina
medical emergency;

(13) authorization for and follow up of lab tests;
(14) transportation, including the accessibility of
emergency information for a client;

(15) services of volunteers, including supervision
and requirements for maintaining client
confidentiality;

(16) areas In which staff, including
nonprofessional staff, receive training and

Lic. & Cert. Section

Me
QLSYt1 ‘continuation sheet 1 of 14

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

MHLO011-384

B. WING

(X41
PREFIX
TAG

—_

NAME OF PROVIDER OR SUPPLIER

(X2) MULTIPLE CONSTRUCTION
A. BUILDING: __

PRINTED: 11/23/2022
FORM APPROVED.

(X3) DATE SURVEY
COMPLETED

10/26/2022

STREET ADDRESS, CITY, STATE, ZIP CODE

450 MONFORD AVENUE

MARY BENSON HOUSE

ASHEVILLE, NC 28801

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)

(xs)
COMPLETE
DATE

V 106

Continued From page 1

continuing education;

(17) safety precautions and requirements for
facility areas including special client activity
areas; and

(18) client grievance policy, including procedures
for review and disposition of client grievances.
(b) Minutes of the governing body shall be
permanently maintained.

This Rule is not met as evidenced by:

Based on record reviews and interviews, the
facility failed to implement their written policy for
the use of medications by clients affecting 3 of 3
audited clients (Client #1, #2, and #3). The
findings are:

| Refer to V118 for information for Client #1, #2 and

#3 regarding:

-admission dates and diagnoses for Client #1, #2,
and #3;

-physician orders for currently prescribed
medication;

-self-administration documentation for Over the
Counter (OTC) and prescription medications;
-missing staff initials on the Medication
Administration Record (MAR) documenting that
staff monitored clients administering their own

| medications

Review on 10/12/22 of the facility's Medication
Policy revealed:

-"1003.05 Medication Manitoring-

- .., Mary Benson House does not have licensed
or qualified nursing staff to administer or
dispense medication. Mary Benson House

V 106

The Medication Administration Record will

have a statement added which indicates that the
residents at Mary Benson House self-administer
boo own medications. An In-Service training will

be completed with staff members who monitor
he residents’ self-administration of medications
to ensure that they are aware of RHA MAR
Documentation requirements. Training to also
include that the MAR should indicate if a residen'
is not at the facility on a particular day (i.e., ona
day pass, overnight, in the hospital, etc.); staff
ill identify this information on the MAR by
documentation which medications were taken
with the resident on the day pass (i.e., name of
medication and how much of the medication was
‘ken with the resident).
Monitoring of this process will be completed
through the Service Record Review Process.
(Attachment A)

Division of Health Service Regulation

STATE FORM

eaeg

QLsY11

42/25/2022

If continuation sheet 2 of 14

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FORM APPROVED
Division of Health Service Regulation

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

Ei WING 10/26/2022

MHL011-384

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
450 MONFORD AVENUE
MARY BENSON HOUSE
ASHEVILLE, NC 28801
(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES iD PROVIDER'S PLAN OF CORRECTION os)
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 Dare
DEFICIENCY)
fee —_
V 106 Continued From page 2 V 106

| employees monitor clients’ self-administration of
medications to ensure proper adherence to the
written prescription order."

-"1003.052 MAR (Medication Administration
Record) Documentation-

Medications monitored shall be recorded
immediately after self-administration. The MAR
sheet is to include the following:

1. Client's name

2. Name, strength and quantity of the drug

3. Instructions for administering the drug

4. Date and time the drug is administered

5. Name or initials of person monitoring the drug

6. Explanation of request for a PRN...”

-"1003.056 Special Issues |
| When consumers leave the facility for an
overnight or day pass and require medications
during their time away, staff will document on the |
MAR sheet what medications were taken and
how much the client has in her possession. When
medication doses are missed, staff will document
| on the MAR sheet stating what dose was missed,
why, and what action was taken."

Interview on 10/26/22 with the Regional Director
revealed:

-the facility used the electronic MAR provided by
the pharmacy that filled the prescriptions;

| -the facility was in the process of switching to a
different electronic health record which allows for
customization of fields for documentation by staff;
-they will add a statement at the top of the MAR
that clients self-administered their medications; |
-the medication policy will be reviewed to ensure
it reflected their current processes.

V 114 27G .0207 Emergency Plans and Supplies | Vv 114

l
Division of Health Service Regulation
STATE FORM aa aisyi4 If continuation sheet 3 of 14

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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:
MHLO011-384 BIWING 10/26/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
450 MONFORD AVENUE
MARY BENSON HOUSE
ASHEVILLE, NC 28801
(X4) 1D. SUMMARY STATEMENT OF DEFICIENCIES. ] 10 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, j oATE
DEFICIENCY)
—_—___ i
Vv 114 Continued From page 3 | Vv 114 |

10A NCAC 27G .0207 EMERGENCY PLANS
AND SUPPLIES

(a) Awritten fire plan for each facility and
area-wide disaster plan shall be developed and }
shall be approved by the appropriate local |
authority.
(b) The plan shall be made available to all staff |
and evacuation procedures and routes shall be
posted in the facility.

(c) Fire and disaster drills in a 24-hour facility
shall be held at least quarterly and shall be
repeated for each shift. Drills shall be conducted
| under conditions that simulate fire emergencies.
(d) Each facility shall have basic first aid supplies |
| accessible for use.

This Rule is not met as evidenced by:

Based on records reviews and interviews, the
_ facility failed to conduct fire and disaster drills on
each shift at least quarterly. The findings are:

Fire and Disaster Drills will be completed on a 12/25/2022
quarterly basis per shift (ata minimum) per rule
requirements. An Outlook calendar reminder has
been developed for the Program Manager and
Safety Liaison to ensure that these drills are

Review on 8/19/22 of the facility's fire and completed (times during the day will be varied).
disaster drills for 7/1/21-6/30/22 revealed: Monitoring of this will be completed through the
-no documentation that fire or disaster drills were local QAPI Committee.

| conducted on any shift from 10/1/21-12/31/22; (Attachment B)

-no documentation that a disaster drill was |
conducted on 2nd shift from 1/1/22-3/31/22. |

Interview on 8/18/22 and 8/22/22 with the
Program Manager (PM) revealed:
-shifts are "am" and "pm" for Residential
Treatment Specialists (RTS);

| -their shifts were 12 hours each;
-RTS's on "am" shift worked 8:00am to 8:00pm
but some may work until only 4:00pm-5:00pm

| depending on staff needs; "pm" shift was 8:00pm
to 8:00am;

Division of Health Service Regulation

STATE FORM oa89 OLSY114 if continuation sheet 4 of 14

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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: ____
MHL011-384 BAWING 10/26/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
450 MONFORD AVENUE
MARY BENSON HOUSE
ASHEVILLE, NC 28801
(xa SUMMARY STATEMENT OF DEFICIENCIES ID | PROVIDER'S PLAN OF CORRECTION | 1x5)
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 114) Continued From page 4 Vv 114 |

-she wanted to designate a safety officer for tasks | |
such as the drills.

Interview on 8/22/22 with Client #2 revealed:
-facility did fire and disaster drills "more than |
care to say."

Interview on 8/22/22 with Client #3 revealed:
-had been at the facility for almost 90 days;
-heard that the facility had fire and disaster drills
but she had not been involved in one yet. |

Interview on 8/18/22 with the facility's Case
Manager/Residential Treatment Specialist
(CM/RTS) revealed:

-the staff person who was scheduling the drills
left; staff were now rotating responsibility of doing
the drills among staff again;

-she "followed the sound of the air horn and exits
the building."

Interview on 8/23/22 with Staff #1 revealed:
-position was RTS; she worked 8:00pm to
8:00am on Sundays, Mondays, and Tuesdays;
-she had done fire/disaster drills;

-drills were assigned to different staff; she had not
been chosen recently to complete a drill.

V 118 27G .0209 (C) Medication Requirements | v118

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

Division of Health Service Regulation
STATE FORM 209 alsy14 if continuation sheet § of 14

Division of Health Service Regulation

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FORM APPROVED

Vv 118, Continued From page 5

client's physician.

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

(A) client's name;

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

(C) instructions for administering the drug;

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

| drug.

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

This Rule is not met as evidenced by:

Based on observation, interviews and record
reviews, the facility failed to ensure that 2 of 2
audited staff (Staff #1 and the Case
Manager/Residential Treatment Specialist
(CM/RTS) who administered medications were
trained by a legally qualified person privileged to
administer medication; failed to ensure that
medications were administered only on the
written order of 4 person legally authorized to

| prescribe medications for 3 of 3 audited clients

| (Clients #1, #2, and #3) and failed to ensure that

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED
MHLO011-384 B-WING 10/26/2022
NAME OF PROVIDER OR SUPPLIER, STREET ADDRESS, CITY, STATE, ZIP CODE
450 MONFORD AVENUE
MARY BENSON HOUSE
ASHEVILLE, NC 28804
(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)
Vv 118

An In Service Training will be held with Lisa
Nickerson, RN from RHA's Neil Dobbins Center.
Training by this licensed staff member is being

ompleted to ensure Mary Benson House staff
Fromoers competencies to oversee the
medication monitoring at Mary Benson House as

As discussed earlier in this SOD/POC, staff will
lalso receive an in-service on MAR
documentation requirements.

(Attachment C)

Division of Health Service Regulation
STATE FORM

the residents there self-administer medications. |

12/25/2022

QLsy14 If continuation sheet 6 of 14

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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

MHL011-384 8. WING __________ 10/26/2022

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

MARY BENSON HOUSE
ASHEVILLE, NC 28801

(X4)1D. SUMMARY STATEMENT OF DEFICIENCIES. 1D PROVIDER'S PLAN OF CORRECTION 4X5)
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 6 V 118 |

MARs were kept current for 3 of 3 audited clients
| (Clients #1, #2, and #3). The findings are:

Finding #1:

| Review on 8/18/22 of Client #1's record revealed:
-date of admission: 12/29/21;

-diagnoses of Opiate Use Disorder (d/o), severe, |
in sustained remission, on maintenance therapy;
Sedative, Hypnotic, Anxiolytic d/o, severe, in early |
remission; Stimulant Use d/o, amphetamine type,
| severe, early remission; Tobacco Use do,
moderate; Post Traumatic Stress d/o (PTSD); |
-was approved on 1/10/22 by the facility's
physician to self-administer both over the counter
(OTC) and prescription medication.

Review on 8/18/22 of Client #2's record revealed:
-date of admission: 5/3/22;
-diagnoses of Opiate Use d/o, severe, on
maintenance therapy; Alcohol Use d/o, severe;
| Sedative, Hypnotic, Anxiolytic Use d/o, severe, in
early remission; Stimulant Use d/o, cocaine,
severe, in sustained remission; PTSD; Attention
Deficit Hyperactivity d/o (ADHD); Tobacco Use
d/o, severe;
-was approved on 5/4/22 by the facility's
| physician to self-administer both OTC and |
prescription medication.

| Review on 8/18/22 and 8/19/22 of Client #3's
record revealed:

-date of admission was 6/13/22

| -diagnoses of Stimulant Use d/o, amphetamine
type, severe; Opiate Use d/o, moderate; ADHD,

| predominantly inattentive type; Major Depression,
| mild; Generalized Anxiety d/o; PTSD;

| -was approved on 6/20/22 by the facility's
physician to self-administer both OTC and

| prescription medication.

Division of Health Service Regulation
STATE FORM e899 aisy14 If continuation sheet 7 of 14

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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.
MHL 011-384 BE: WING. 10/26/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
450 MONFORD AVENUE
MARY BENSON HOUSE
ASHEVILLE, NC 28801
(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION os)
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 7 Vv 118 |

Review on 8/18/22 of physician's orders for Client
#1 revealed: |
-Buprenorphine (opioid maintenance therapy)
8mg (milligram) SL (sublingual) tablet, dissolve 1
tablet under tongue three times daily (TID)
ordered 4/27/22;

| -Gabapentin (pain) 300mg, 1 capsule TID
ordered 6/8/22; |
-Docusate (constipation) 100mg take capsule TID
| ordered 7/22/22.

Review on 8/18/22 and 8/19/22 of Client #1's
MARs dated 6/1/22-8/18/22 revealed:
-Gabapentin 300mg, 1 capsule TID was
administered 6/1/22-6/7/22 without a written
physician order;
-there were no staff initials on the MAR to indicate
that Client #1 self-administered her medications
on the following dates and times:

| -6/5/22 for the 8:00pm doses for Buprenorphine
8mg and Gabapentin 300mg; | |
-7/13/22 for the 12:00pm doses for
Buprenorphine 8mg SL;
-7/13/22- no initials for the 12:00pm dose of
Gabapentin 300mg;
-8/9/22 and 8/13/22- for the 8:00pm doses
Buprenorphine 8mg, Docusate 100mg, and
Gabapentin 300mg.

| Review on 8/18/22 and 8/22/22 of physician
orders for Client #2 revealed:

-Enoxaparin (blood clotting) 40mg syr (syringe),

| administer under the skin daily (evening), ordered
on 6/13/22;

-Suboxone (opioid maintenance therapy)
8mg-2mg sl film, dissolve % film under tongue
every afternoon ordered 5/20/22;

-Suboxone 8mg-2mg sl film, dissolve 1 film under
tongue twice daily (BID) ordered 5/20/22. |
Division of Health Service Regulation

STATE FORM 209 aisy14 If continuation sheet 8 of 14

Division of Health Service Regulation

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

MHLO011-384

PRINTED: 11/23/2022
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

WING oo 10/26/2022

NAME OF PROVIDER OR SUPPLIER,

Review on 8/18/22 and 8/23/22 of the MARs
dated 6/1/22- 8/18/22 for Client #2 revealed:
~Enoxaparin 40mg was administered 6/1/22 and
6/3/22-6/1 2/22 without a written physicians order;
-there were no staff initials on the MAR to indicate
that Client #2 self-administered her medications
on the following dates and times:

-6/2/22, 7/9/22, 8/10/22 for Enoxaparin 40mg;
-6/29/22, 6/30/22, 7/1/22, 7/26/22, 8/6/22, for
Suboxone 8mg-2mg (afternoon dose);

-7/12/22 (8:00am) and 7/26/22 (8:00am) for
Suboxone 8mg-2mg, 1 film under tongue twice
daily.

Review on 8/22/22 of physician orders for Client
#3 revealed:

-Bupropion (smoking cessation/depression)
300mg, one tab daily ordered 6/22/22;
-Acetaminophen (pain), 500mg, take 2 gel caps
every 6 hours while symptoms last. Do not take
more than 6 gel caps in 24 hours unless
prescribed by a doctor. Do not take for more
than 10 days unless directed by a doctor. OTC
physician orders were signed on 6/20/22.

Review on 8/18/22 and 8/22/22 of MARS dated
6/1/22-8/1 8/22 for Client #3 revealed:
-Acetaminophen 300mg was documented as
administered for 15 consecutive days from
7/16/22 to 7/30/22 without a written doctors order
to administer for more than 10 days;

-there were no staff initials on the MAR on

| 7/12/22 to indicate that Client #3

| self-administered bupropion 300mg.

Finding #2

Review on 8/19/22 of Staff #1's personnel record
revealed:

STREET ADDRESS, CITY, STATE, ZIP CODE

450 MONFORD AVENUE
MARY BENSON HOUSE
ASHEVILLE, NC 28801
a
(xa) 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 118) Continued From page 8 Vv 118

Division of Health Service Regulation
STATE FORM

6200 aisy11 If continuation sheet 9 of 14

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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
MHL011-384 B WING —_________ 40/26/2022
NAME OF PROVIDER OR SUPPLIER. STREET ADDRESS, CITY, STATE, ZIP CODE
450 MONFORD AVENUE
MARY BENSON HOUSE
ASHEVILLE, NC 28801
—
(X4) ID. 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 OATE
| DEFICIENCY)
|
V 118) Continued From page 9 | Vv 118

| -hired on 11/29/21;

-position was Residential Treatment Specialist
(RTS);

-medication administration training completed on
| 1415/21; |
| -the training, “Your role in the Medication
Process," was a one hour, online only training.

Review on 8/19/22 of the Case

| Manager/Residential Treatment Specialist's
(CM/RTS) personnel record revealed: |
-hired on 12/28/20;

| -position was Case Manager/RTS;

-medication administration training completed on
12/28/20;

-the training, "Your role in the Medication |
Process," was a one hour, online only training.

Interview on 8/23/22 with Staff #1 revealed:

-had been working at the facility since October or
November 2021; |
-she observed clients “administer meds
(medications) to themselves;"

-she had training on medications, the "5 rights of
meds;"

-a traveling nurse came to the facility and
assisted with how to use the "Quick Mar;"

-the facility was working with (local pharmacy) on
how best to use the MAR.

Interview on 8/18/22 with the CM/RTS revealed:
-she worked 9:00am-3:00pm Monday and
Tuesday, Wednesday for 11 hrs, Thursday for 9
hours and off on Fridays;

-there were "regimented" times for med pass;
-she administered medications "occasionally" if
she needed too.

Interview on 8/19/22 and 10/26/22 with the
Regional Director revealed:

Division of Health Service Regulation
STATE FORM 9 aLsy11 If continuation sheat 10 of 14

Division of Health Service Re:
STATEMENT OF DEFICIENCIES:
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

MHL011-384

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

8. WING

PRINTED: 11/23/2022
FORM APPROVED.

(X3) DATE SURVEY
COMPLETED

10/26/2022

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

450 MONFORD AVENUE
ASHEVILLE, NC 28801

MARY BENSON HOUSE

| o |

Vv 118

-clients self-administered their medication;
-their physician approved and signed a form

| approving clients to self-administer both OTC and

prescription medication;

| -staff "don't actually administer medications" and

that is why there was no medication
administration training; staff take an online only
training for medications when they are hired;

-she will talk with staff about language and use of
the word administer; "staff say they administer but
they don't really;"

-the facility will incorporate a face to face
component by an RN (Registered Nurse) for the
medication training.

Interview on 8/19/22 with Client #1 revealed:
-she was responsible to follow up with the
doctor's office regarding her appointments and
medications;

-(local care manager program) helped her with
her medications; they prescribed and monitored
her medications;

-there had been no problems with her
medications.

Interview on 8/22/22 with Client #2 revealed:
-she was responsible for getting her refills called
in to the pharmacy:

-there were no concerns with her medications.

Interview on 8/22/22 with Client #3 revealed:
-medications were helpful; she took her
medications at certain times;

-knew when to get a refill "when it gets into the
blue column on the pack;"

-she had to call the doctor when she needed a
refill.

Due to the failure to accurately document
medication administration, if could not be

(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION} TAG CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY) |
Continued From page 10 Vv 118

Division of Health Service Regulation

STATE FORM

e209

QLsyY11

If continuation sheet 11 of 14

Division of Health Service Regulation

PRINTED: 11/23/2022

FORM APPROVED.

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

MHL011-384

(X2) MULTIPLE CONSTRUCTION

A. BUILDING:

B. WING

NAME OF PROVIDER OR SUPPLIER,

MARY BENSON HOUSE

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

aio |
PREFIX |
TAG

V 118) Continued From page 11

determined if clients received their medication as
ordered by the physician.

V 732, 27G .0303(a) Site Location

10A NCAC 27G .0303 LOCATION AND
EXTERIOR REQUIREMENTS.

| (a) Each facility shall be located on a site where:
(1) fire protection is available;

(2) water supply, sewage and solid waste
disposal services have been approved by the
local health department;

(3) occupants are not exposed to hazards and
pollutants that may constitute a threat to their
health, safety, and welfare: and

(4) local ordinances and zoning laws are met.

This Rule is not met as evidenced by:

Based on observations, record reviews and

interviews, the facility failed to ensure that clients

were not exposed to hazards and pollutants that

may constitute a threat to their health, safety and

welfare affecting 3 of 3 audited clients (Client #1,
#2 and #3).

Interview on 8/22/22 with the (Local) County
Environmental Health Staff revealed:

-during a standard sanitation inspection June
2022, an inspector found the presence of lead
hazards;

| -a copy of the report was sent to the provider.

STREET ADDRESS, CITY, STATE, ZIP CODE
450 MONFORD AVENUE
ASHEVILLE, NC 28801

(X3) DATE SURVEY
COMPLETED

10/26/2022

1D PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH CORRECTIVE ACTION SHOULD BE

TAG CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

(x5)
COMPLETE
DATE

Vv 118

V 732

|Belfour has assessed the facility for lead
remediation of the fireplace and a plan is being
made to remediate this concern. Note: due to
contractor and supply chain concerns, full
remediation may exceed the 60 day time frame
indicated.

12/25/2022

Division of Health Service Regulation
STATE FORM

oe aisy11

a |

If continuation sheet 12 of 14

Division of Health Service Regulation

PRINTED: 11/23/2022
FORM APPROVED.

(X2) MULTIPLE CONSTRUCTION
A. BUILDING.

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

8. WING

MHL01 1-384

(X3) DATE SURVEY
COMPLETED

10/26/2022

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

A referral was made by phone on 8/22/22 by the
DHSR (Division of Health Service Regulation)
surveyor to the DHSR Construction Section
tegarding the (local) County Environmental
Health report. A copy of the report was forwarded
to the DHSR Construction Section.

Review on 8/23/22 of the (Local) County
Environmental Health report dated 7/29/22
revealed:

-an inspection revealed the presence of "paint
and dust have been identified as a source of lead
exposure to a child less than 6 years of age;"

-a recommendation that "lead poisoning hazards
identified on the property be remediated."

Interview on 8/26/22 with the Director of Safety

and Workman's Compensation for the licensee

revealed:

-the facility was addressing the report but

disagreed with it;

-was trying to schedule a meeting with the county
| to discuss the report;

-the (local) county (who issued the report) sold

them the building years ago and "it was never an |

issue."

Interview on 10/26/22 with the facility's Regional
| Director revealed: |
| -DHSR construction staff conducted a site visit at

the facility recently (she didn't have the specific

| date on hand);

-the area of concern was a non-functioning

fireplace in bedroom (room 106) on the first floor;
-DHSR construction staff made

| recommendations to close off the part of the

bedroom near the fireplace;

-the facility will construct a wall to cover the

fireplace;

-the facility sent letters to the eight women |

450 MONFORD AVENUE
MARY BENSON HOUSE
ASHEVILLE, NC 28801
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION 0)
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 732| Continued From page 12 | Vv732

Division of Health Service Regulation
STATE FORM cad aQLsyY11

If continuation sheet 13 of 14

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

MHL011-384

(X1) PROVIDER/SUPPLIER/CLIA.

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

B. WING.

PRINTED: 11/23/2022
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

10/26/2022

NAME OF PROVIDER OR SUPPLIER

MARY BENSON HOUSE

STREET ADDRESS, CITY, STATE, ZIP CODE
450 MONFORD AVENUE
ASHEVILLE, NC 28801

SUMMARY STATEMENT OF DEFICIENCIES

i?) ]

| residing at the facility as required by the (Local)
| County's report.

Division of Health Service Regulation
STATE FORM

899

qQusy14

(K4) 1D | 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)
a
V 732| Continued From page 13 V 732

If continuation sheet 14 of 14

MAR Mary Benson House

DATE OF BIRTH

PATIENT NAME

PHYSICIAN
OIAGNOSIS & COMMENTS
Person seli-adininisters all medications

| SUBOXONE 8 MG-2 MG SL FILM 8MG-2STR

| PLAGE 1 FILM UNpER TONGUE donee DAILY.
* SUSPENDED 01 Dac 2022 TO 04 Dec 2022: mig | .

* SUSPENDED 02 Neo 2022 TO 02 Dec 2022: Sees cath erat

* SUSPENDED 08 Dac 2022 TO 06 Des 2022; for.
*™ SUSPENDED 08 Deo 2022 TO 06 Dec 2022: suspending haifa dim forwosk
™ SUSPENDED 07 Deo 2022 TO 07 Dec 2022: suspending noon dose to take at work **
Praseriber:

RX # 04126244

Attachment A

rok"

”

Equiv to: SUSOXONE 8 MG-2 MS SL
FILA

Otig: 18-Nov-2022 Dala Written: 18-Nov-2022

SUBOXONE 8 MG-2 MG SL FILM 8MQ-2 STR
PLACE 1/2 FILMUNDER TONGUE EVERY DAY AT NOON

* SUSPENDED 07 Deo 2022 TO 01 Ose 2022: Signad oul 4 mg far work, ™

™ SUSPENDED 62 Dac 2022 TO 02 Due 2022: Signad cut 4 mg for work ™

* SUSPENDED 06 Dec 2022 TO 05 Dec 2022: suspending helfa flim, 4mg, for wark *

SUSPENDED 06 Dec 2022 TO 08 Dec 2022: suspending half a fim for wark “*

** SUSPENDED 07 Dac 2022 TO 07 Dee 2022: suspending noon dose to take at wark *

Prescriber:

RX #0612424)

eae to: SUBOXONE 8 MG-2 MG St
LM

(Orig; 18-Nov-2022 Date Written: 18-Nov-2022

ACETAMINOPHEN 500 MG CAPS Rapid Relaase 500 MG CAPS

Extra Strength
{ake 2 goleaps avarty avery 6 hours while symptoms last, do not take mora Man 6 galeaps in 24 hours,
unlass diracled by a doctor.

IBUPROFEN 200 MG GAPS 200 MG CAPS

Take 4 capaule avery 4 to 6 hours while aymptoma parsist. {t pain or iever does not respond to 1
capsute, 2 capsules may be used. Do not exceed 6 capsules in 24 hours, unlasa direcied by a doctor.

PANTOPRAZOLE 40MG TAS 40 NG TAB

TAKE 1 TABLET BY MOUTH_ EVERY DAY "DO NOT CRUSH"
rect

Caregiver Key
Ema) Gatien ae) « eRe ——_

®xcaotlons for i

QuickMAR: fag Paint Date: 7-80-2072

Mary Benson House

MAR

Given By Dolwiis Notes

Attachment A

Date [Tims Madlcation Quanity Reason Ghen Given By Resulis/By
Vitals Not Shown Above (or Ta
Dale/ Tine Order GWwen By Reason Given Vitel Results

Hody Location Site Key

Late’ arm, ReAcright arm, LAT-left anterior thigh, RAT-right antesor thigh, LO-lefi deltoid, RD-rightdeltold, LG-left gluteus,

RG-right gluteus

2of2
Print Date: 7-Dac-2022

QuickMAR

1:58 PM Attachment B Mail - Leila Allen - Outlook

Review completed Fire and Safety Drills, Complete any remaining assessments and drills
before the end of the month. This reminder occurs every first Monday of the month until
12/5/2023

{12/5/2022

© 4:00 PM - 4:30 PM

httne-Hantinnt: affica camimalilinhnwidsis 20k AN VNil lyM2F kl TRIMIN-NNEZNVISN2k71 TOV7TVIZAVKY ze YwAOAKKml P99ON, IPIAAWSH.IrRAEY% AN 4

Attachment C

g

es

“nf 8 bt | Avieey Denson Hoe yous

documentation to include ocumenting if a person
»mpetencies of staff to oversee monitoring of residents’ medications

Last Modifled: 2/24/2005 Formi#: 3002

inspection_type: MHLCS Annual and Complaint


state: NC

facility_name: Mary Benson House

summary: Statement of Deficiency - MHLCS Annual and Complaint

raw_content:
Division of Health Service Regulation

PRINTED: 11/23/2022
FORM APPROVED

POLICIES

10A NCAC 27G .0201 GOVERNING BODY
POLICIES

(a) The governing body responsible for each
facility or service shall develop and implement
written policies for the following:

(8) use of medications by clients in accordance
with the rules in this Section;

(9) reporting of any incident, unusual occurrence
or medication error;

(10) voluntary non-compensated work performed
by a client;

(11) client fee assessment and collection
practices;

(12) medical preparedness plan to be utilized ina
medical emergency;

(13) authorization for and follow up of lab tests;
(14) transportation, including the accessibility of
emergency information for a client;

(15) services of volunteers, including supervision
and requirements for maintaining client
confidentiality;

(16) areas in which staff, including
nonprofessional staff, receive training and

Division of Health Service Regulation

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

STATE FORM

e088 aLsy11

TITLE

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
MHL011-384 10/26/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
450 MONFORD AVENUE
MARY BENSON HOUSE
ASHEVILLE, NC 28801
(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 10/26/22. The complaint was unsubstantiated
(intake #NC00192537). Deficiencies were cited.
This facility is licensed for the following service
category: 10A NCAC 27G .4100 Residential
Recovery Programs for Individuals with
Substance Abuse Disorders and Their Children.
This facility is licensed for 12 and currently has a
census of 5. The survey sample consisted of
audits of 3 current clients.
V 106] 27G .0201 (A) (8-18) (B) GOVERNING BODY V 106

(X6) DATE

If continuation sheet 1 of 14

Division of Health Service Regulation

PRINTED: 11/23/2022
FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
MHL011-384 10/26/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
450 MONFORD AVENUE
MARY BENSON HOUSE
ASHEVILLE, NC 28801
(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 106 | Continued From page 1

continuing education;

(17) safety precautions and requirements for
facility areas including special client activity
areas; and

(18) client grievance policy, including procedures
for review and disposition of client grievances.
(b) Minutes of the governing body shall be
permanently maintained.

This Rule is not met as evidenced by:

Based on record reviews and interviews, the
facility failed to implement their written policy for
the use of medications by clients affecting 3 of 3
audited clients (Client #1, #2, and #3). The
findings are:

Refer to V118 for information for Client #1, #2 and
#3 regarding:

-admission dates and diagnoses for Client #1, #2,
and #3;

-physician orders for currently prescribed
medication;

-self-administration documentation for Over the
Counter (OTC) and prescription medications;
-missing staff initials on the Medication
Administration Record (MAR) documenting that
staff monitored clients administering their own
medications.

Review on 10/12/22 of the facility's Medication
Policy revealed:

-"1003.05 Medication Monitoring-

- ... Mary Benson House does not have licensed
or qualified nursing staff to administer or
dispense medication. Mary Benson House

Division of Health Service Regulation
STATE FORM

V 106

e088 aLsy11

If continuation sheet 2 of 14

Division of Health Service Regulation

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

MHL011-384

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 11/23/2022

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

450 MONFORD AVENUE
ASHEVILLE, NC 28801

MARY BENSON HOUSE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

10/26/2022

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

ID
PREFIX
TAG

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

(xs)
COMPLETE
DATE

V 106] Continued From page 2

employees monitor clients’ self-administration of
medications to ensure proper adherence to the
written prescription order."

-"1003.052 MAR (Medication Administration
Record) Documentation-

Medications monitored shall be recorded
immediately after self-administration. The MAR
sheet is to include the following:

1. Client's name

2. Name, strength and quantity of the drug

3. Instructions for administering the drug

4. Date and time the drug is administered

5. Name or initials of person monitoring the drug

6. Explanation of request for a PRN ..."
-"1003.056 Special Issues

When consumers leave the facility for an
overnight or day pass and require medications
during their time away, staff will document on the
MAR sheet what medications were taken and
how much the client has in her possession. When
medication doses are missed, staff will document
on the MAR sheet stating what dose was missed,
why, and what action was taken."

Interview on 10/26/22 with the Regional Director
revealed:

-the facility used the electronic MAR provided by
the pharmacy that filled the prescriptions;

-the facility was in the process of switching to a
different electronic health record which allows for
customization of fields for documentation by staff;
-they will add a statement at the top of the MAR
that clients self-administered their medications;
-the medication policy will be reviewed to ensure
it reflected their current processes.

V 114) 27G .0207 Emergency Plans and Supplies

V 106

Vv 114

Division of Health Service Regulation
STATE FORM

6809

If continuation sheet 3 of 14

PRINTED: 11/23/2022

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
MHL011-384 10/26/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
450 MONFORD AVENUE
MARY BENSON HOUSE
ASHEVILLE, NC 28801
(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 114] Continued From page 3 Vv 114

10A NCAC 27G .0207 EMERGENCY PLANS
AND SUPPLIES

(a) Awritten fire plan for each facility and
area-wide disaster plan shall be developed and
shall be approved by the appropriate local
authority.

(b) The plan shall be made available to all staff
and evacuation procedures and routes shall be
posted in the facility.

(c) Fire and disaster drills in a 24-hour facility
shall be held at least quarterly and shall be
repeated for each shift. Drills shall be conducted
under conditions that simulate fire emergencies.
(d) Each facility shall have basic first aid supplies
accessible for use.

This Rule is not met as evidenced by:

Based on records reviews and interviews, the
facility failed to conduct fire and disaster drills on
each shift at least quarterly. The findings are:

Review on 8/19/22 of the facility's fire and
disaster drills for 7/1/21-6/30/22 revealed:

-no documentation that fire or disaster drills were
conducted on any shift from 10/1/21-12/31/22;
-no documentation that a disaster drill was
conducted on 2nd shift from 1/1/22-3/31/22.

Interview on 8/18/22 and 8/22/22 with the
Program Manager (PM) revealed:

-shifts are "am" and "pm" for Residential
Treatment Specialists (RTS);

-their shifts were 12 hours each;

-RTS's on "am" shift worked 8:00am to 8:00pm
but some may work until only 4:00pm-5:00pm
depending on staff needs; "pm" shift was 8:00pm
to 8:00am;

Division of Health Service Regulation
STATE FORM

6809

If continuation sheet 4 of 14

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL011-384

MARY BENSON HOUSE

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 11/23/2022

STREET ADDRESS, CITY, STATE, ZIP CODE
450 MONFORD AVENUE
ASHEVILLE, NC 28801

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

10/26/2022

(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)

(xs)
COMPLETE
DATE

V114

V 118)

Continued From page 4

-she wanted to designate a safety officer for tasks
such as the drills.

Interview on 8/22/22 with Client #2 revealed:
-facility did fire and disaster drills "more than |
care to say."

Interview on 8/22/22 with Client #3 revealed:
-had been at the facility for almost 90 days;
-heard that the facility had fire and disaster drills
but she had not been involved in one yet.

Interview on 8/18/22 with the facility's Case
Manager/Residential Treatment Specialist
(CM/RTS) revealed:

-the staff person who was scheduling the drills
left; staff were now rotating responsibility of doing
the drills among staff again;

-she "followed the sound of the air horn and exits
the building."

Interview on 8/23/22 with Staff #1 revealed:
-position was RTS; she worked 8:00pm to
8:00am on Sundays, Mondays, and Tuesdays;
-she had done fire/disaster drills;

-drills were assigned to different staff; she had not
been chosen recently to complete a drill.

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

Division of Health Service Regulation
STATE FORM

Vv 114

V 118

6809

If continuation sheet 5 of 14

Division of Health Service Regulation

PRINTED: 11/23/2022
FORM APPROVED

client's physician.

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

‘A) client's name;

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

C) instructions for administering the drug;

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

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

(
(
(
(
(

This Rule is not met as evidenced by:

Based on observation, interviews and record
reviews, the facility failed to ensure that 2 of 2
audited staff (Staff #1 and the Case
Manager/Residential Treatment Specialist
(CM/RTS) who administered medications were
trained by a legally qualified person privileged to
administer medication; failed to ensure that
medications were administered only on the
written order of a person legally authorized to
prescribe medications for 3 of 3 audited clients
(Clients #1, #2, and #3) and failed to ensure that

Division of Health Service Regulation

STATE FORM

e088 aLsy11

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL011-384 10/26/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
450 MONFORD AVENUE
MARY BENSON HOUSE
ASHEVILLE, NC 28801
(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 5 Vv 118

If continuation sheet 6 of 14

Division of Health Service Regulation
(X1) PROVIDER/SUPPLIER/CLIA

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 11/23/2022
FORM APPROVED

(X3) DATE SURVEY

MARs were kept current for 3 of 3 audited clients
(Clients #1, #2, and #3). The findings are:

Finding #1:

Review on 8/18/22 of Client #1's record revealed:
-date of admission: 12/29/21;

-diagnoses of Opiate Use Disorder (d/o), severe,
in sustained remission, on maintenance therapy;
Sedative, Hypnotic, Anxiolytic d/o, severe, in early
remission; Stimulant Use d/o, amphetamine type,
severe, early remission; Tobacco Use do,
moderate; Post Traumatic Stress d/o (PTSD);
-was approved on 1/10/22 by the facility's
physician to self-administer both over the counter
(OTC) and prescription medication.

Review on 8/18/22 of Client #2's record revealed:
-date of admission: 5/3/22;

-diagnoses of Opiate Use d/o, severe, on
maintenance therapy; Alcohol Use d/o, severe;
Sedative, Hypnotic, Anxiolytic Use d/o, severe, in
early remission; Stimulant Use d/o, cocaine,
severe, in sustained remission; PTSD; Attention
Deficit Hyperactivity d/o (ADHD); Tobacco Use
d/o, severe;

-was approved on 5/4/22 by the facility's
physician to self-administer both OTC and
prescription medication.

Review on 8/18/22 and 8/19/22 of Client #3's
record revealed:

-date of admission was 6/13/22

-diagnoses of Stimulant Use d/o, amphetamine
type, severe; Opiate Use d/o, moderate; ADHD,
predominantly inattentive type; Major Depression,
mild; Generalized Anxiety d/o; PTSD;

-was approved on 6/20/22 by the facility's
physician to self-administer both OTC and
prescription medication.

Division of Health Service Regulation

STATE FORM

6809

QLSY11

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL011-384 10/26/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
450 MONFORD AVENUE
MARY BENSON HOUSE
ASHEVILLE, NC 28801
(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 6 Vv 118

If continuation sheet 7 of 14

Division of Health Service Regulation
(X1) PROVIDER/SUPPLIER/CLIA

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 11/23/2022
FORM APPROVED

(X3) DATE SURVEY

Review on 8/18/22 of physician's orders for Client
#1 revealed:

-Buprenorphine (opioid maintenance therapy)
8mg (milligram) SL (sub-lingual) tablet, dissolve 1
tablet under tongue three times daily (TID)
ordered 4/27/22;

-Gabapentin (pain) 300mg, 1 capsule TID
ordered 6/8/22;

-Docusate (constipation) 100mg take capsule TID
ordered 7/22/22.

Review on 8/18/22 and 8/19/22 of Client #1's
MARs dated 6/1/22-8/18/22 revealed:
-Gabapentin 300mg, 1 capsule TID was
administered 6/1/22-6/7/22 without a written
physician order;

-there were no staff initials on the MAR to indicate
that Client #1 self-administered her medications
on the following dates and times:

-6/5/22 for the 8:00pm doses for Buprenorphine
8mg and Gabapentin 300mg;

-7/13/22 for the 12:00pm doses for
Buprenorphine 8mg SL;

-7/13/22- no initials for the 12:00pm dose of
Gabapentin 300mg;

-8/9/22 and 8/13/22- for the 8:00pm doses
Buprenorphine 8mg, Docusate 100mg, and
Gabapentin 300mg.

Review on 8/18/22 and 8/22/22 of physician
orders for Client #2 revealed:

-Enoxaparin (blood clotting) 40mg syr (syringe),
administer under the skin daily (evening), ordered
on 6/13/22;

-Suboxone (opioid maintenance therapy)
8mg-2mg sl film, dissolve % film under tongue
every afternoon ordered 5/20/22;

-Suboxone 8mg-2mg sl film, dissolve 1 film under
tongue twice daily (BID) ordered 5/20/22.

Division of Health Service Regulation

STATE FORM

6809

QLSY11

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL011-384 10/26/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
450 MONFORD AVENUE
MARY BENSON HOUSE
ASHEVILLE, NC 28801
(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 7 Vv 118

If continuation sheet 8 of 14

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL011-384

MARY BENSON HOUSE

A. BUILDING:

ASHEVILLE, NC 28801

(X2) MULTIPLE CONSTRUCTION

PRINTED: 11/23/2022

STREET ADDRESS, CITY, STATE, ZIP CODE
450 MONFORD AVENUE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

10/26/2022

Review on 8/18/22 and 8/23/22 of the MARs
dated 6/1/22- 8/18/22 for Client #2 revealed:
-Enoxaparin 40mg was administered 6/1/22 and
6/3/22-6/12/22 without a written physicians order;
-there were no staff initials on the MAR to indicate
that Client #2 self-administered her medications
on the following dates and times:

-6/2/22, 7/9/22, 8/10/22 for Enoxaparin 40mg;
-6/29/22, 6/30/22, 7/1/22, 7/26/22, 8/6/22, for
Suboxone 8mg-2mg (afternoon dose);

-7/12/22 (8:00am) and 7/26/22 (8:00am) for
Suboxone 8mg-2mg, 1 film under tongue twice
daily.

Review on 8/22/22 of physician orders for Client
#3 revealed:

-Bupropion (smoking cessation/depression)
300mg, one tab daily ordered 6/22/22;
-Acetaminophen (pain), 500mg, take 2 gel caps
every 6 hours while symptoms last. Do not take
more than 6 gel caps in 24 hours unless
prescribed by a doctor. Do not take for more
than 10 days unless directed by a doctor. OTC
physician orders were signed on 6/20/22.

Review on 8/18/22 and 8/22/22 of MARS dated
6/1/22-8/18/22 for Client #3 revealed:
-Acetaminophen 300mg was documented as
administered for 15 consecutive days from
7/16/22 to 7/30/22 without a written doctors order
to administer for more than 10 days;

-there were no staff initials on the MAR on
7/12/22 to indicate that Client #3
self-administered bupropion 300mg.

Finding #2

Review on 8/19/22 of Staff #1's personnel record
revealed:

Division of Health Service Regulation
STATE FORM

6809

QLSY11

(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 8 Vv 118

If continuation sheet 9 of 14

Division of Health Service Regulation
(X1) PROVIDER/SUPPLIER/CLIA

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 11/23/2022
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL011-384 10/26/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
450 MONFORD AVENUE
MARY BENSON HOUSE
ASHEVILLE, NC 28801
(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 9 Vv 118

-hired on 11/29/21;

-position was Residential Treatment Specialist
(RTS);

-medication administration training completed on
11/15/21;

-the training, "Your role in the Medication
Process," was a one hour, online only training.

Review on 8/19/22 of the Case
Manager/Residential Treatment Specialist's
(CM/RTS) personnel record revealed:

-hired on 12/28/20;

-position was Case Manager/RTS;

-medication administration training completed on
12/28/20;

-the training, "Your role in the Medication
Process," was a one hour, online only training.

Interview on 8/23/22 with Staff #1 revealed:

-had been working at the facility since October or
November 2021;

-she observed clients "administer meds
(medications) to themselves;"

-she had training on medications, the "5 rights of
meds;"

-a traveling nurse came to the facility and
assisted with how to use the "Quick Mar;"

-the facility was working with (local pharmacy) on
how best to use the MAR.

Interview on 8/18/22 with the CM/RTS revealed:
-she worked 9:00am-3:00pm Monday and
Tuesday, Wednesday for 11 hrs, Thursday for 9
hours and off on Fridays;

-there were "regimented" times for med pass;
-she administered medications "occasionally" if
she needed too.

Interview on 8/19/22 and 10/26/22 with the
Regional Director revealed:

Division of Health Service Regulation
STATE FORM

6809

QLSY11

If continuation sheet 10 of 14

Division of Health Service Regulation

PRINTED: 11/23/2022
FORM APPROVED

-clients self-administered their medication;

-their physician approved and signed a form
approving clients to self-administer both OTC and
prescription medication;

-staff "don't actually administer medications" and
that is why there was no medication
administration training; staff take an online only
training for medications when they are hired;

-she will talk with staff about language and use of
the word administer; "staff say they administer but
they don't really;"

-the facility will incorporate a face to face
component by an RN (Registered Nurse) for the
medication training.

Interview on 8/19/22 with Client #1 revealed:
-she was responsible to follow up with the
doctor's office regarding her appointments and
medications;

-(local care manager program) helped her with
her medications; they prescribed and monitored
her medications;

-there had been no problems with her
medications.

Interview on 8/22/22 with Client #2 revealed:
-she was responsible for getting her refills called
in to the pharmacy;

-there were no concerns with her medications.

Interview on 8/22/22 with Client #3 revealed:
-medications were helpful; she took her
medications at certain times;

-knew when to get a refill "when it gets into the
blue column on the pack;"

-she had to call the doctor when she needed a
refill.

Due to the failure to accurately document
medication administration, if could not be

Division of Health Service Regulation
STATE FORM

e088 aLsy11

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL011-384 10/26/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
450 MONFORD AVENUE
MARY BENSON HOUSE
ASHEVILLE, NC 28801
(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 10 Vv 118

If continuation sheet 11 of 14

Division of Health Service Regulation

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

MHL011-384

NAME OF PROVIDER OR SUPPLIER

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

450 MONFORD AVENUE

MARY BENSON HOUSE

ASHEVILLE, NC 28801

PRINTED: 11/23/2022

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

10/26/2022

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

DEFICIENCY)
V 118) Continued From page 11 Vv 118
determined if clients received their medication as
ordered by the physician.
V 732} 27G .0303(a) Site Location V 732

10A NCAC 27G .0303 LOCATION AND
EXTERIOR REQUIREMENTS

(a) Each facility shall be located on a site where:
(1) fire protection is available;

(2) water supply, sewage and solid waste
disposal services have been approved by the
local health department;

(3) occupants are not exposed to hazards and
pollutants that may constitute a threat to their
health, safety, and welfare; and

(4) local ordinances and zoning laws are met.

This Rule is not met as evidenced by:

Based on observations, record reviews and
interviews, the facility failed to ensure that clients
were not exposed to hazards and pollutants that
may constitute a threat to their health, safety and
welfare affecting 3 of 3 audited clients (Client #1,
#2 and #3).

Interview on 8/22/22 with the (Local) County
Environmental Health Staff revealed:

-during a standard sanitation inspection June
2022, an inspector found the presence of lead
hazards;

-a copy of the report was sent to the provider.

Division of Health Service Regulation
STATE FORM

6809

QLSY11

If continuation sheet 12 of 14

Division of Health Service Regulation

PRINTED: 11/23/2022
FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
MHL011-384 10/26/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
450 MONFORD AVENUE
MARY BENSON HOUSE
ASHEVILLE, NC 28801
(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 732] Continued From page 12

Areferral was made by phone on 8/22/22 by the
DHSR (Division of Health Service Regulation)
surveyor to the DHSR Construction Section
regarding the (local) County Environmental
Health report. A copy of the report was forwarded
to the DHSR Construction Section.

Review on 8/23/22 of the (Local) County
Environmental Health report dated 7/29/22
revealed:

-an inspection revealed the presence of "paint
and dust have been identified as a source of lead
exposure to a child less than 6 years of age;"

-a recommendation that "lead poisoning hazards
identified on the property be remediated."

Interview on 8/26/22 with the Director of Safety
and Workman's Compensation for the licensee
revealed:

-the facility was addressing the report but
disagreed with it;

-was trying to schedule a meeting with the county
to discuss the report;

-the (local) county (who issued the report) sold
them the building years ago and "it was never an
issue."

Interview on 10/26/22 with the facility's Regional
Director revealed:

-DHSR construction staff conducted a site visit at
the facility recently (she didn't have the specific
date on hand);

-the area of concern was a non-functioning
fireplace in bedroom (room 106) on the first floor;
-DHSR construction staff made
recommendations to close off the part of the
bedroom near the fireplace;

-the facility will construct a wall to cover the
fireplace;

-the facility sent letters to the eight women

Division of Health Service Regulation
STATE FORM

V 732

e088 aLsy11

If continuation sheet 13 of 14

PRINTED: 11/23/2022

FORM APPROVED
Division of Health Service Re
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL011-384 — 10/26/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
450 MONFORD AVENUE
MARY BENSON HOUSE
ASHEVILLE, NC 28801
(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 732] Continued From page 13 V 732

residing at the facility as required by the (Local)
County's report.

Division of Health Service Regulation
STATE FORM 6809 asy11 If continuation sheet 14 of 14

document_type: Statement of Deficiency


summary: Statement of Deficiency - MHLCS Annual

raw_content:
PRINTED: 06/13/2019

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
MHL011-384 B. WING 06/05/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
450 MONFORD AVENUE
MARY BENSON HOUSE
ASHEVILLE, NC 28801
(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 6/5/19. No
deficiencies were cited.
This facility is licensed for the following service
categories: 10A NCAC 27G .4100 Residential
Recovery Programs for Individuals with
Substance Abuse Disorders and Their Children.
Division of Health Service Regulation
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
STATE FORM 6899 YVQU11 If continuation sheet 1 of 1

inspection_type: MHLCS Annual


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

raw_content:
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA

AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
MHL011-384

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE
450 MONFORD AVENUE

PRINTED: 05/31/2018

FORM APPROVED
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
A. BUILDING: COMPLETED
R
B.WING 05/25/2018

MARY BENSON HOUSE
ASHEVILLE, NC 28801
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000) INITIAL COMMENTS V 000
An annual and follow up survey was completed
May 25, 2018. No deficiencies were cited.
This facility is licensed for the following service
category: 10A NCAC 27G .4100 Residential
Recovery Programs for Individuals with
Substance Abuse Disorders and their children.
Division of Health Service Regulation
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
STATE FORM 6899 V7EX11 If continuation sheet 1 of 1

inspection_type: MHLCS Annual and Follow-up


facility_name: Livingstone's Home

summary: Statement of Deficiency - MHLCS Annual

raw_content:
Division of Health Service Regulation

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

MHL011-386

NAME OF PROVIDER OR SUPPLIER

LIVINGSTONE'S HOME

STREET ADDRESS, CITY, STATE, ZIP CODE

212 BALDWIN ROAD
ARDEN, NC 28704

PRINTED: 03/05/2026

FORM APPROVED
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

A. BUILDING: COMPLETED
B.WING 03/05/2026

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

(X4) ID
PREFIX
TAG

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

(x5)
COMPLETE
DATE

V 000} INITIAL COMMENTS

An annual survey was completed on 3/5/26. No
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.

The facility is licensed for 3 and has a current
census of 2. The survey sample consisted of an
audit of 2 current clients.

Division of Health Service Regulation

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

V 000

TITLE (X6) DATE

STATE FORM

809

500411 If continuation sheet 1 of 1


raw_content:
PRINTED: 01/24/2025

FORM APPROVED
Division of Health Service Re
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHLO011-386 01/23/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
. 212 BALDWIN ROAD
LIVINGSTONE'S HOME
ARDEN, NC 28704
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000} INITIAL COMMENTS V 000

An annual and follow up survey was completed

on January 23, 2025. No deficiencies were cited.

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

This facility is licensed for 3 and has a current
census of 2. The survey sample consisted of
audits of 2 current clients.

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

STATE FORM

6899

TITLE (X6) DATE

If continuation sheet 1 of 1


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

raw_content:
PRINTED: 06/16/2023

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:
MHLO011-386 8. WING 06/14/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
LIVINGSTONE'S HOME ZAR BALOWIN ROAD
ARDEN, NC 28704
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES 10 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 000 INITIAL COMMENTS. Vv 000

| An annual and follow up survey was completed
6/14/23. A deficiency was cited

This facility is licensed for the following service
category, 10A NCAC 27G Supervised Living for
Alternative Family Living

The facility is licensed for 3 and currently has a
census of 2. The survey sample consisted of
audits of 2 current clients

27G .5602 Supervised Living - Staff Vv 290

10A NCAC 27G 5602 STAFF |
(a) Staff-client ratios above the minimum |
numbers specified in Paragraphs (b), (c) and (d)
of this Rule shall be determined by the facility to
enable staff to respond to individualized client
needs.

| (b) Aminimum of one staff member shall be
present at all times when any adult client is on the
Premises, except when the client's treatment or

| habilitation plan documents that the client is
capable of remaining in the home or community
without supervision. The plan shall be reviewed
as needed but not less than annually to ensure

| the client continues to be capable of remaining in
the home or community without supervision for |
specified periods of time DHS® . Mental Health |
(c) Staff shall be present in a facility in the
following client-staff ratios when more than one 05 2023
child or adolescent client is present: ali
(1) children or adolescents with substance |
abuse disorders shall be served with a minimum Lic. .& Cert, Section
of one staff present for every five or fewer minor
clients present. However, only one staff need be
present during sleeping hours if specified by the
emergency back-up procedures determined by
the governing body; or

Division of Health Service Regulation

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (x6) DATE

STATE FORM me 66U111 if continuation sheet + of 4

lo far [23

Division of Health Service Requlation

PRINTED: 06/16/2023
FORM APPROVED

STATEMENT OF DEFICIENCIES (M1) PROVIDER/SUPPLIER/CLIA

(X2) MULTIPLE CONSTRUCTION

(X3) DATE SURVEY

developmental disabilities shall be served with
one staff present for every one to three clients
Present and two staff present for every four or
more clients present. However, only one staff
need be present during sleeping hours if
specified by the emergency back-up procedures
determined by the governing body.

(d) In facilities which serve clients whose primary
diagnosis is substance abuse dependency:

(1) at least one staff member who is on
duty shail be trained in alcohol and other drug
withdrawal symptoms and symptoms of
secondary complications to alcohol and other
drug addiction; and

(2) the services of a certified substance
abuse counselor shall be available on an
as-needed basis for each client.

| This Rule is not met as evidenced by

| Based on record review and interview, the facility
failed to ensure the client's treatment or
habilitation plan documented the client was
capable of remaining in the home or community
without supervision affecting 1 of 2 clients (Client
#2). The findings are

Review on 6/13/23 of Client #2's record revealed
-Admitted 4/1/03.

| -Diagnoses of Autism Spectrum Disorder,
Oppositional Defiant Disorder, Impulse Disorder
and Unspecified Mood Disorder.

| -3/10/22 - unsupervised time assessment -

| approved up to 3 hours - includes home and

community time - completed by the Qualified

Professional (QP).

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A BUILDING: COMPLETED
MHLO011-386 06/14/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
212 BALDWIN ROAD
LIVINGSTONE'S HOME
ARDEN, NC 28704
i ——$__—_—
(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 290) Continued From page 1 V 290
|
| (2) children or adolescents with

Unrapecyi sed tame
has Now bean acide
to chytumer’s TSP
Noe Cane Caer nado |
frown VAYA MICO. -
QPs pun trained) to |

Qanur. Mtormat on
poke” nm add TSR

Qa NOD worl aw rw
vienna Ow AES gous

Division of Health Service Regulation
STATE FORM 6899

66U111 If continuation sheet 2 of 4

Division of Health Service Regulation

PRINTED: 06/16/2023
FORM APPROVED

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

MHL011-386

NAME OF PROVIDER OR SUPPLIER

LIVINGSTONE’S HOME
(x4) 1D | SUMMARY STATEMENT OF DEFICIENCIES

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

—

TAG

(X2) MULTIPLE CONSTRUCTION
A. BUILDING.

B.WING

(X3) DATE SURVEY
COMPLETED

06/14/2023

ID
PREFIX
TAG

STREET ADDRESS, CITY, STATE, ZIP CODE
212 BALDWIN ROAD
ARDEN, NC 28704

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

V 290 | Continued From page 2

-3/9/23 - Person-Centered Profile - no treatment
goal indicating the client's ability to remain in the
home or community unsupervised.

| Interview on 6/13/23 with Client #2 and his
guardian, who was also present, revealed
-Confirmed he was able to stay at home alone, up
to 2 hours, per the guardian.
-Client was unsure of how many hours he had
approved.
-Per the guardian, it had been documented in his
treatment plan for "like 7 years now."

Interview on 6/13/23 with the AFL provider
revealed:
| -Client #2 had 3 to 4 hours of approved
unsupervised time.
-He spent "maybe 30 minutes” alone at the facility
every once in a while when he got home before
anyone else.
-She believed this was documented in his
treatment plan.

Interview on 6/13/23 with the QP revealed

-She had an updated unsupervised time
assessment for Client #2, but it was in her other

| office.

-The client continued to have up to 3 hours of
unsupervised time, which included in the home
and community.

-She had not put it in the treatment plan yet, she
just learned from the Program Manager yesterday
that this needed to be in the pian

Interview on 6/14/23 with the Program Manager
| fevealed:
| -Client #2's unsupervised time was in his
| treatment plan and must have been deleted
-She would contact the Local Management Entity
and ensure it was put back into the plan

Vv 290

Division of Health Service Regulation
STATE FORM

f continuation sheet 3 of 4

9 [22/45

66U111

Division of Health Service Regulation

PRINTED: 06/16/2023
FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: Seu COMPLETED
MHLO011-386 2 WING — 06/14/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
212 BALDWIN ROAD
LIVINGSTONE'S HOME
ARDEN, NC 28704
——_—
(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
j DEFICIENCY)
|
|
|
|
|
|
|
|
|
|
Division of Health Service Regulation
STATE FORM oss 66U114 If continuation sheet 4 of 4

Fede Samer lQypua
o|z+/ 33

document_type: Plan of Correction


raw_content:
Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

PRINTED: 06/16/2023

MHLO011-386

STREET ADDRESS, CITY, STATE, ZIP CODE

212 BALDWIN ROAD
ARDEN, NC 28704

LIVINGSTONE'S HOME

FORM APPROVED
(X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
A. BUILDING: COMPLETED
06/14/2023

(x4) ID
PREFIX
TAG

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

ID PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH CORRECTIVE ACTION SHOULD BE

TAG CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

(xs)
COMPLETE
DATE

V 000!

V 290]

INITIAL COMMENTS

An annual and follow up survey was completed
6/14/23. A deficiency was cited.

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

The facility is licensed for 3 and currently has a
census of 2. The survey sample consisted of
audits of 2 current clients.

27G .5602 Supervised Living - Staff

10A NCAC 27G .5602 STAFF

(a) Staff-client ratios above the minimum
numbers specified in Paragraphs (b), (c) and (d)
of this Rule shall be determined by the facility to
enable staff to respond to individualized client
needs.

(b) Aminimum of one staff member shall be
present at all times when any adult client is on the
premises, except when the client's treatment or
habilitation plan documents that the client is
capable of remaining in the home or community
without supervision. The plan shall be reviewed
as needed but not less than annually to ensure
the client continues to be capable of remaining in
the home or community without supervision for
specified periods of time.

(c) Staff shall be present in a facility in the
following client-staff ratios when more than one
child or adolescent client is present:

(1) children or adolescents with substance
abuse disorders shall be served with a minimum
of one staff present for every five or fewer minor
clients present. However, only one staff need be
present during sleeping hours if specified by the
emergency back-up procedures determined by
the governing body; or

Division of Health Service Regulation

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

STATE FORM

V 000

V 290

TITLE

6808 66U111

(X6) DATE

If continuation sheet 1 of 4

Division of Health Service Regulation

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

MHLO011-386

NAME OF PROVIDER OR SUPPLIER

PRINTED: 06/16/2023

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

STREET ADDRESS, CITY, STATE, ZIP CODE

212 BALDWIN ROAD
ARDEN, NC 28704

LIVINGSTONE'S HOME

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

06/14/2023

(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 290] Continued From page 1 V 290

(2) children or adolescents with
developmental disabilities shall be served with
one staff present for every one to three clients
present and two staff present for every four or
more clients present. However, only one staff
need be present during sleeping hours if
specified by the emergency back-up procedures
determined by the governing body.

(d) In facilities which serve clients whose primary
diagnosis is substance abuse dependency:

(1) at least one staff member who is on
duty shall be trained in alcohol and other drug
withdrawal symptoms and symptoms of
secondary complications to alcohol and other
drug addiction; and

(2) the services of a certified substance
abuse counselor shall be available on an
as-needed basis for each client.

This Rule is not met as evidenced by:

Based on record review and interview, the facility
failed to ensure the client's treatment or
habilitation plan documented the client was
capable of remaining in the home or community
without supervision affecting 1 of 2 clients (Client
#2). The findings are:

Review on 6/13/23 of Client #2's record revealed:
-Admitted 4/1/03.

-Diagnoses of Autism Spectrum Disorder,
Oppositional Defiant Disorder, Impulse Disorder
and Unspecified Mood Disorder.

-3/10/22 - unsupervised time assessment -
approved up to 3 hours - includes home and
community time - completed by the Qualified
Professional (QP).

Division of Health Service Regulation
STATE FORM

6808 66U111

If continuation sheet 2 of 4

Division of Health Service Regulation

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

MHLO011-386

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
212 BALDWIN ROAD
ARDEN, NC 28704

LIVINGSTONE'S HOME

PRINTED: 06/16/2023

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

06/14/2023

(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 290] Continued From page 2 V 290

-3/9/23 - Person-Centered Profile - no treatment
goal indicating the client's ability to remain in the
home or community unsupervised.

Interview on 6/13/23 with Client #2 and his
guardian, who was also present, revealed:
-Confirmed he was able to stay at home alone, up
to 2 hours, per the guardian.

-Client was unsure of how many hours he had
approved.

-Per the guardian, it had been documented in his
treatment plan for "like 7 years now."

Interview on 6/13/23 with the AFL provider
revealed:

-Client #2 had 3 to 4 hours of approved
unsupervised time.

-He spent "maybe 30 minutes" alone at the facility
every once in a while when he got home before
anyone else.

-She believed this was documented in his
treatment plan.

Interview on 6/13/23 with the QP revealed:

-She had an updated unsupervised time
assessment for Client #2, but it was in her other
Office.

-The client continued to have up to 3 hours of
unsupervised time, which included in the home
and community.

-She had not put it in the treatment plan yet, she
just learned from the Program Manager yesterday
that this needed to be in the plan.

Interview on 6/14/23 with the Program Manager
revealed:

-Client #2's unsupervised time was in his
treatment plan and must have been deleted.
-She would contact the Local Management Entity
and ensure it was put back into the plan.

Division of Health Service Regulation
STATE FORM

6808 66U111

If continuation sheet 3 of 4

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

(X2) MULTIPLE CONSTRUCTION

PRINTED: 06/16/2023

FORM APPROVED

(X3) DATE SURVEY

DEFICIENCY)

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
MHLO011-386 06/14/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
. 212 BALDWIN ROAD
LIVINGSTONE'S HOME
ARDEN, NC 28704
(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

Division of Health Service Regulation

STATE FORM

6809

66U111

If continuation sheet 4 of 4


summary: Statement of Deficiency - MHLCS Annual

raw_content:
PRINTED: 09/27/2021

FORM APPROVED
Division of Health Service Re
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL011-386 — 08/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
. 212 BALDWIN ROAD
LIVINGSTONE'S HOME
ARDEN, NC 28704
(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 Vv 000

An annual survey was completed 8/2/21. No
deficiencies were cited.

This facility is licensed for the following service
category:

10A NCAC 27G Supervised Living for Individuals
of all Disability Groups-Alternative Family Living.

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

STATE FORM 6609 CVFX11 If continuation sheet 1 of 1


raw_content:
PRINTED: 06/07/2019
FORM APPROVED

Division of Health Service Regulation

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

MHLO11-386 B WING 05/16/2019

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

212 BALDWIN ROAD
ARDEN, NG 28704

LIVINGSTONE’S HOME

4) 10 SUMMARY STATEMENT OF DEFICIENCIES iD PROVIDER'S PLAN OF CORRECTION 5)
PREFIX (EACH DEFICIENCY MUST 8E 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 complaint survey was completed
5/16/19. The complaint was unsubstantiated RECEIVED
(Intake #NC 00150609). Deficiencies were cited. ‘By DHSR- Manta Heaits Lic Cocz ecco Gel ie

This facility is licensed for the following service
categories:

10A NCAC 27G .5100 Community Respite
Services for individuals of all Disability Groups
10A NCAC 27G Supervised Living for Individuals
of all Disability Groups-Alternative Family Living.

27G .0209 (B) Medication Requirements

10A NCAC 27G .0209 MEDICATION
REQUIREMENTS

(b) Medication packaging and labeling:

(1) Non-prescription drug containers not
dispensed by a pharmacist shall retain the
manufacturer's label with expiration dates clearly
visible;

(2) Prescription medications, whether purchased
or obtained as samples, shall be dispensed in
tamper-resistant packaging that will minimize the
risk of accidental ingestion by children. Such
Packaging includes plastic or glass bottles/vials
with tamper-resistant caps, or in the case of
unit-of-use packaged drugs, a zip-lock plastic bag
may be adequate;

(3) The packaging label of each prescription
drug dispensed must include the following:

(A) the client's name;

(B) the prescriber's name;

(C) the current dispensing date;

(D} clear directions for self-administration;

(E) the name, strength, Quantity, and expiration
date of the prescribed drug; and

(F) the name, address, and phone number of the
pharmacy or dispensing location (e.g., mhidd/sa
center), and the name of the dispensing

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

STATE FORM 6909 eDizit eontinuation shoot 1 of 6

Bo Cre
lh Bre

PRINTED: 06/07/2018
FORM APPROVED
Division of Health Service Regulation

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

(2) MULTIPLE CONSTRUCTION
A. BUILDING:

(x3) DATE SURVEY
COMPLETED

8, WING

MHL011-386

08/16/2019

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

ARDEN, NC 28704

LIVINGSTONE’S HOME

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES: PROVIDER'S PLAN OF CORRECTION (x8)

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

DEFICIENCY)

Continued From page 1

practitioner.

This Rule is not met as evidenced by:

Based on record reviews, observation and de b eine) \Ling ve -crted

interviews, the facility staff failed to ensure

prescription medications contained the packaging land
label for each prescription drug with the

information required: client's name, prescriber's aad tne
name,date medication was dispensed by vo vEMC ‘t

pharmacy, administration instructions, name,

strength, quantity, and expiration date of the New etand

prescribed drug; and the name, address, and .

phone number of the pharmacy or dispensing Ge IC AE WCHL

location and dispensing practitioner/pharmacist. Ga 6 ome ence Vee { jSouUL ,

The findings are:
rection

Review on 5/13/19 of Client #2's record revealed: Hao pion oh Co

-admission date of 8/17/16.

-diagnoses of Moderate Intellectual and (p vers osn \osueo

Developmental Disability, Hypothyroidism,

Obstructive Sleep Apnea, Allergic Rhinitis, High Orne N Qwraee) QNDO ider

Cholesterol, Depression Disorder, Speech

ie(%/19

Impediment, Tracheotomy Implant, . 1S NOUd Way) an ‘Nv
Gastro-Esophageal Reflux Disease, Chronic Ren ods Wr
Obstructive Pulmonary Disease, and Parkinson's pir ecmy

Disease. ; ; RIO Kawa

-Physician's orders included: Seah DA
-1/24/19- Polyethylene Glycol 17 gram/dose OY earn

powder - 1 capful with any liquid daily, except

when having diarrhea Pecocdn Apt  orbiaa hows
-3/22/19- Saline Bullets - use 1 vial via Ow Cc \nom ay \

nebulizer as needed. OCC ULE a- movi, O New

Observation on 6/13/19 at approximately 2:30

MAR will Cone Grom Une
Division of Health Service Regulation

STATE FORM ase 9D1Z11 Hcontinuation sheet 2 of 8

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

MHL011-386

PRINTED: 06/07/2019
FORM APPROVED

(X2) MULTIPLE CONSTRUCTION (<4) DATE SURVEY
A. BUILDING:

COMPLETED

05/16/2019

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

212 BALDWIN ROAD
ARDEN, NC 28704

LIVINGSTONE'S HOME

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

Continued From page 2

p.m. of Client #2's medications revealed:
-Polyethylene Glycol 17 gram/dase powder -
“Prescription Laxative" - with no prescription
label.

-AddiPak - 3 ML sterile 0.9% Na Cf Solution for
inhalation USP - unit dose vials - "RX only" - with
no prescription label.

Interview on 5/13/19 with the Alternative Family
Living provider revealed:

-the Polyethylene Glycol was Client #2's and the
label fell off; she could not pravide the label for
the Polyethylene Glycol.

-she ordered the AddiPak (Saline Bullets) off the
Internet due to the pharmacy not having any
available.

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:

Division of Health Service Regulation
STATE FORM

Ons
vie rte nan yee Oo Crs obKiedh

PROVIDER'S PLAN OF CORRECTION . (X5}
(EACH CORRECTIVE ACTION SHOULD 8 COMPLETE

CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

Raa one The. ae Mar,
WA we immed ic

“s nad inte she Opie cat
~ aP walt Cone nug

reader
Oe prea tik

nes Ren

ond ot sony ceman

exk lo worth
a er Akate eral
oh C aes wadicadicn
ren ens,

ON ve “has
Medico on lows wnemk
ou ne, Ye ieter OC

NY Thee AMND WWD
ES jada doe Ane pre vider
allows 14 ima

9D1Z11 If continuation sheet 3 of 6

PRINTED: 08/07/2019
FORM APPROVED

gulation

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(XS) DATE SURVEY
COMPLETED

B. WING

MHL011-386 05/16/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
212 BALDWIN ROAD
ARDEN, NC 28704

(X4y 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)

LIVINGSTONE’S HOME

Continued From page 3

(A) client's name; IF. HW Quetabed “ob an' mabe (9

{B) name, strength, and quantity of the drug; _
(C) instructions for administering the drug; inthuo reajion Werte Te

(D) date and time the drug is administered; and ave wrod an a Aor cle"

(E) name or initials of person administering the

drug. a of Mad codon TEVIEW

(5) Client requests for medication changes or

checks shall be recorded and kept with the MAR wvanes will he

fe owen! uo by appointment or consultation Lanrour fh Dux ne Ceayan
Kip url) UAL & meodicatiaq
TOVWAD Coen bese

This Rule is not met as evidenced by: ON Ying form UAL ws
Based on record review and interview the facility kh, WS apaiatin ones OP;

failed to administer medications on the written
order of a physician affecting two of two clients WwW) hil \ dd
(Clients #1 and #2). The findings are:

Review on 5/13/19 of Client #1 d revealed during nonin, rome
eview on of Hen 's recore revealed: ‘ -
-acimission date of 1/1/16. AWW IDiONS EN te

-diagnoses of Autism Disorder, Impulse Controt bow) red
Disorder, Mild Intellectual and Developmental C0 ¢

Disability, Unspecified BiPolar Disorder, on pari we (ovis
Narcissistic Personality Disorder, Imperforated . : vide

Anus, and Fecal Impaction. wo wn ac Ci doe
~Physician’s orders included: < {\ fac KO a rm.

~4/26/19 - Magnesium Hydroxide 400 mg/5 ml - loft [ 1Q
30 mi two times a day, her

5/3/19 - Magnesium Citrate - 500 mg - daily. He yd QR, Wee’ Karl +
Leoaned OOrene AMOS creping

Review on 5/13/19 of Client #1's Medication

Administration Record (MAR) from March 2019 Movndactro Lor pre

through May 2019 revealed: nd ‘A Lho modi i dons
-Magnesium Hydroxide 400 mg/5 mi - 30 ml two \ 0 O

times a day - discontinued hand-written on May vod, wine PNWOC n

MAR.

-Magnesium Citrate - 500 mg - 1 tablet daily -
Division of Health Service Regulation
STATE FORM 5699 9D1Z11 If continuation sheet 4 of 6

PRINTED: 06/07/2019
FORM APPROVED

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (83) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

A. BUILDING: COMPLETED

MHL011-386 B. WING £____. 05/16/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
, 212 BALDWIN ROAD
LIVINGSTONE’S HOME ARDEN, NG 28704
(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 LSG IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118] Continued From page 4 v118 puro oad Over Une
was initialed as started on 5/3/19 . The. cate
Counor- h har
Interview on 5/13/19 and 5/14/19 with the home pane ou foe Lo vance
Alternative Family Living (AFL) provider revealed: c eacr eke ray
~Magnesium Hydroxide was replaced with the
Magnesium Citrate but she could not locate the Abe Oneal (camovs aud
physician's order. \
-on 5/14/19 she provided a physician note to Ww \ \ co WAR +b in ire
discontinue the Magnesium Hydroxide and start aire UG
Magnesium Citrate 500 mg daily, however there med 3 Haro
was no physician signature. @lnorm Cue win: a
Review on 5/13/19 of Client #2's record revealed: (a lopbe ach € d .

-admission date of 8/17/16.
-diagnoses of Moderate Intellectual and
Developmental Disability, Hypothyroidism,
Obstructive Sleep Apnea, Allergic Rhinitis, High
Cholesterol, Depression Disorder, Speech
impediment, Tracheotomy Implant,
Gastro-Esophageal Reflux Disease, Chronic
Obstructive Pulmonary Disease, and Parkinson's
Disease.
Physician's orders included:

~3/22/19- Saline Bullets - use 1 vial via
nebulizer as needed.

-4/4/18 - Fluticasone Propionate (Flonase) 50
mcg - activation nasal - 1 spray each nare daily.

-5/3/19 - Fluticasone Propionate 50 mcg - 1
spray each nare - changed toe as needed.

-4/4/18 - olopatadine (Pataday) 0.2 %
ophthalmic solution - 1 drop bath eyes daily for 30
days.

-§/3/19 - olopatadine 0.2% ophthalmic
solution - 1 drop both eyes - changed to as
needed.

Review on 5/13/19 of Client #2's MAR from
March 2019 through May 2019 revealed:

- Saline Bullets - use 1 vial via nebulizer as
needed - was not listed for March.

Division of Health Service Regulation

STATE FORM ae epiztt W continuation sheet 5 of 6

PRINTED: 06/07/2019
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X83) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: ° COMPLETED

MHLO14-386 B, WING 05/16/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
212 BALDWIN ROAD
ARDEN, NC 28704

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION 1x5}

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)

LIVINGSTONE'S HOME

Continued From page 5

-Fluticasone Propionate (Flonase) 50 meg -
activation nasal - 1 spray each nare daily - was.
not listed on any of the MARs.

Fluticasone Propionate 50 mcg - 1 spray each
nare - changed to as needed - was not listed on
the May MAR.

-olopatadine (Pataday) 0.2 % ophthalmic solution
- 1 drop both eyes daily for 30 days - was not
initialed as given for the remaining days in May
2019. .

-olopatadine 0.2% ophthalmic solution - 1 drop
both eyes - changed to as needed - was not on
the May MAR.

Interview on 5/13/19 and 5/14/19 with the AFL
provider revealed:

-the Saline Bullets, Fluticasone Propionate and
olopatadine were not listed on the MARs as noted
above.

-on 5/14/19 she provided one page MARs with
the above medications listed for the missing
months.

-she stated she turned in the wrong MARs to the
office and found these at the facility.

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

Division of Health Service Regulation
STATE FORM . e809 epizt1 Ifcontinuation sheet 6 of 6

MEDICATION REVIEW

Facility Name:

Client Name:

1,Med & Strength
Directions

1. Med & Strength
Directions

MAR Transcription

Total Previous Month:

Totai Curent Month:

MHL#:
Client #:

RX DX date

1. Med & Strength Date of Signed Order jor Change

Directions

|

as

ry

[a =
N B