facility_name: Just In Time Youth Services

raw_content:
PRINTED: 09/08/2025
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA. (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
R
MHL001-149 B. WING _____ 09/05/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

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

DEFICIENCY)
V 000} INITIAL COMMENTS V 000

An annual, complaint and follow up survey was
completed on September 5, 2025. The complaint
was unsubstantiated (intake #NC00232848).
Deficiencies were cited.

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

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

V 132) G.S. 131E-256(G) HCPR-Notification, V 132
Allegations, & Protection

G.S. §131E-256 HEALTH CARE PERSONNEL
REGISTRY

(g) Health care facilities shall ensure that the
Department is notified of all allegations against
health care personnel, including injuries of
unknown source, which appear to be related to
any act listed in subdivision (a)(1) of this section.
(which includes:

a. Neglect or abuse of a resident in a healthcare
facility or a person to whom home care services
as defined by G.S. 131E-136 or hospice services
as defined by G.S. 131E-201 are being provided.
b. Misappropriation of the property of a resident
in a health care facility, as defined in subsection
(b) of this section including places where home
care services as defined by G.S. 131E-136 or
hospice services as defined by G.S. 131E-201
are being provided.

c. Misappropriation of the property of a
healthcare facility.

d. Diversion of drugs belonging to a health care
facility or to a patient or client.

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

STATE FORM 6899 KOBR11 If continuation sheet 1 of 11

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL001-149 B. WING

NAME OF PROVIDER OR SUPPLIER
1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/08/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
09/05/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

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

(X4) ID
PREFIX
TAG

ID
PREFIX
TAG

CROSS-REFERENCED TO THE APPROPRIATE

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

(x5)
COMPLETE
DATE

DEFICIENCY)

V 132] Continued From page 1 V 132

e. Fraud against a health care facility or against
a patient or client for whom the employee is
providing services).

Facilities must have evidence that all alleged
acts are investigated and must make every effort
to protect residents from harm while the
investigation is in progress. The results of all
investigations must be reported to the
Department within five working days of the initial
notification to the Department.

This Rule is not met as evidenced by:

Based on record review and interviews, the
facility failed to ensure an allegation of abuse was
investigated and the results of investigation were
reported to Health Care Personnel Registry
(HCPR) within five working days of the initial
notification. The findings are:

Review on 8/19/25 of the North Carolina (NC)
ncident Response Improvement System (IRIS)
revealed:

-There was no Level III incident report submitted
by the facility for an allegation of abuse against
he Program Director (PD). It was alleged the PD
assaulted Former Client (FC) #3.

-The 5-day working report was not submitted by
acility staff.

Review on 8/19/25 of facility records revealed:
-There was no documentation to indicate the
Associate Professional (AP)/Licensee conducted
an investigation for the issue above.

nterview on 8/20/25 with the local Department of
Social Services (DSS) Investigator revealed:

-A law enforcement officer reported the incident to
her related to the PD and FC #3.

-They investigated the incident with the PD and
FC #3.

Division of Health Service Regulation

STATE FORM

6899 KOBR11

If continuation sheet 2 of 11

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA

AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

MHL001-149

NAME OF PROVIDER OR SUPPLIER

JUST IN TIME YOUTH SERVICES

PRINTED: 09/08/2025

FORM APPROVED
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
A. BUILDING: COMPLETED
R
B.WING 09/05/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET
BURLINGTON, NC 27215

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

(X4) ID
PREFIX
TAG

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

ID
PREFIX
TAG

(x5)
COMPLETE
DATE

V 132] Continued From page 2

-The allegation of abuse against the PD and FC
#3 was later unsubstantiated by DSS.

Interview on 8/20/25 with the AP/Licensee
revealed:

-The PD brought the allegation to her attention
because a DSS Investigator showed up to the
facility.

-"It was said by a police officer that [PD] punched
[FC #3] in his face in July 2025."

-"| did an investigation, however | don't always
document the investigations."

-"| did not document anything related to this
incident."

-She confirmed the facility failed to ensure an
allegation of abuse was investigated and the
results of investigation were reported to HCPR
within five working days of the initial notification.

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

V 366} 27G .0603 Incident Response Requirements

10A NCAC 27G .0603 INCIDENT
RESPONSE REQUIREMENTS FOR
CATEGORY AAND B PROVIDERS

(a) Category A and B providers shall develop and
implement written policies governing their
response to level I, Il or Ill incidents. The policies
shall require the provider to respond by:

(1) attending to the health and safety needs
of individuals involved in the incident;

(2) determining the cause of the incident;
(3) developing and implementing corrective
measures according to provider specified
timeframes not to exceed 45 days;

(4) developing and implementing measures
to prevent similar incidents according to provider

Division of Health Service Regulation
STATE FORM

V 132

V 366

6899

KOBR11 If continuation sheet 3 of 11

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

MHL001-149

PRINTED: 09/08/2025

FORM APPROVED
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
A. BUILDING: COMPLETED
R
B.WING 09/05/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET
BURLINGTON, NC 27215

JUST IN TIME YOUTH SERVICES

specified timeframes not to exceed 45 days;

(5) assigning person(s) to be responsible
for implementation of the corrections and
preventive measures;

(6) adhering to confidentiality requirements
set forth in G.S. 75, Article 2A, 10A NCAC 26B,
42 CFR Parts 2 and 3 and 45 CFR Parts 160 and
164; and

(7) maintaining documentation regarding
Subparagraphs (a)(1) through (a)(6) of this Rule.
(b) In addition to the requirements set forth in
Paragraph (a) of this Rule, ICF/MR providers
shall address incidents as required by the federal
regulations in 42 CFR Part 483 Subpart |.

(c) In addition to the requirements set forth in
Paragraph (a) of this Rule, Category A and B
providers, excluding ICF/MR providers, shall
develop and implement written policies governing
their response to a level III incident that occurs
while the provider is delivering a billable service
or while the client is on the provider's premises.
The policies shall require the provider to respond
by:
(1)

immediately securing the client record

by:

(A) obtaining the client record;

(B) making a photocopy;

(C) certifying the copy's completeness; and
(D) transferring the copy to an internal
review team;

(2) convening a meeting of an internal

review team within 24 hours of the incident. The
internal review team shall consist of individuals
who were not involved in the incident and who
were not responsible for the client's direct care or
with direct professional oversight of the client's
services at the time of the incident. The internal
review team shall complete all of the activities as
follows:

Division of Health Service Regulation
STATE FORM

(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 366} Continued From page 3 V 366

6899 KOBR11 If continuation sheet 4 of 11

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL001-149 B. WING

NAME OF PROVIDER OR SUPPLIER
1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/08/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
09/05/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

(A) review the copy of the client record to
determine the facts and causes of the incident
and make recommendations for minimizing the
occurrence of future incidents;

(B) gather other information needed;

(C) issue written preliminary findings of fact
within five working days of the incident. The
preliminary findings of fact shall be sent to the
LME in whose catchment area the provider is
located and to the LME where the client resides,
if different; and

(D) issue a final written report signed by the
owner within three months of the incident. The
final report shall be sent to the LME in whose
catchment area the provider is located and to the
LME where the client resides, if different. The
final written report shall address the issues
identified by the internal review team, shall
include all public documents pertinent to the
incident, and shall make recommendations for
minimizing the occurrence of future incidents. If
all documents needed for the report are not
available within three months of the incident, the
LME may give the provider an extension of up to
three months to submit the final report; and

(3) immediately notifying the following:

(A) the LME responsible for the catchment
area where the services are provided pursuant to
Rule .0604;

(B) the LME where the client resides, if
different;

(C) the provider agency with responsibility

for maintaining and updating the client's
treatment plan, if different from the reporting
provider;

(D) the Department;

(E) the client's legal guardian, as
applicable; and

(F) any other authorities required by law.

Division of Health Service Regulation

STATE FORM 6899

KOBR11

(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 366} Continued From page 4 V 366

If continuation sheet 5 of 11

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL001-149 B. WING

NAME OF PROVIDER OR SUPPLIER

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/08/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
09/05/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

This Rule is not met as evidenced by:

Based on record review and interview, the facility
ailed to implement a policy governing their
response to Level Ill incidents as required. The
indings are:

Reviews on 8/19/25 and 8/21/25 of Former Client
(FC) #3's record revealed:

-Admission date of 5/24/24.

-Diagnoses of Disruptive Mood Dysregulation
Disorder, Adjustment Disorder with Mixed
Disturbance of Emotions and Conduct and
Attention Deficit Hyperactivity Disorder.
-Discharge date of 7/15/25.

-He was 12 years old.

Review on 8/19/25 of the North Carolina (NC)
ncident Response Improvement System (IRIS)
revealed:

-There was no level III incident report submitted
by the facility for an allegation of abuse against
he Program Director (PD). It was alleged the PD
assaulted FC #3.

-There was no documentation to determine: The
cause of the incident; If the facility developed and
implemented corrective measures according to
he provider specified timeframes not to exceed
45 days; no measures to prevent similar incidents
according to provider specified timeframes not to
exceed 45 days and assigning person(s) to be
responsible for implementation of the corrections
and preventive measures.

Division of Health Service Regulation

STATE FORM 6899

KOBR11

(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 366] Continued From page 5 V 366

If continuation sheet 6 of 11

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL001-149 B. WING

NAME OF PROVIDER OR SUPPLIER
1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/08/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
09/05/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

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

(X4) ID
PREFIX
TAG

ID
PREFIX
TAG

CROSS-REFERENCED TO THE APPROPRIATE

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

(x5)
COMPLETE
DATE

DEFICIENCY)

V 366 | Continued From page 6 V 366

Interview on 8/20/25 with the Associate
Professional/Licensee revealed:

-The PD brought the allegation to her attention
because a Department of Social Services
Investigator showed up to the facility.

-"It was said by a police officer that [PD] punched
[FC #3] in his face in July 2025."

-"[The PD] did the incident reports for most of the
incidents."

-She confirmed the facility failed to implement a
policy governing their response to Level III
incidents as required.

V 367| 27G .0604 Incident Reporting Requirements V 367
10A NCAC 27G .0604 INCIDENT
REPORTING REQUIREMENTS FOR
CATEGORY AAND B PROVIDERS

(a) Category A and B providers shall report all
level Il incidents, except deaths, that occur during
the provision of billable services or while the
consumer is on the providers premises or level III
incidents and level II deaths involving the clients
to whom the provider rendered any service within
90 days prior to the incident to the LME
responsible for the catchment area where
services are provided within 72 hours of
becoming aware of the incident. The report shall
be submitted on a form provided by the
Secretary. The report may be submitted via mail,
in person, facsimile or encrypted electronic
means. The report shall include the following
information:

(1) reporting provider contact and
identification information;

(2) client identification information;

(3) type of incident;

(4) description of incident;

(5) status of the effort to determine the

Division of Health Service Regulation

STATE FORM 6899

KOBR11

If continuation sheet 7 of 11

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL001-149 B. WING

NAME OF PROVIDER OR SUPPLIER
1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/08/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
09/05/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

cause of the incident; and

(6) other individuals or authorities notified
or responding.

(b) Category A and B providers shall explain any
missing or incomplete information. The provider
shall submit an updated report to all required
report recipients by the end of the next business
day whenever:

(1) he provider has reason to believe that
information provided in the report may be
erroneous, misleading or otherwise unreliable; or
(2) he provider obtains information
required on the incident form that was previously
unavailable.

(c) Category A and B providers shall submit,
upon request by the LME, other information
obtained regarding the incident, including:

(1) hospital records including confidential
information;
(2) reports by other authorities; and

(3) he provider's response to the incident.
(d) Category A and B providers shall send a copy
of all level III incident reports to the Division of
Mental Health, Developmental Disabilities and
Substance Abuse Services within 72 hours of
becoming aware of the incident. Category A
providers shall send a copy of all level III
incidents involving a client death to the Division of
Health Service Regulation within 72 hours of
becoming aware of the incident. In cases of
client death within seven days of use of seclusion
or restraint, the provider shall report the death
immediately, as required by 10A NCAC 26C
.0300 and 10A NCAC 27E .0104(e)(18).

(e) Category A and B providers shall send a
report quarterly to the LME responsible for the
catchment area where services are provided.
The report shall be submitted on a form provided
by the Secretary via electronic means and shall

Division of Health Service Regulation

STATE FORM 6899

KOBR11

(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 367 | Continued From page 7 V 367

If continuation sheet 8 of 11

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL001-149 B. WING

NAME OF PROVIDER OR SUPPLIER
1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/08/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
09/05/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

include summary information as follows:

(1) medication errors that do not meet the
definition of a level II or level III incident;

(2) restrictive interventions that do not meet
the definition of a level II or level III incident;

(3) searches of a client or his living area;
(4) seizures of client property or property in
the possession of a client;

(5) the total number of level II and level III
incidents that occurred; and

(6) a statement indicating that there have
been no reportable incidents whenever no
incidents have occurred during the quarter that
meet any of the criteria as set forth in Paragraphs
(a) and (d) of this Rule and Subparagraphs (1)
through (4) of this Paragraph.

This Rule is not met as evidenced by:

Based on record review and interview, the facility
failed to ensure an incident was reported to the
Local Management Entity/Managed Care
Organization (LME/MCO) for the catchment area
where services are provided within 72 hours of
becoming aware of the incident. The findings are:

Reviews on 8/19/25 and 8/21/25 of Former Client
(FC) #3's record revealed:

-Admission date of 5/24/24.

-Diagnoses of Disruptive Mood Dysregulation
Disorder, Adjustment Disorder with Mixed
Disturbance of Emotions and Conduct and
Attention Deficit Hyperactivity Disorder.
-Discharge date of 7/15/25.

Division of Health Service Regulation

STATE FORM

6899 KOBR11

(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 367 | Continued From page 8 V 367

If continuation sheet 9 of 11

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL001-149 B. WING

NAME OF PROVIDER OR SUPPLIER

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/08/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
09/05/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

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

(X4) ID
PREFIX
TAG

ID
PREFIX
TAG

CROSS-REFERENCED TO THE APPROPRIATE

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

(x5)
COMPLETE
DATE

DEFICIENCY)

V 367 | Continued From page 9 V 367

-He was 12 years old.

Review on 8/19/25 of the North Carolina (NC)
ncident Response Improvement System (IRIS)
revealed:

-There was no level III incident report submitted
by the facility for an allegation of abuse against
he Program Director (PD). It was alleged the PD
assaulted FC #3.

nterview on 8/20/25 with the Associate
Professional/Licensee revealed:

-The PD brought the allegation to her attention
because a Department of Social Services
nvestigator showed up to the facility.

-"It was said by a police officer that [PD] punched
[FC #3] in his face in July 2025."

-"[The PD] did the incident reports for most of the
incidents."

-She confirmed the facility failed to report the
above incident to LME/MCO within 72 hours.

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

V 736| 27G .0303(c) Facility and Grounds Maintenance | V 736
10A NCAC 27G .0303 LOCATION AND

EXTERIOR REQUIREMENTS

(c) Each facility and its grounds shall be

maintained in a safe, clean, attractive and orderly
manner and shall be kept free from offensive

odor.

This Rule is not met as evidenced by:

Based on observation and interview, the facility
was not maintained in a clean, attractive and
orderly manner. The findings are:

Division of Health Service Regulation

STATE FORM 6899

KOBR11

If continuation sheet 10 of 11

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL001-149 B. WING

NAME OF PROVIDER OR SUPPLIER
1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/08/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
09/05/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Observation on 8/21/25 at approximately 11:35
am revealed:

-Client #2's bedroom-Paint peeling on walls.
Black stains on wall near bed. Wooden floor had
approximately 50 black scrapes.

-Empty bedroom-Approximately 25 black and
grays scrapes on wooden floor.

-Bathroom in hallway-Blind slats were crumbled
and 3 slates were missing. Porcelain toilet paper
holder was cracked. Peeling paint on walls.
Linoleum flooring had pink paint and grayish
stains.

-Client #1's bedroom-One of the glass panes was
missing from the window. The bigger window's
inside glass pane was missing. The curtain rods
were bent, and the curtains were sagging.

Interview on 8/21/25 with the Program Director
revealed:

- He was not sure what happened to the windows
in client #1's bedroom.

-He was aware of most of the maintenance
issues with the facility.

-He acknowledged all of the above issues with
the facility.

Division of Health Service Regulation

STATE FORM 6899

KOBR11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 736 | Continued From page 10 V 736

If continuation sheet 11 of 11


state: NC

summary: Statement of Deficiency - MHLCS Complaint

raw_content:
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHLO001-149

A. BUILDING:

1710 SYKES STREET
BURLINGTON, NC 27215

JUST IN TIME YOUTH SERVICES

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 04/15/2025

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

Cc
04/09/2025

(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

V 000!

V 132|

INITIAL COMMENTS

Acomplaint survey was completed on April 9,
2025. The complaint was unsubstantiated (intake
#NC00228911). Deficiencies were cited.

This facility is licensed for the following service
category: 10A NCAC 27G .1900 Psychiatric
Residential Treatment for Children and
Adolescents.

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

G.S. 131E-256(G) HCPR-Notification,
Allegations, & Protection

G.S. §131E-256 HEALTH CARE PERSONNEL
REGISTRY

(g) Health care facilities shall ensure that the
Department is notified of all allegations against
health care personnel, including injuries of
unknown source, which appear to be related to
any act listed in subdivision (a)(1) of this section.
(which includes:

a. Neglect or abuse of a resident in a healthcare
facility or a person to whom home care services
as defined by G.S. 131E-136 or hospice services
as defined by G.S. 131E-201 are being provided.
b. Misappropriation of the property of a resident
in a health care facility, as defined in subsection
(b) of this section including places where home
care services as defined by G.S. 131E-136 or
hospice services as defined by G.S. 131E-201
are being provided.

c. Misappropriation of the property of a
healthcare facility.

d. Diversion of drugs belonging to a health care
facility or to a patient or client.

e. Fraud against a health care facility or against

Division of Health Service Regulation

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

STATE FORM

V 000

V 132

6899

28V711

TITLE

(X6) DATE

If continuation sheet 1 of 6

Division of Health Service Regulation

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

MHLO001-149

NAME OF PROVIDER OR SUPPLIER

A. BUILDING:

1710 SYKES STREET
BURLINGTON, NC 27215

JUST IN TIME YOUTH SERVICES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 04/15/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

Cc
04/09/2025

(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 132] Continued From page 1 V 132

a patient or client for whom the employee is
providing services).

Facilities must have evidence that all alleged
acts are investigated and must make every effort
to protect residents from harm while the
investigation is in progress. The results of all
investigations must be reported to the
Department within five working days of the initial
notification to the Department.

This Rule is not met as evidenced by:

Based on record review and interviews, the
facility failed to ensure an allegation of abuse was
reported to Health Care Personnel Registry
(HCPR) within five working days. The findings
are:

Review on 4/3/25 of the North Carolina (NC)
Incident Response Improvement System (IRIS)
revealed:

-There was no level III incident report submitted
by the facility for an allegation of abuse against
the facility staff related to the 4/1/25 incident with
client #1.

Interview on 4/9/25 with the Qualified
Professional (QP) revealed:

-"The [Program Director] and the [Owner]
completes all documentation of any incidents in
the facility."

-"I'm not sure if the [Program Director] or the
[Owner] reported the incident to HCPR."

Review on 4/2/25 and Review 4/9/25 with the
Program Director revealed:

-"| did not report the incident to HCPR, and | did
not complete the IRIS report."

-"It was so much going on that | forgot to do the
report."

Division of Health Service Regulation
STATE FORM

6809

28V711

If continuation sheet 2 of 6

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHLO001-149

A. BUILDING:

1710 SYKES STREET
BURLINGTON, NC 27215

JUST IN TIME YOUTH SERVICES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 04/15/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

Cc
04/09/2025

(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

V 132

V 367|

Continued From page 2

Review on 4/9/25 with the Owner revealed:

-"| did not know if HCPR was notified or if the
IRIS report was completed because the [Program
Director] handles that."

-"| did not know about the allegation until later and
didn't realize we had to report it."

-"It was a lot going on and the [Program Director]
forgot to complete the report."

27G .0604 Incident Reporting Requirements

10A NCAC 27G .0604 INCIDENT
REPORTING REQUIREMENTS FOR
CATEGORY AAND B PROVIDERS

(a) Category A and B providers shall report all
level Il incidents, except deaths, that occur during
the provision of billable services or while the
consumer is on the providers premises or level III
incidents and level II deaths involving the clients
to whom the provider rendered any service within
90 days prior to the incident to the LME
responsible for the catchment area where
services are provided within 72 hours of
becoming aware of the incident. The report shall
be submitted on a form provided by the
Secretary. The report may be submitted via mail,
in person, facsimile or encrypted electronic
means. The report shall include the following
information:

(1) reporting provider contact and
identification information;

(2) client identification information;

(3) type of incident;

(4) description of incident;

(5) status of the effort to determine the
cause of the incident; and

(6) other individuals or authorities notified

or responding.
(b) Category A and B providers shall explain any

Division of Health Service Regulation
STATE FORM

V 132

V 367

6809

28V711

If continuation sheet 3 of 6

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHLO001-149

A. BUILDING:

1710 SYKES STREET
BURLINGTON, NC 27215

JUST IN TIME YOUTH SERVICES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 04/15/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

Cc
04/09/2025

missing or incomplete information. The provider
shall submit an updated report to all required
report recipients by the end of the next business
day whenever:

(1) the provider has reason to believe that
information provided in the report may be
erroneous, misleading or otherwise unreliable; or
(2) the provider obtains information
required on the incident form that was previously
unavailable.

(c) Category A and B providers shall submit,
upon request by the LME, other information
obtained regarding the incident, including:

(1) hospital records including confidential
information;

(2) reports by other authorities; and

(3) the provider's response to the incident.

(d) Category A and B providers shall send a copy
of all level III incident reports to the Division of
Mental Health, Developmental Disabilities and
Substance Abuse Services within 72 hours of
becoming aware of the incident. Category A
providers shall send a copy of all level III
incidents involving a client death to the Division of
Health Service Regulation within 72 hours of
becoming aware of the incident. In cases of
client death within seven days of use of seclusion
or restraint, the provider shall report the death
immediately, as required by 10A NCAC 26C.
.0300 and 10A NCAC 27E .0104(e)(18).

(e) Category A and B providers shall send a
report quarterly to the LME responsible for the
catchment area where services are provided.

The report shall be submitted on a form provided
by the Secretary via electronic means and shall
include summary information as follows:

(1) medication errors that do not meet the
definition of a level II or level Ill incident;
(2) restrictive interventions that do not meet

Division of Health Service Regulation
STATE FORM

6809

28V711

(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 367 | Continued From page 3 V 367

If continuation sheet 4 of 6

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHLO001-149

A. BUILDING:

1710 SYKES STREET
BURLINGTON, NC 27215

JUST IN TIME YOUTH SERVICES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 04/15/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

Cc
04/09/2025

the definition of a level II or level III incident;

(3) searches of a client or his living area;
(4) seizures of client property or property in
the possession of a client;

(5) the total number of level II and level III
incidents that occurred; and

(6) a statement indicating that there have

been no reportable incidents whenever no
incidents have occurred during the quarter that
meet any of the criteria as set forth in Paragraphs
(a) and (d) of this Rule and Subparagraphs (1)
through (4) of this Paragraph.

This Rule is not met as evidenced by:

Based on record reviews and interviews, the
facility failed to ensure incidents were reported to
the Local Management Entity/Managed Care
Organization (LME/MCO) for the catchment area
where services are provided within 72 hours of
becoming aware of the incident. The findings are:

Review on 4/3/25 of client #1's record revealed:
-Admission date of 6/23/23.

-Disruptive Mood Dysregulation Disorder, Other
Specified Attention-Deficit Hyperactivity Disorder,
Other Specified Problems Related to Primary
Support Group and Child in

Welfare Custody.

-He was 13 years old.

Review on 4/3/25 of the North Carolina (NC)
Incident Response Improvement System (IRIS)
revealed:

Division of Health Service Regulation
STATE FORM

6809

28V711

(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 367 | Continued From page 4 V 367

If continuation sheet 5 of 6

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHLO001-149

A. BUILDING:

1710 SYKES STREET
BURLINGTON, NC 27215

JUST IN TIME YOUTH SERVICES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 04/15/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

Cc
04/09/2025

-There was no level III incident report submitted
by the facility for an allegation of abuse against
the facility staff related to the 4/1/25 incident with
client #1.

Interview on 4/9/25 with the Qualified
Professional (QP) revealed:

-"The [Program Director] and the [Owner]
completes all documentation of any incidents in
the facility."

-"I'm not sure if the [Program Director] or the
[Owner] completed the IRIS report.

Review on 4/2/25 and Review 4/9/25 with the
Program Director revealed:

-"| did not report the incident to HCPR, and | did
not complete the IRIS report."

-"| did not complete the IRIS report because no
staff was listed, and | didn't know how to fill it out."
-"It was so much going on that | forgot to do the
report."

Review on 4/9/25 with the Owner revealed:

-"| did not know if HCPR was notified or if the
IRIS report was completed because the [Program
Director] handles that."

-"| did not know about the allegation until later and
didn't realize we had to report it."

-"It was a lot going on and the [Program Director]
forgot to complete the report."

Division of Health Service Regulation
STATE FORM

6809

28V711

(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 367 | Continued From page 5 V 367

If continuation sheet 6 of 6

inspection_type: MHLCS Complaint

document_type: Statement of Deficiency


raw_content:
PRINTED: 03/17/2025

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL001-149 B. WING 03/14/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

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

DEFICIENCY)
V 000} INITIAL COMMENTS V 000

Acomplaint survey was completed on March 14,
2025. The complaint was unsubstantiated (intake
#NC00228175). No deficiencies were cited.

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

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

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

STATE FORM 6899 NHH311 If continuation sheet 1 of 1


summary: Statement of Deficiency - MHLCS Annual and Complaint

raw_content:
Division of Health Service Regulation

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

MHLO001-149

NAME OF PROVIDER OR SUPPLIER

A. BUILDING:

1710 SYKES STREET
BURLINGTON, NC 27215

JUST IN TIME YOUTH SERVICES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/26/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

09/20/2024

(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 000} INITIAL COMMENTS

An annual and complaint survey was completed
on September 20, 2024. The complaint (intake
#NC00221914) was unsubstantiated. A
deficiency was cited.

This facility is licensed for the following service
category: 10A NCAC 27G. 1700

Residential Treatment Staff Secure for Children
or Adolescents

The facility is licensed for 4 and currently has a
census of 4.

The survey sample consisted of audits of 3
current clients.

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

10A NCAC 27G .0303 LOCATION AND
EXTERIOR REQUIREMENTS

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

This Rule is not met as evidenced by:

Based on observation and interview, the facility
was not maintained in a safe, clean, and
attractive manner. The findings are:

Observation on 9/19/24 at 11:15 a.m. of the
facility revealed:

-The bathroom near the front door sink was
clogged.

-The full-size bathroom wall vent was rusted, bent
and detached from the wall.

-The full-size bathroom toilet paper holder was
broken and unable to use.

-There were brown stains on the kitchen tile floor
in front of the deep freezer.

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

STATE FORM

V 000

V 736

6899

X4ZL11

TITLE

(X6) DATE

If continuation sheet 1 of 2

Division of Health Service Regulation

PRINTED: 09/26/2024
FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHLO001-149 09/20/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1710 SYKES STREET
JUST IN TIME YOUTH SERVICES
BURLINGTON, NC 27215
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 736 | Continued From page 1 V 736

-The handle to the stove was broken.

Interview on 9/20/24 with the Program Director
revealed:

-They were currently painting and fixing items in
the facility.

-They would be purchasing a new stove and
replacing other items in the facility.

Division of Health Service Regulation
STATE FORM

6809

X4ZL11

If continuation sheet 2 of 2

inspection_type: MHLCS Annual and Complaint


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

raw_content:
Division of Health Service Regulation

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

PRINTED: 06/24/2024

(X2) MULTIPLE CONSTRUCTION (x3)
A. BUILDING:

MHLO001-149

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

1710 SYKES STREET
BURLINGTON, NC 27215

JUST IN TIME YOUTH SERVICES

FORM APPROVED

) DATE SURVEY
COMPLETED

R-C
06/19/2024

(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

Acomplaint and follow-up survey was completed
on June 19, 2024. The complaint (intake
#NC00218065 and #NC00217947) were
unsubstantiated. No deficiencies were cited.

This facility is licensed for the following service
category: 10A NCAC 27G. 1700

Residential Treatment Staff Secure for Children
or Adolescents

The facility is licensed for 4 and currently has a
census of 4.

The survey sample consisted of audits of 3
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

inspection_type: MHLCS Complaint and Follow-up


raw_content:
Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

IDENTIFICATION NUMBER:

MHLO001-149

A. BUILDING:

1710 SYKES STREET
BURLINGTON, NC 27215

JUST IN TIME YOUTH SERVICES

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 05/29/2024

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

R-C
05/17/2024

(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

V 000!

V 366|

INITIAL COMMENTS

Acomplaint and follow-up survey was completed
on May 17, 2024. The complaint (intake
#NC00216574, #NC00216390 and
#NC00216982) were unsubstantiated.
Deficiencies were cited.

This facility is licensed for the following service
category: 10A NCAC 27G. 1700

Residential Treatment Staff Secure for Children
or Adolescents

The facility is licensed for 4 and currently has a
census of 4.

The survey sample consisted of audits of 3
current clients.

27G .0603 Incident Response Requirements

10A NCAC 27G .0603 INCIDENT
RESPONSE REQUIREMENTS FOR

CATEGORY AAND B PROVIDERS

(a) Category A and B providers shall develop and
implement written policies governing their
response to level |, Il or Ill incidents. The policies
shall require the provider to respond by:

(1) attending to the health and safety needs
of individuals involved in the incident;

(2) determining the cause of the incident;
(3) developing and implementing corrective

measures according to provider specified
timeframes not to exceed 45 days;

(4) developing and implementing measures
to prevent similar incidents according to provider
specified timeframes not to exceed 45 days;

(5) assigning person(s) to be responsible
for implementation of the corrections and
preventive measures;

(6) adhering to confidentiality requirements
set forth in G.S. 75, Article 2A, 10A NCAC 26B,

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

STATE FORM

V 000

V 366

6899

BWC511

TITLE

(X6) DATE

If continuation sheet 1 of 8

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHLO001-149

A. BUILDING:

1710 SYKES STREET
BURLINGTON, NC 27215

JUST IN TIME YOUTH SERVICES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/29/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R-C
05/17/2024

42 CFR Parts 2 and 3 and 45 CFR Parts 160 and
164; and

(7) maintaining documentation regarding
Subparagraphs (a)(1) through (a)(6) of this Rule.
(b) In addition to the requirements set forth in
Paragraph (a) of this Rule, ICF/MR providers
shall address incidents as required by the federal
regulations in 42 CFR Part 483 Subpart I.

(c) In addition to the requirements set forth in
Paragraph (a) of this Rule, Category A and B
providers, excluding ICF/MR providers, shall
develop and implement written policies governing
their response to a level Ill incident that occurs
while the provider is delivering a billable service
or while the client is on the provider's premises.
The policies shall require the provider to respond

by:

(1) immediately securing the client record
by:

(A) obtaining the client record;

(B) making a photocopy;

(C) certifying the copy's completeness; and
(D) transferring the copy to an internal
review team;

(2) convening a meeting of an internal

review team within 24 hours of the incident. The
internal review team shall consist of individuals
who were not involved in the incident and who
were not responsible for the client's direct care or
with direct professional oversight of the client's
services at the time of the incident. The internal
review team shall complete all of the activities as
follows:

(A) review the copy of the client record to
determine the facts and causes of the incident
and make recommendations for minimizing the
occurrence of future incidents;

(B) gather other information needed;

(C) issue written preliminary findings of fact

Division of Health Service Regulation
STATE FORM

6809

BWC511

(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 366 | Continued From page 1 V 366

If continuation sheet 2 of 8

Division of Health Service Regulation

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

MHLO001-149

NAME OF PROVIDER OR SUPPLIER

A. BUILDING:

1710 SYKES STREET
BURLINGTON, NC 27215

JUST IN TIME YOUTH SERVICES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/29/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

R-C
05/17/2024

(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 366 | Continued From page 2 V 366

within five working days of the incident. The
preliminary findings of fact shall be sent to the
LME in whose catchment area the provider is
located and to the LME where the client resides,
if different; and

(D) issue a final written report signed by the
owner within three months of the incident. The
final report shall be sent to the LME in whose
catchment area the provider is located and to the
LME where the client resides, if different. The
final written report shall address the issues
identified by the internal review team, shall
include all public documents pertinent to the
incident, and shall make recommendations for
minimizing the occurrence of future incidents. If
all documents needed for the report are not
available within three months of the incident, the
LME may give the provider an extension of up to
three months to submit the final report; and

(3) immediately notifying the following:

(A) the LME responsible for the catchment
area where the services are provided pursuant to
Rule .0604;

(B) the LME where the client resides, if
different;

(C) the provider agency with responsibility

for maintaining and updating the client's
treatment plan, if different from the reporting
provider;

(D) the Department;

(E) the client's legal guardian, as
applicable; and

(F) any other authorities required by law.

Division of Health Service Regulation
STATE FORM

6809

BWC511

If continuation sheet 3 of 8

Division of Health Service Regulation

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

MHLO001-149

NAME OF PROVIDER OR SUPPLIER

A. BUILDING:

1710 SYKES STREET
BURLINGTON, NC 27215

JUST IN TIME YOUTH SERVICES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/29/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R-C
05/17/2024

(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 366 | Continued From page 3 V 366

This Rule is not met as evidenced by:

Based on record reviews and interviews, the
facility failed to implement a policy governing their
response to Level Ill incidents as required. The
findings are:

Review on 5/6/24 of Client #2's record revealed:
-He was 17 years old.

-Admission date of 9/30/23.

-Diagnoses of Oppositional Defiant Disorder,
Unspecified Mood Disorder, Mild Intellectual
Developmental Disability, Post Traumatic Stress
Disorder, Intermittent Explosive Disorder,
Conduct Disorder and Other Specified Trauma
and Stressor Related Disorder.

Review on 5/6/24 of the facility's level | incident
report revealed:

-Client #2 eloped from the facility the evening of
5/1/24.

-Client #2 left the facility without permisson with
no shoes, socks and shirt.

-Police was called, located client #2 and
transported back to the facility.

-Client #2 refused to return to enter the facility
and the police escorted him to the hospital.

Review on 5/6/24 of the North Carolina Incident
Response Improvement System (IRIS) revealed:
-There was no incident documented in the system
as of 9:00 a.m.

Interview on 5/6/24 with the Program Director
revealed:

-Client #2 eloped from the facility on 5/1/24.
-The police was called and returned client #2
about 12:00 a.m. on 5/2/24.

-The police took client #2 to the hospital due to
client refusing to enter the facility.

Division of Health Service Regulation
STATE FORM

6809

BWC511

If continuation sheet 4 of 8

Division of Health Service Regulation

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

MHLO001-149

NAME OF PROVIDER OR SUPPLIER

A. BUILDING:

1710 SYKES STREET
BURLINGTON, NC 27215

JUST IN TIME YOUTH SERVICES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/29/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R-C
05/17/2024

(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 366] Continued From page 4

-The IRIS report was not completed.

-He was responsible for completing the IRIS
report.

-He would designate staff to train to complete the
IRIS report in case he was out.

-He reported the CEO generally would complete
the IRIS report as a backup.

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

V 367] 27G .0604 Incident Reporting Requirements

10A NCAC 27G .0604 INCIDENT
REPORTING REQUIREMENTS FOR
CATEGORY AAND B PROVIDERS

(a) Category A and B providers shall report all
level Il incidents, except deaths, that occur during
the provision of billable services or while the
consumer is on the providers premises or level III
incidents and level II deaths involving the clients
to whom the provider rendered any service within
90 days prior to the incident to the LME
responsible for the catchment area where
services are provided within 72 hours of
becoming aware of the incident. The report shall
be submitted on a form provided by the
Secretary. The report may be submitted via mail,
in person, facsimile or encrypted electronic
means. The report shall include the following

information:

(1) reporting provider contact and
identification information;

(2) client identification information;

(3) type of incident;

(4) description of incident;

(5) status of the effort to determine the
cause of the incident; and

(6) other individuals or authorities notified

Division of Health Service Regulation
STATE FORM

V 366

V 367

6809

BWC511

If continuation sheet 5 of 8

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHLO001-149

A. BUILDING:

1710 SYKES STREET
BURLINGTON, NC 27215

JUST IN TIME YOUTH SERVICES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/29/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R-C
05/17/2024

or responding.

(b) Category A and B providers shall explain any
missing or incomplete information. The provider
shall submit an updated report to all required
report recipients by the end of the next business
day whenever:

(1) the provider has reason to believe that
information provided in the report may be
erroneous, misleading or otherwise unreliable; or
(2) the provider obtains information
required on the incident form that was previously
unavailable.

(c) Category A and B providers shall submit,
upon request by the LME, other information
obtained regarding the incident, including:

(1) hospital records including confidential
information;

(2) reports by other authorities; and

(3) the provider's response to the incident.

(d) Category A and B providers shall send a copy
of all level III incident reports to the Division of
Mental Health, Developmental Disabilities and
Substance Abuse Services within 72 hours of
becoming aware of the incident. Category A
providers shall send a copy of all level III
incidents involving a client death to the Division of
Health Service Regulation within 72 hours of
becoming aware of the incident. In cases of
client death within seven days of use of seclusion
or restraint, the provider shall report the death
immediately, as required by 10A NCAC 26C.
.0300 and 10A NCAC 27E .0104(e)(18).

(e) Category A and B providers shall send a
report quarterly to the LME responsible for the
catchment area where services are provided.
The report shall be submitted on a form provided
by the Secretary via electronic means and shall
include summary information as follows:

(1) medication errors that do not meet the

Division of Health Service Regulation
STATE FORM

6809

BWC511

(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 367 | Continued From page 5 V 367

If continuation sheet 6 of 8

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHLO001-149

A. BUILDING:

1710 SYKES STREET
BURLINGTON, NC 27215

JUST IN TIME YOUTH SERVICES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/29/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

R-C
05/17/2024

definition of a level II or level Ill incident;

(2) restrictive interventions that do not meet
the definition of a level II or level III incident;

(3) searches of a client or his living area;
(4) seizures of client property or property in
the possession of a client;

(5) the total number of level II and level III
incidents that occurred; and

(6) a statement indicating that there have

been no reportable incidents whenever no
incidents have occurred during the quarter that
meet any of the criteria as set forth in Paragraphs
(a) and (d) of this Rule and Subparagraphs (1)
through (4) of this Paragraph.

This Rule is not met as evidenced by:

Based on record review and interviews, the
facility failed to ensure an incident report was
submitted to the Local Management Entity
(LME)/Managed Care Organization (MCO) within
72 hours as required. The findings are:

Review on 5/6/24 of the North Carolina Incident
Response Improvement System (IRIS) reports
revealed:

- Client #2 eloped out of the facility through the
front door on 5/1/24 and local law enforcement
was notfied.

- No documentation the IRIS report was
submitted as required until 5/6/24 at 5:05 p.m.

Interview on 5/17/24 with the Program Director
revealed:

Division of Health Service Regulation
STATE FORM

6809

BWC511

(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 367] Continued From page 6 V 367

If continuation sheet 7 of 8

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

JUST IN TIME YOUTH SERVICES

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

MHLO001-149

1710 SYKES STREET

BURLINGTON, NC 27215

PRINTED: 05/29/2024

(X2) MULTIPLE CONSTRUCTION (x3)
A. BUILDING:

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

DATE SURVEY
COMPLETED

R-C
05/17/2024

PROVIDER'S PLAN OF CORRECTION

-He was responsible for completing the IRIS
report.

-He would designate staff to train to complete the
IRIS report in case he was out.

-He reported the CEO generally would complete
the reports as a backup.

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

Division of Health Service Regulation
STATE FORM

6809

BWC511

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID (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 367] Continued From page 7 V 367

If continuation sheet 8 of 8