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

raw_content:
Division of Health Service Regulation

PRINTED: 06/04/2025

FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL002-028 06/03/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(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 June 3, 2025. Deficiencies were cited.
This facility is licensed for the following service
category: 10A NCAC 27G .1300 Residential
Treatment for Children or Adolescents.
This facility is licensed for 6 and has a current
census of 5. The survey sample consisted of
audits of 3 current clients.
V 114| 27G .0207 Emergency Plans and Supplies Vv 114

10A NCAC 27G .0207 EMERGENCY PLANS
AND SUPPLIES

(a) Each facility shall develop a written fire plan
and a disaster plan and shall make a copy of
these plans available

to the county emergency services agencies upon
request. The plans shall include evacuation
procedures and routes.

(b) The plans 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 the facility's response to fire
emergencies.

(d) Each facility shall have a first aid kit
accessible for use.

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

STATE FORM

6808 Né6W11

TITLE

(X6) DATE

If continuation sheet 1 of 9

Division of Health Service Regulation

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

MHLO002-028

NAME OF PROVIDER OR SUPPLIER

A. BUILDING:

243 LILEDOUN ROAD
TAYLORSVILLE, NC 28681

LUCA'S HOPE III

(X2) MULTIPLE CONSTRUCTION

PRINTED: 06/04/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R
06/03/2025

(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 114] Continued From page 1

This Rule is not met as evidenced by:
Based on record reviews and interviews, the
facility failed to ensure disaster drills were
completed at least quarterly and repeated for
each shift. The findings are:

Review on 6/2/25 of the facility's disaster drills
revealed:

disaster drills completed.

-Fourth quarter 2024 (October, November,
December); no disaster drills completed.

-First quarter 2025 (January, February, March);
no third shift disaster drill completed.

Interviews on 6/2/25 with Clients #1-3 revealed:
-Had participated in disaster drills.
-Knew what to do if something happened.

Interviews on 6/2/25 and 6/3/25 with the Director
revealed:

-"Won't be an issue...(missing drills)"
"Understand it (drill requirements) more now."
-Staff #1 will be assisting with ensuring drills are
completed.

-Was also hiring another staff to help with
oversight.

-"If | have a schedule, they will follow that but if |
don't monitor..."

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

10A NCAC 27G .0209 MEDICATION
REQUIREMENTS

(c) Medication administration:

(1) Prescription or non-prescription drugs shall
only be administered to a client on the written
order of a person authorized by law to prescribe
drugs.

Division of Health Service Regulation
STATE FORM

-Third quarter 2024 (July, August, September); no

Vv 114

V 118

6809

N66W11

If continuation sheet 2 of 9

Division of Health Service Regulation

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

MHLO002-028

NAME OF PROVIDER OR SUPPLIER

A. BUILDING:

243 LILEDOUN ROAD

(X2) MULTIPLE CONSTRUCTION

PRINTED: 06/04/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R
06/03/2025

LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118] Continued From page 2 Vv 118

(2) Medications shall be self-administered by
clients only when authorized in writing by the
client's physician.

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

(A) client's name;

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

C) instructions for administering the drug;

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

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

(
(
(
(

This Rule is not met as evidenced by:

Based on record reviews and interviews, the
facility failed to ensure MARs were kept current
for 2 of 3 audited clients. (Clients #2 and #3). The
findings are:

Review on 6/2/25 of Client #2's record revealed:
-Age: 16

-Admission date: 4/4/25

-Diagnosis: Attention Deficit Hyperactivity

Division of Health Service Regulation
STATE FORM

6809

N66W11

If continuation sheet 3 of 9

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHLO002-028

A. BUILDING:

243 LILEDOUN ROAD

(X2) MULTIPLE CONSTRUCTION

PRINTED: 06/04/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R
06/03/2025

Disorder, Mild Intellectual Developmental
Disability, and Disruptive Mood Dysregulation
Disorder.

-Physician Orders: 5/6/25 - Nicotine 21Milligrams
(mg)/24 hour (hr) Transdermal Patch. Apply 1
patch every 24 hours.

Review on 6/2/25 of Client #2's MARs dated
5/1/25 through 5/31/25 revealed:

-Nicotine 21mg Patch to be applied every 24
hours, not documented as administered for 29
out of 31 doses.

Review on 6/2/25 of Client #3's record revealed:
-Age: 13

-Admission date: 7/10/23

Diagnosis: Reactive Attachment Disorder
-Physician Orders: 3/11/25 - Guanfacine
Extended Release (ER) 2mg, Twice Daily.

Review on 6/2/25 of Client #3's MARs dated
5/1/25 through 5/31/25 revealed:

-Guanfacine ER 2mg, One tab, two times daily,
not documented as administered for 2 out of 31
doses.

Interviews on 6/2/25 and 6/3/25 with the Director
revealed:

-"That's a hole." (Nicotine patch)

-"| don't make the schedule; | have been out.
Everybody was doing the meds..."

-"Once again. Doesn't matter what is happening
with me. | need to have someone (to provide
oversight of medications)."

-Staff #1 was going to be making a transition from
residential counselor to having more oversight of
medications and checking medications and
MARs weekly.

This deficiency constitutes a re-cited deficiency

Division of Health Service Regulation

STATE FORM

6809

N66W11

LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(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 3 Vv 118

If continuation sheet 4 of 9

Division of Health Service Regulation

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

MHLO002-028

NAME OF PROVIDER OR SUPPLIER

A. BUILDING:

243 LILEDOUN ROAD

(X2) MULTIPLE CONSTRUCTION

PRINTED: 06/04/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R
06/03/2025

LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(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 4 Vv 118
and must be corrected within 30 days.
V 536] 27E .0107 Client Rights - Training on Alt to Rest. V 536

Int.

10A NCAC 27E .0107 TRAINING ON
ALTERNATIVES TO RESTRICTIVE
INTERVENTIONS

(a) Facilities shall implement policies and
practices that emphasize the use of alternatives
to restrictive interventions.

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

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

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

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

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

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

Division of Health Service Regulation
STATE FORM

6809

N66W11

If continuation sheet 5 of 9

Division of Health Service Regulation

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

MHLO002-028

NAME OF PROVIDER OR SUPPLIER

A. BUILDING:

243 LILEDOUN ROAD

(X2) MULTIPLE CONSTRUCTION

PRINTED: 06/04/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R
06/03/2025

LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 536 | Continued From page 5 V 536

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

(2) recognizing and interpreting human
behavior;

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

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

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

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

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

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

(9) positive behavioral supports (providing

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

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

(1) Documentation shall include:

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

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

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

review/request this documentation at any time.

(i) Instructor Qualifications and Training
Requirements:

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

Division of Health Service Regulation
STATE FORM

6809

N66W11

If continuation sheet 6 of 9

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION

IDENTIFICATION NUMBER: A. BUILDING

MHLO002-028

PRINTED: 06/04/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

243 LILEDOUN ROAD

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R
06/03/2025

annually.

Division of Health Service Regulation
STATE FORM

need for restrictive interventions.

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

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

(4) The content of the instructor training the
service provider plans to employ shall be
approved by the Division of MH/DD/SAS pursuant
to Subparagraph (i)(5) of this Rule.

(5) Acceptable instructor training programs
shall include but are not limited to presentation of:
(A) understanding the adult learner;

(B) methods for teaching content of the
course;

(C) methods for evaluating trainee
performance; and

(D) documentation procedures.

(6) Trainers shall have coached experience

teaching a training program aimed at preventing,
reducing and eliminating the need for restrictive
interventions at least one time, with positive
review by the coach.

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

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

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

(1) Documentation shall include:

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

809 N66W11

LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 536] Continued From page 6 V 536

If continuation sheet 7 of 9

Division of Health Service Regulation

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

MHLO002-028

A. BUILDING:

PRINTED: 06/04/2025

(X2) MULTIPLE CONSTRUCTION (x3)

NAME OF PROVIDER OR SUPPLIER

243 LILEDOUN ROAD

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

) DATE SURVEY
COMPLETED

R
06/03/2025

LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 536 | Continued From page 7 V 536

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

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

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

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

(3) Coaches shall demonstrate
competence by completion of coaching or
train-the-trainer instruction.

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

This Rule is not met as evidenced by:

Based on record reviews and interviews, the
facility failed to ensure staff received annual
training in alternatives to restrictive interventions
affecting 2 of 3 staff (Staff #1 and the Director).
The findings are:

Review on 6/2/25 of Staff #1's personnel record
revealed:

-Date of Hire: 12/14/23

-Job Title: Residential Counselor

-Date of Evidence Based Protective Interventions
(EBPI) - Prevent training: 12/12/23

Review on 6/2/25 of the Director's personnel
record revealed:
-Date of Hire: 6/2/09

Division of Health Service Regulation
STATE FORM

6809

Né6W11

If continuation sheet 8 of 9

PRINTED: 06/04/2025

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
MHLO002-028 06/03/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
\ 243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 536 | Continued From page 8 V 536

-Job Title: Director
-Date of EBPI - Prevent training: 1/9/24

Interviews on 6/2/25 and 6/3/25 with the Director
revealed:

-Was aware that some of the EBPI trainings were
out of date.

-She had been out of work recently and had
attempted to get a training scheduled.

-"...Going to get on that immediately (scheduling
a training). | know how important that is."
-Reviewed the EBPI list of trainers and attempted
to make phone calls to several trainers on 6/2/25.

Division of Health Service Regulation
STATE FORM

6809

Né6W11

If continuation sheet 9 of 9

inspection_type: MHLCS Annual and Follow-up

document_type: Statement of Deficency


state: NC

facility_name: Luca's Hope III

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

raw_content:
Division of Health Service Regulation

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

MHL002-028

(X2) MULTIPLE CONSTRUCTION
A, BUILDING:

PRINTED: 01/31/2024
FORM APPROVED

(X3) DATE SURVEY.
COMPLETED

B. WING

01/29/2024

NAME OF PROVIDER OR SUPPLIER

LUCA'S HOPE Ill

SUMMARY STATEMENT OF DEFICIENCIES

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

STREET ADDRESS, CITY, STATE, ZIP CODE

243 LILEDOUN ROAD
TAYLORSVILLE, NC 28681

ID
PREFIX
TAG

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

V000 INITIAL COMMENTS

An annual, complaint and follow up survey was
completed on 1/29/24. The complaint was
unsubstantiated (intake #NC00210793).
Deficiencies were cited.

This facility is licensed for the following service
category: 10A NCAC 27G .1300 Residential
Treatment for Children or Adolescents.

This facility is licensed for 6 and currently has a
census of 4. The survey sample consisted of
audits of 3 current clients and 2 former clients.

V 118 27G .0209 (C) Medication Requirements

10A NCAC 27G .0209 MEDICATION
REQUIREMENTS.
(c) Medication administration:
(1) Prescription or non-prescription drugs shall
only be administered to a client on the written
order of a person authorized by law to prescribe
drugs.
(2) Medications shall be self-administered by
clients only when authorized in writing by the
client's physician,

| (3) Medications, including injections, shall be
administered only by licensed persons, or by
unlicensed persons trained by a registered nurse,
pharmacist or other legally qualified person and
privileged to prepare and administer medications.
(4) A Medication Administration Record (MAR) of
all drugs administered to each client must be kept
current. Medications administered shall be
recorded immediately after administration. The
MAR is to include the following:
(A) client's name;
(B) name, strength, and quantity of the drug;
(C) instructions for administering the drug;
(D) date and time the drug is administered; and

Division of Health Service Regulation
LABORATORY DIRECTOR'S OR PROVIDERK

STATE FORM

| Vv 118

RECEIVED
FEB 12 2024

DHSR-MH Licensure Sect

Lucas Woe wil Sek in Place
Anew Neasare Maat <hould
Elim: nate Whe Cured AeFicienses
Flom ofCuting AGAIN: A . wad
PetSon 1 STAFE Wilt be ASS

de Posi fon DE Monitscins Ve
MALS 1N.@ weelly basts Grd
Nis Witt MACIALE Vhemn) be
ResPonsible For wddasing Lhe
De a mony basis taCludioy
Ains Any Netw medications
¢ a ar at ReCeive: Luca's
oMe Will Qiso Provide a New
Raine ng Fon ok Stare What
Adminis tas medicalion so.
nck We Car ensure ll STAPE
AN€ Knodusledgoble wn tohel
Should be doCumetad OA Yue
MAL. The DieectOn will meaniton

(X6) DATE

If continuation Theed 10f5

TITLE

Dieec dog

6A7N11

PRINTED: 01/31/2024
FORM APPROVED

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: Ac BUIEBING:

(X3) DATE SURVEY
COMPLETED

B. WING

MHL002-028 01/29/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

243 LILEDOUN ROAD
TAYLORSVILLE, NC 28681

NAME OF PROVIDER OR SUPPLIER

LUCA'S HOPE Ill

SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (xs)

(K4)10

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

V 118 Continued From page 1

bend Hae re Stare

de or initials of person administering the Leek writk b e eSPons. bie
(5) Client requests for medication changes or | Fou Pp avi Cw in Une GAS.

checks shall be recorded and kept with the MAR | The BD Rector Ww. (W CASA]

he ed appointment or consultation ob al Mart abe lagu
GCCudate a
be done oN a monly bass

The meric process wll
be up we ensure [fret
This Rule is not met as evidenced by: | do rat es el ca e)
Based on observation, record review, and - \ A Shoul ie
interview, the facility failed to ensure MARs were | time 5s Wee \ Ceckee +2
kept current for 2 of 3 audited clients (Clients #1 | | Th Ned aim
and #2). The findings are: | | b € q Verne € uf, Ve

| : of
will alsa zaclude He fe

Review on 1/24/24 of Client #1's record revealed: | OF Mw ned Ae

-admission date 6/6/23. | DF hav: iW O Co

“diagnoses of Attention-Deficit Hyperactivity | me fa) aden to Jushe ch Yer
Disorder (ADHD), Anxiety Disorder unspecified, | 1: Cats On, the Q
and Developmental Coordination Disorder. | a Cipenk m J te
-physici - - idi | Wee
physician orders - 10/11/23 - Clonidine HCL | j Cae Nee wi (\ sntlud agree

(Hydrochloride) (ADHD) - 0.1 milligrams (mg) - 1 |
tablet at bedtime. documtenrakior~ Ft ris vee
wW
| Observation on 1/23/24 at 1:14 p.m. of Client #1's Mea Ass r+ wi Sho $
medications revealed: a\ lowed > new Mea Stes

-Clonidine HCL 0.1 mg - 1 tablet at bedtime. | opiate.
| ian R eg avd to GY r

Review on 1/24/24 of Client #1's MARs for
10/1/23 through 1/23/24 revealed: Mae do Cumen bation

-Clonidine HCL 0.1 mg was not listed starting
10/11/23, when ordered, or soon thereafter.

-11/1/23 through 11/13/23 had a line marked
through for Clonidine HCL 0.1 mg with no initials.

Review on 1/24/24 of Client #2's record revealed:
Division of Health Service Regulation
STATE FORM ae 6A7N11 If continuation sheet 2 of 5

PRINTED: 01/31/2024

FORM APPROVED.
Division of Health Service Requlation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: BULBINE COMPLETED
MHL002-028 Be WING —_________ 01/29/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
243 LILEDOUN ROAD
LUCA'S HOPE Ill
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
{ DEFICIENCY)
V 118 Continued From page 2 v118 |

-admission date 7/10/23.

-diagnosis of Reactive Attachment Disorder of
Childhood.

-physician's order- 11/29/23 - Polymyxin B-TMP.
(Trimethoprim) (Acute Bacterial Conjunctivitis)
Eye drops - 1 drop into affected eye 4 times a day
for 7 days.

Observation on 1/23/24 at 1:05 p.m. of Client #2's
medications revealed:

-Polymyxin B-TMP Eye drops - 1 drop into

affected eye 4 times a day for 7 days - dispensed |
11/29/23. |

Review on 1/24/24 of Client #2's MARs for |
10/1/23 through 12/31/23 revealed: |
-"Polymyxin 3 times a day for 7 day... Hour 8AM |
8PM 4PM." | |
-11/29/23 and 11/30/23 - initialed as administered
2 times - 8:00 a.m. and 8:00 p.m.

-December - Polymyxin was not listed.

Interview on 1/23/24 with Client #1 revealed:
-he did not know the names of the medications
he took, but was administered them by staff |
everyday.

-there was no medication he missed.

Interview on 1/23/24 with Client #2 revealed:

-he received medications in the morning and in
the evenings, but was not sure what he took.

-he knew he took eye drops, his eye "...turns
red...teachers say | have pink eye, but the doctor
says | don't."

Interview on 1/24/24 with the Director revealed: |
-she called the local pharmacy today (1/24/24) |
and was told Client #1's Clonidine was first picked
up on 10/15/23,
_ -she thought Client #1's Clonidine was started |
Division of Health Service Regulation
STATE FORM me 6ATN11 If continuation sheet 3 of 5

Division of Health Service Requlation

PRINTED: 01/31/2024
FORM APPROVED

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

(X2) MULTIPLE CONSTRUCTION

(X3) DATE SURVEY
COMPLETED

01/29/2024

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

(X5)
COMPLETE
DATE

Verification |

G.S. §131E-256 HEALTH CARE PERSONNEL |
REGISTRY |
(d2) Before hiring health care personnel into a |
health care facility or service, every employer at a
health care facility shall access the Health Care

Personnel Registry and shall note each incident

of access in the appropriate business files. |

This Rule is not met as evidenced by:

Based on record review, and interview the facility
failed to complete Health Care Personnel
Registry (HCPR) checks prior to hire for 2 of 3
audited staff (House Manager and Qualified
Professional). The findings are:

|
|
|

Review on 1/24/24 of the House Manager's |
employee file revealed: |
| -date of hire 7/25/22. |
-HCPR completed 7/29/22. |

Division of Health Service Regulation
STATE FORM

6209

A. BUILDING:
MHL002-028 BEWING,
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
243 LILEDOUN ROAD
UCA'S HOPE Ill
ul TAYLORSVILLE, NC 28681
(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES ID
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG
r Vv 118 Continued From page 3 | v 118 |
and given as ordered, but it just wasn't written on
the MAR, "...that's all | can figure.”
-she feels Client #2 received his eye drops as she
remembered him going to the doctor and the |
school thinking he had pink eye, but it wasn't that. |
-Staff didn't document it as given, "I can see we |
need to have more training (in medication |
administration)...| need to think about who | can
put in charge to monitor this." |
V 131 G.S. 131E-256 (D2) HCPR - Prior Employment Vv 131

Lucas HP? Wit ensure pat
THe FO Hidtay Q ped emnPloy

ce Weal CALE Resey

built be Cometeted. This

“will be comPeted br Une
Tare ctor OCH will be done
Une Same Yme Uae

Dot ground Clreck-rs
Compigla, AN annual
Health Cane Reg dag One
will be Compiled on ail
STAFF wWolking For ne Facilit
The Névw Process wil\ be
ComPlex€d Pri0h xo EmPloymy

€€

6A7N11 If continuation sheet 4 of 5

PRINTED: 01/31/2024
FORM APPROVED

Division of Health Service Regulation
‘STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X3) DATE SURVEY
COMPLETED

A. BUILDING:
MHL002-028 5. WING 01/29/2024
-——_____——
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
243 LILEDOUN ROAD
BUC Ae HOPEII TAYLORSVILLE, NC 28681
Lo 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 131 Continued From page 4 | Vv 131 |

Review on 1/24/24 of the Qualified Professional's
employee file revealed:

-date of hire 8/7/23.

-no HCPR check found.

Interview on 1/24/24 with the Director revealed:
-knew she completed the HCPR check for the |
Qualified Professional, but could not locate it.

-she knew the HCPR checks needed to be

completed prior to hire.

Division of Health Service Regulation
STATE FORM See8 6ATN11 If continuation sheet 5 of 5

inspection_type: MHLCS Annual, Complaint, and Follow-up

document_type: Plan of Correction


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

raw_content:
PRINTED: 03/01/2023
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED

R
MHL002-028 B. WING _____ 02/24/2023

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
243 LILEDOUN ROAD
TAYLORSVILLE, NC 28681

(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)

LUCA'S HOPE Ill

V 000} INITIAL COMMENTS Vv 000

An annual, complaint and follow up survey was
completed on 2/23/23. Complaint # NC196737
was unsubstantiated and complaint #NC197731
was substantiated. Deficiencies were cited.

This facility is licensed for the following service
category: 10A NCAC 27G .1300 Residential
Treatment for Children or Adolescents.

This facility is licensed for 6 and currently has a
census of 3. The survey sample consisted of
audits of 3 current clients and 2 former clients.

V 114) 27G .0207 Emergency Plans and Supplies 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 record reviews and interviews, the
facility failed to hold fire and disaster drills on
each shift at least quarterly. The findings are:

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

STATE FORM 6899 ZVZZ11 If continuation sheet 1 of 2

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

MHL002-028

(X2) MULTIPLE CONSTRUCTION

A.

B.

BUILDING:

WING

STREET ADDRESS, CITY, STATE, ZIP CODE

243 LILEDOUN ROAD

PRINTED: 03/01/2023
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
02/24/2023

Review on 2/21/22 of fire and disaster drills
revealed:

-There was no documentation of fire drills having
been conducted on 1st shift in the quarter from
October - December 2022.

-There was no documentation of disaster drills
having been conducted on 2nd shift in the quarter
from October - December 2022.

-There was no documentation of disaster drills
having been conducted on 3rd shift in the quarter
from July - September 2022.

Interview on 9/21/23 with the Executive Director
revealed:

-Did not have a master schedule to follow for
drills.

-Will have the new House Manager create a
schedule to meet requirements.

Division of Health Service Regulation
STATE FORM

6899

LUCA'S HOPE Ill
TAYLORSVILLE, NC 28681
(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 1 Vv 114

ZVZZ11

If continuation sheet 2 of 2

document_type: Statement of Deficiency


summary: Statement of Deficiency - MHLCS Follow-up

raw_content:
Division of Health Service Re

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

NAME OF PROVIDER OR SUPPLIER

MHLO002-028

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

243 LILEDOUN ROAD

PRINTED: 12/12/2022

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

12/07/2022

A limited follow up survey for the Type B was
completed on December 7, 2022. This was a
limited follow up survey, only 10A NCAC
27G.0204 Competencies and Supervision of
Paraprofessionals (V110) were reviewed for
compliance. The following were brought back into
compliance: 10A NCAC 27G.0204
Competencies and Supervision of
Paraprofessionals (V110). No deficiencies were
cited.

The facility is licensed for the following service
category: 10A NCAC 27G .1300 Residential
Treatment for Children or Adolescents.

The facility is licensed for 6 and had a census of
6 clients.

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

STATE FORM

6899

GM4H11

LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(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

TITLE

(X6) DATE

If continuation sheet 1 of 1

inspection_type: MHLCS Follow-up


summary: Statement of Deficiency - MHLCS Complaint

raw_content:
DHSR LIMITED USE STATEMENT OF | (X1) PROVIDER/SUPPLIERICLIA]_ (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
DEFICIENCIES IDENTIFICATION NUMBER: COMPLETED
AND PLAN OF CORRECTION A. BUILDING:
Cc
10/10/22
MHL002-028 B. WING
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Luca's Hope III 243 Liledoun Road
Taylorsville, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x8)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

Vvo00

Vv110

Initial Comments:

A complaint survey was completed on 10/10/22.
The complaint was substantiated (Intake #
NC00193246). Deficiencies were cited.

This facility is licensed for the following service
category: 10A NCAC 27G. 1300 Residential
Treatment for Children and Adolescents.

The facility is licensed for 6 and had a census of 4
clients. The survey sample consisted of audits of 1
current client.

27G .0204 Training/Supervision Paraprofessionals!

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

(a) There shall be no privileging requirements for
paraprofessionals.
(b) Paraprofessionals shall be supervised by an
associate professional or by a qualified
professional as specified in Rule .0104 of this
Subchapter.
(c) Paraprofessionals shall demonstrate
nowledge, skills and abilities required by the
population served.
(d) At such time as a competency-based
employment system is established by rulemaking,
hen qualified professionals and associate
professionals shall demonstrate competence.

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

(1) technical knowledge;

(2) cultural awareness;

(3) analytical skills;

(4) decision-making;

(5) interpersonal skills;

(6) communication skills; and

Voo00

Vv110

(7) clinical skills.

PROVIDER LICENSEE OR LICENSEE DESIGNEE'S SIGNATURE

TITLE

DATE

STATE FORM — DHSR LIMITED USE STATEMENT OF DEFICIENCIES

DHSR LIMITED USE STATEMENT OF | (X1) PROVIDER/SUPPLIERICLIA]_ (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
DEFICIENCIES IDENTIFICATION NUMBER: COMPLETED
AND PLAN OF CORRECTION A. BUILDING:

Cc
10/10/22
MHL002-028 B. WING
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Luca's Hope III 243 Liledoun Road
Taylorsville, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x8)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

Vv110

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

This Rule is not met as evidenced by:

Based on interview and record review the facility
failed to ensure staff demonstrated the
knowledge, skills and abilities required by the
population served for one of one staff (Staff #1).
The findings are:

Review on 9/29/22 of Staff #1’s employee file
revealed:

-Date of hire — 7/15/19.

-Date of training on alternatives to restrictive
interventions — 9/9/21. Expires 9/30/22.

Review on 9/29/22 of Client #1’s record revealed:
-Date of admission — 7/19/22.

-Age — 13 years.

-Diagnoses of Attention-Deficit Hyperactivity
Disorder, Disruptive Mood Dysregulation Disorder,
Specific Learning Disorder, Anxiety Disorder,
Depression and Autism Spectrum Disorder.
-Person-Centered Profile dated 7/11/22 and
revised 8/15/22 — “...continues to struggle abiding
by rules...ignores boundaries...tried to fight staff
while cursing others...bullies younger smaller
peers hitting them and choking them even where
there is no issue or altercation happening...”

Review on 9/29/22 of an Incident Response
Improvement System (IRIS) report last submitted
on 9/20/22 by the Director/Chief Executive Officer
(CEO) revealed:

-Date of incident 9/12/22 involving Client #1 and
Staff #1.

-Client #1 punched Staff #1 in the face for telling
him he could not eat Nutella directly out of the jar.
-Staff #1 sent client to his room “...because he
was out of control and being very loud and
combative. Client later calmed down and staff took|

PROVIDER LICENSEE OR LICENSEE DESIGNEE'S SIGNATURE

Vv110

TITLE

DATE

STATE FORM — DHSR LIMITED USE STATEMENT OF DEFICIENCIES

DHSR LIMITED USE STATEMENT OF | (X1) PROVIDER/SUPPLIERICLIA]_ (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
DEFICIENCIES IDENTIFICATION NUMBER: COMPLETED
AND PLAN OF CORRECTION A. BUILDING:

Cc
10/10/22
MHL002-028 B. WING
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Luca's Hope III 243 Liledoun Road
Taylorsville, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x8)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

Vv110

the trash outside...when he came back inside, he
saw [Client #1] and one of his peers fighting. Staff
(Staff #1) separated the two clients by pulling
[Client #1] by his wrist and leading him to his room
because he was still trying to fight/kick staff for
breaking them up preventing him from continuing
to fight...[Client #1] stated that his arm was
bruised, and he felt that staff caused this and not
his peers....”

-“This incident could have been prevented if staff
had walked away from client as soon as he
realized client was verbally and inappropriately
upset. This may have assisted with client calming
down and the situation deescalating itself without
client punching staff...”

-Staff #1 “...was informed that he would not be
able to work with the clients until after the
investigation was completed by DSS (Department
of Social Services) and found unsubstantiated.”

Interviews on 9/27/22 with Clients #2 and #3
revealed:

-They had fought with Client #1.

-They witnessed him trying to knock Staff #1 down
and hitting and kicking staff.

Interview on 9/27/22 with Client #4 revealed:

-He was aware of a separate incident when Client
#1 locked himself in the bathroom.

-He saw Staff #1 “...yanked his (Client #1)
arm...pulling him out...yanking and he (Staff #1)
slid him (Client #1) across the floor...[Client #1]
was trying to fight back...”

-He did not know when this incident occurred.

Interviews on 9/29/22 and 10/6/22 with Client #1
revealed:

-On 9/12/22 Staff #1 “...was mad at me for being
defiant...he grabbed my arm and twisted it around
my back....”

-He remembered locking himself in the bathroom
shortly after he was admitted to the facility.

PROVIDER LICENSEE OR LICENSEE DESIGNEE'S SIGNATURE

Vv110

TITLE

DATE

STATE FORM — DHSR LIMITED USE STATEMENT OF DEFICIENCIES

DHSR LIMITED USE STATEMENT OF | (X1) PROVIDER/SUPPLIERICLIA]_ (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
DEFICIENCIES IDENTIFICATION NUMBER: COMPLETED
AND PLAN OF CORRECTION A. BUILDING:
Cc
10/10/22
MHL002-028 B. WING
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Luca's Hope III 243 Liledoun Road
Taylorsville, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x8)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

Vv110

-He did not remember anything else about this
incident.

Interviews on 10/3/22 and 10/5/22 with Staff #1
revealed:

-The morning of 9/12/22 there were several
altercations between clients.

-When he returned after taking the trash out Client
#1 and Client #2 were on the floor fighting.

-Client #2 was willing to quit but Client #1
continued to fight and hit him (Staff #1).

-“I tried to take him to the bedroom to get him
away, pretty much a struggle with that...! grabbed
his (Client #1’s) right arm around the
elbow...helped him off the floor. He was getting up!
but was trying to fight...let go of his arm when got
into the hallway...”
-In order to de-escalate “...a lot of times have to
call [Director/CEO] and let her talk to him (Client
#1).”
-Another incident that occurred on a date
unknown, Client #1 locked himself in the bathroom
he first weekend he worked with him.

-Once Client #1 opened the bathroom door, “...he
came out fighting...pulled him by his legs and
pulled him out...he slid across the floor...”

-“The incident lasted about 15 minutes and he
(Client #1) kept saying I’m not coming out. When
he did finally open the door, he was on the floor,
icking and kicked me in the groin. That’s when |
grabbed his ankles.”

-He told Client #1 to “...get up and grabbed his
arm just above the elbow....”

-He de-escalated Client #1 by “...getting control of
him and not getting hurt. Things happen so fast
and stop it as fast as you can...minimize the
struggle...get them (clients) by the elbow....”

Interviews on 9/29/22, 10/5/22 and 10/6/22 with
he Director/CEO revealed:

-She found out about the 9/12/22 incident the next
day (9/13/22) after another staff member told her
and then Client #1’s school called her.

Vv110

PROVIDER LICENSEE OR LICENSEE DESIGNEE'S SIGNATURE

TITLE

DATE

STATE FORM — DHSR LIMITED USE STATEMENT OF DEFICIENCIES

DHSR LIMITED USE STATEMENT OF | (X1) PROVIDER/SUPPLIERICLIA]_ (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
DEFICIENCIES IDENTIFICATION NUMBER: COMPLETED
AND PLAN OF CORRECTION A. BUILDING:

Cc
10/10/22
MHL002-028 B. WING
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Luca's Hope III 243 Liledoun Road
Taylorsville, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x8)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

Vv110

-Staff #1 was immediately suspended on 9/13/22
and had not returned to the facility since.

-When clients are fighting she would expect staff
to “...keep everybody safe...get everyone else out
of the way to their rooms...! would want them
(staff) to separate them...keep them out of the
same room...what is that going to solve if you
force them to go to their room...ask other guys
(clients) to go if he [Client #1] won't...”

-The only thing she was told by Staff #1 when
Client #1 locked himself in the bathroom was that
he was “acting out” because he didn’t want to do
chores.
-What she “understood it only lasted a few
minutes.”
-“He (Staff #1) didn’t say he dragged him out of
the bathroom. That would have been written up.
They (staff) are not to touch the clients. We are
taught not to do that.”

Review on 10/10/22 of the Plan of Protection
dated 10/10/22 written by the Director/CEO
revealed:

-“What immediate action will the facility take to
ensure the safety of the consumers in your care?
Luca’s Hope will implement an immediate plan
that will ensure the safety of all consumers moving
forward. The facility will follow through with
suspending or possibly terminating staff that was
involved in this report because of his own
admission that he inappropriately engaged with
client on multiple occasions. The facility will
provide extra training immediately to all staff
regarding how to appropriately engage and
respond in certain situations that may arise
without engaging with clients physically and
inappropriately. The facility will hire a staff that can
assist with monitoring staff to ensure staff are
providing safe services for all clients. The facility
will install cameras within the entire home in all
common areas except for client bedrooms and
bathrooms.

-Describe your plans to make sure the above
happens.

PROVIDER LICENSEE OR LICENSEE DESIGNEE'S SIGNATURE

Vv110

TITLE

DATE

STATE FORM — DHSR LIMITED USE STATEMENT OF DEFICIENCIES

DHSR LIMITED USE STATEMENT OF | (X1) PROVIDER/SUPPLIERICLIA]_ (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
DEFICIENCIES IDENTIFICATION NUMBER: COMPLETED
AND PLAN OF CORRECTION A. BUILDING:

Cc
10/10/22
MHL002-028 B. WING
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Luca's Hope III 243 Liledoun Road
Taylorsville, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x8)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

Vv110

Luca’s Hope will hire a house manager that will
assist with monitoring all staff that work and
engage with all clients that are enrolled in the
program. The home will contact and schedule a
trainer to be a part of the next staff meeting so
that additional training can be offered to all staff
that engage with the clients. The home will focus
more on client incident de-escalation. Luca’s Hope}
will also have camera’s installed and will they will
be monitored on a regular basis ensuring client
safety. Luca’s Hope will have all cameras installed
immediately.”

Review on 10/10/22 of a Plan of Protection
addendum dated 10/10/22 written by the
Director/CEO revealed:

-“The facility suspended staff on 9/13/2022 and
staff has not worked at the facility since that date.
The facility will be meeting in the next 2 weeks to
determine whether staff will be permanently
suspended/terminated...The facility will also
schedule additional training on Effective
Communication Skills based on the fact that this
incident was not Communicated to the Director
immediately. The Director was not informed about
this incident and did not learn about the incident
until the following day. The Director was informed
about the incident by another staff member the
following day that the incident happened...
-The Director will monitor staff and clients to
ensure that safe services are being provided by all
staff. Luca’s Hope will be hiring a house manager
that will assist the Director with monitoring all staff
that work and engage with all clients that are
enrolled in the program moving forward... The
meeting, training and cameras will all be in place
within the next two weeks no later than
10/31/2022...All cameras will be monitored on a
regular basis ensuring client safety.”

This is a residential facility for adolescents with
diagnoses including Attention-Deficit Hyperactivity
Disorder, Disruptive Mood Dysregulation Disorder,
Anxiety Disorder, Depression and Autism

PROVIDER LICENSEE OR LICENSEE DESIGNEE'S SIGNATURE

Vv110

TITLE

DATE

STATE FORM — DHSR LIMITED USE STATEMENT OF DEFICIENCIES

DHSR LIMITED USE STATEMENT OF | (X1) PROVIDER/SUPPLIERICLIA]_ (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
DEFICIENCIES IDENTIFICATION NUMBER: COMPLETED
AND PLAN OF CORRECTION A. BUILDING:
Cc
10/10/22
MHL002-028 B. WING
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Luca's Hope III 243 Liledoun Road
Taylorsville, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x8)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

Vv110

Spectrum Disorder. Client #1 tended to be defiant
and fight other clients and staff. Staff #1 was not
able to de-escalate the situation in at least two
incidents when Client #1 had locked himself in the
bathroom on an unknown date and when he was
fighting with other clients on 9/12/22. During both
incidents Staff #1 physically intervened by
grabbing Client #1 on the ankles to pull him out of
the bathroom and by grabbing his wrist/forearm to
get him off the floor. This deficiency constitutes a
Type B rule violation which is detrimental to the
health, safety, and welfare of the clients. If the
violation is not corrected within 45 days, an
administrative penalty of $200.00 per day will be
imposed for each day the facility is out of
compliance beyond the 45" day.

Vv110

PROVIDER LICENSEE OR LICENSEE DESIGNEE'S SIGNATURE

TITLE

DATE

STATE FORM — DHSR LIMITED USE STATEMENT OF DEFICIENCIES

DHSR LIMITED USE STATEMENT OF | (X1) PROVIDER/SUPPLIERICLIA] (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
DEFICIENCIES IDENTIFICATION NUMBER: COMPLETED
AND PLAN OF CORRECTION A. BUILDING:
Cc
10/10/22
MHL002-028 B. WING

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

243 Liledoun Road

Luca's Hope III
Taylorsville, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x)
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)

DATE

PROVIDER LICENSEE OR LICENSEE DESIGNEE'S SIGNATURE TITLE

STATE FORM — DHSR LIMITED USE STATEMENT OF DEFICIENCIES

DHSR LIMITED USE STATEMENT OF | (X1) PROVIDER/SUPPLIERICLIA]_ (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
DEFICIENCIES IDENTIFICATION NUMBER: COMPLETED
AND PLAN OF CORRECTION A. BUILDING:
Cc
10/10/22
MHL002-028 B. WING
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Luca's Hope III 243 Liledoun Road
Taylorsville, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x8)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

PROVIDER LICENSEE OR LICENSEE DESIGNEE'S SIGNATURE

TITLE

STATE FORM — DHSR LIMITED USE STATEMENT OF DEFICIENCIES

DATE

DHSR LIMITED USE STATEMENT OF | (X1) PROVIDER/SUPPLIERICLIA]_ (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
DEFICIENCIES IDENTIFICATION NUMBER: COMPLETED
AND PLAN OF CORRECTION A. BUILDING:
Cc
10/10/22
MHL002-028 B. WING
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Luca's Hope III 243 Liledoun Road
Taylorsville, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x8)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

PROVIDER LICENSEE OR LICENSEE DESIGNEE'S SIGNATURE

TITLE

STATE FORM — DHSR LIMITED USE STATEMENT OF DEFICIENCIES

DATE

DHSR LIMITED USE STATEMENT OF | (X1) PROVIDER/SUPPLIERICLIA]_ (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
DEFICIENCIES IDENTIFICATION NUMBER: COMPLETED
AND PLAN OF CORRECTION A. BUILDING:
Cc
10/10/22
MHL002-028 B. WING
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Luca's Hope III 243 Liledoun Road
Taylorsville, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x8)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

PROVIDER LICENSEE OR LICENSEE DESIGNEE'S SIGNATURE

TITLE

STATE FORM — DHSR LIMITED USE STATEMENT OF DEFICIENCIES

DATE

DHSR LIMITED USE STATEMENT OF | (X1) PROVIDER/SUPPLIERICLIA]_ (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
DEFICIENCIES IDENTIFICATION NUMBER: COMPLETED
AND PLAN OF CORRECTION A. BUILDING:
Cc
10/10/22
MHL002-028 B. WING
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Luca's Hope III 243 Liledoun Road
Taylorsville, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x8)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

PROVIDER LICENSEE OR LICENSEE DESIGNEE'S SIGNATURE

TITLE

STATE FORM — DHSR LIMITED USE STATEMENT OF DEFICIENCIES

DATE

inspection_type: MHLCS Complaint


summary: Plan of Correction - MHLCS Complaint

raw_content:
DHSR LIMITED USE STATEMENT OF
DEFICIENCIES

(x1) PROVIDER/SUPPLIER/CLI
IDENTIFICATION NUMBER

AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

Luca's Hope Il

MHL002-028

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

243 Liledoun Road

Taylorsville, NC 28681

(X3) DATE SURVEY
COMPLETED

Cc
10/10/22

STREET ADDRESS, CITY, STATE, ZIP CODE

(X4) 1D
PREFIX
TAG

ooo

v110

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

Initial Comments:

A complaint survey was completed on 10/10/22.
The complaint was substantiated (Intake #
NC00193246). Deficiencies were cited.

This facility is licensed for the following service
category: 10A NCAC 27G. 1300 Residential
| Treatment for Children and Adolescents.

|

The facility is licensed for 6 and had a census of 4
clients. The survey sample consisted of audits of 1
current client.

27G .0204 Training/Supervision Paraprofessionals;

410A NCAC 27G .0204 COMPETENCIES AND
SUPERVISION OF PARAPROFESSIONALS
(a) There shall be no privileging requirements for
| paraprofessionals.

(b) Paraprofessionals shall be supervised by an
associate professional or by a qualified

| professional as specified in Rule .0104 of this
Subchapter.

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

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

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

(1) technical knowledge;

(2) cultural awareness;

(3) analytical skills;

(4) decision-making;

(5) interpersonal skills;

(6) communication skills; and

| (7) clinical skills.

1D
PREFIX
TAG

vo00

v110

TITLE

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

(xs)
COMPLETE
DATE

DHSR - Mental Health

Lic. & Cert. Section

‘ e will ensuer thet
Luca) Hee < will be Kept

theaai a
st 4 Fr ated we shout

Cusaedck + a * Hore
val derys Cuca $
\aes* ive ‘ad re Ceat

tor tt Py eal
All Stare hegaaning

tia peg omnes de esalare
how * . & having

Q Sika Ne gs with Clients
was Completed

On october Ih

(so
aff were Q ~
Se Commas ation & the

rela in
Tmootrance of relagqing
racidente 40 the acct ¢
Worse *harned @ Gin On tencid

reporting $ Me Im pocrance oF
doing, 52°

DATE

i i] 9/22-

Ufafoa. Ditector

OHSR LIMITED USE STATEMENT OF
DEFICIENCIES
AND PLAN OF CORRECTION

(x1) PROVIDER/SUPPLIER/CLI
IDENTIFICATION NUMBER

MHL002-028

(X2) MULTIPLE CONSTRUCTION
‘A. BUILDING:

(X3) DATE SURVEY
COMPLETED

rs

Cc
10/10/22

B. WING

NAME OF PROVIDER OR SUPPLIER STREET ADDR!

Luca's Hope II 243 Liledoun Ro:

Taylorsville, NC

(X4) ID
PREFIX
TAG

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

ESS, CITY, STATE, ZIP CODE
ad

28681

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

(Xs)
COMPLETE
DATE

PREFIX
TAG

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

This Rule is not met as evidenced by:

| Based on interview and record review the facility
failed to ensure staff demonstrated the
knowledge, skills and abilities required by the
population served for one of one staff (Staff #1).
The findings are:

Review on 9/29/22 of Staff #1’s employee file
revealed:

-Date of hire — 7/15/19.

-Date of training on alternatives to restrictive
interventions — 9/9/21. Expires 9/30/22.

Review on 9/29/22 of Client #1's record revealed:
|-Date of admission — 7/19/22.

-Age — 13 years.

-Diagnoses of Attention-Deficit Hyperactivity
Disorder, Disruptive Mood Dysregulation Disorder,
Specific Learning Disorder, Anxiety Disorder,
Depression and Autism Spectrum Disorder.
-Person-Centered Profile dated 7/11/22 and
revised 8/15/22 —".. continues to struggle abiding
by rules. ..ignores boundaries... tried to fight staff
while cursing others...bullies younger smaller
peers hitting them and choking them even where
there is no issue or altercation happening...”

Review on 9/29/22 of an Incident Response
Improvement System (IRIS) report last submitted
on 9/20/22 by the Director/Chief Executive Officer
(CEO) revealed:
-Date of incident 9/12/22 involving Client #1 and
Staff #1.
-Client #1 punched Staff #1 in the face for telling
him he could not eat Nutella directly out of the jar.
|-Staff #1 sent client to his room “..,.because he
| was out of control and being very loud and

| combative. Client later calmed down and staff took
PROVIDER LICENSEE OR LICENSEE DESIGNEE'S SIGNATURE

TITLE

vito 4CQ'd Hope toil easuce thet

StAFE wil have another tein,
About Cheent Dehavion de-csca
duackg EIS Next me ae
rat ys scheduled oe ii/24|
STAFF lov (\ beaen dif Feet

(5 the

teChaigues + Copia ski
Wil KeeD & Situation with a
Combatve Client Under] Contcol,
Luces Hope recogni2es Yat this
tne eax Could have been Ave

c ad Walked away Flom
etcan a5 Seon as Starr r¥elized

Client wes angry Jd Upset

DATE Ull¢2

STATE FORM ~ DHSR LIMITED USE STATEMENT OF DEFICIENCIES

OHSR LIMITED USE STATEMENT OF
DEFICIENCIES
AND PLAN OF CORRECTION

(x1) PROVIDER/SUPPLIERICLI,
IDENTIFICATION NUMBER.

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

rs

Cc
10/10/22

MHL002-028 B. WING

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Luca's Hope III 243 Liledoun Road
Taylorsville, NC 28681

(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 BATE

DEFICIENCY)
Se

the trash outside...when he came back inside, he
saw [Client #1] and one of his peers fighting. Staff
(Staff #1) separated the two clients by pulling
[Client #1] by his wrist and leading him to his room
because he was still trying to fight/kick staff for
breaking them up preventing him from continuing
to fight...[Client #1] stated that his arm was
bruised, and he felt that staff caused this and not
his peers...”

-"This incident could have been prevented if staff
had walked away from client as soon as he
realized client was verbally and inappropriately
upset. This may have assisted with client calming
down and the situation deescalating itself without
client punching staff...”

-Staff #1 “...was informed that he would not be
able to work with the clients until after the
investigation was completed by DSS (Department |
of Social Services) and found unsubstantiated.”

Interviews on 9/27/22 with Clients #2 and #3
revealed:

-They had fought with Client #1.

-They witnessed him trying to knock Staff #1 down
and hitting and kicking staff.

Interview on 9/27/22 with Client #4 revealed:

-He was aware of a separate incident when Client
#1 locked himself in the bathroom.

-He saw Staff #1 “...yanked his (Client #1)
arm...pulling him out...yanking and he (Staff #1)
slid him (Client #1) across the floor...[Client #1]
was trying to fight back...”

-He did not know when this incident occurred.

Interviews on 9/29/22 and 10/6/22 with Client #1
revealed: |
-On 9/12/22 Staff #1 “...was mad at me for being |
defiant...he grabbed my arm and twisted it around
my back...”

-He remembered locking himself in the bathroom
shortly after he was admitted to the facility.

PROVIDER LICENSEE OR LICENSEE DESIGNEE'S SIGNATURE TITLE DATE /fe Q

STATE FORM — DHSR LIMITED USE STATEMENT OF DEFICIENCIES

DHSR LIMIT!
DEFICIENCII

a

aio |

PREFIX
TAG

V110

AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

ED USE STATEMENT OF
ES

(x1) PROVIDER/SUPPLIER/CLI.
IDENTIFICATION NUMBER:

MHL002-028

(X2) MULTIPLE CONSTRUCTION

A. BUILDING:

B.WING _

(X3) DATE SURVEY
COMPLETED

Cc
10/10/22

Taylorsville, NC 28684

STREET ADDRESS, CITY, STATE, ZIP CODE
Luca's Hope III 243 Liledoun Road

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

-He did not remember anything else about this

Interviews on 10/3/22 and 10/5/22 with Staff #1
revealed:

-The morning of 9/12/22 there were several
altercations between clients.

-When he returned after taking the trash out Client
#1 and Client #2 were on the floor fighting.

-Client #2 was willing to quit but Client #1
Continued to fight and hit him (Staff #1).

~‘I tried to take him to the bedroom to get him
away, pretty much a struggle with that...| grabbed
his (Client #1's) right arm around the

elbow. ..helped him off the floor. He was getting up!
but was trying to fight...let go of his arm when got
into the hallway...”

-In order to de-escalate "...a lot of times have to
call [Director/CEO] and let her talk to him (Client
#1).”

-Another incident that occurred on a date
unknown, Client #1 locked himself in the bathroom
the first weekend he worked with him.

-Once Client #1 opened the bathroom door, “...he
came out fighting. ..pulled him by his legs and
pulled him out...he slid across the floor...”

-“The incident lasted about 15 minutes and he
(Client #1) kept saying I'm not coming out. When
he did finally open the door, he was on the floor,

| kicking and kicked me in the groin. That's when |
grabbed his ankles.”

-He told Client #1 to “...get up and grabbed his
arm just above the elbow...”

-He de-escalated Client #1 by “...getting control of
him and not getting hurt. Things happen so fast
and stop it as fast as you can...minimize the
struggle...get them (clients) by the elbow...”

| Interviews on 9/29/22, 10/5/22 and 10/6/22 with
the Director/CEO revealed:

~She found out about the 9/12/22 incident the next
day (9/13/22) after another staff member told her
and then Client #1's school called her.

PROVIDER LI

ICENSEE OR LICENSEE DESIGNEE'S SIGNATURE

ID
PREFIX
TAG

a

incident. V110

TITLE

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

(x)
COMPLETE
DATE

Luca's Hope Will trsuue Yet
a review oF Tncserss
de-esalation SLs are MUicase
(ON armondnly dass s _ hl
gs & Tronth,
eve mplemented 40 revert
Tnedeank Lite this te ever

Ihagpen again’

STATE FORM — DHSR LIMITED USE STATEMENT OF DEFICIENCIES

DATE (yar

OHSR LIMITED USE STATEMENT OF (x1) PROVIDER/SUPPLIER/CLIA] (X2) MULTIPLE CONSTRUCTION
DEFICIENCIES IDENTIFICATION NUMBER:

(X3) DATE SURVEY
COMPLETED

AND PLAN OF CORRECTION A. BUILDING:
c
10/10/22
MHL002-028 B. WING
=
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Luca's Hope II 243 Liledoun Road

Taylorsville, NC 28681

(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 PATE
| DEFICIENCY)

|-Statt #1 was immediately suspended on 9/1 3/22
V110 and had not returned to the facility since. Vv110
-When clients are fighting she would expect staff
to “...keep everybody safe...get everyone else out
of the way to their rooms...1 would want them
(staff) to separate them...keep them out of the
same room...what is that going to solve if you
force them to go to their room...ask other guys |
(clients) to go if he [Client #1] won't...”

-The only thing she was told by Staff #1 when
Client #1 locked himself in the bathroom was that
he was “acting out” because he didn’t want to do

chores.
-What she “understood it only lasted a few
minutes.”
~“He (Staff #1) didn't say he dragged him out of
the bathroom. That would have been written up.
They (staff) are not to touch the clients. We are
taught not to do that,” ‘
v0 | ° Luca's Hope Kas determined wet
Review on 10/10/22 of the Plan of rotection Fan
dated 10/10/22 written by the Director/CEO orn the Sake OF Eins Mt ait
revealed: ust Move FOCoare Lor | i
-“What immediate action will the facility take to + fe was tave ze
ensure the safety of the consumers in your care? es At rt “The acre has
Luca’s Hope will implement an immediate plan he Ine der ~ alatin
that will ensure the safety of all consumers moving | ed Thro W« |
forward. The facility will follow through with fp [}ow Aciderk Tacney
suspending or possibly terminating staff that was Ail stage on A ’
involved in this report because of his own . BY Code oF Eth BS
admission that he inappropriately engaged with @ fuenk re . | Louse.
client on multiple occasions. The facility will fa . ik has Wi ed a
provide extra training immediately to all staff Th € ae 4
i thak the heme
regarding how to appropriately engage and acenk 50 a .
respond in certain situations that may arise man ~! AR ectHvelg,
without engaging with clients physically and be Mons toned Mo
| inappropriately. The facility will hire a staff that can tw has Purchased
assist with monitoring staff to ensure staff are The Faccls ‘(( be tn je ([eL
Providing safe services for all clients. The facility a's ¢ We
will install cameras within the entire home in all Cama (U LWwée.d dime Fla
common areas except for client bedrooms and th wat the Qa led
bathrooms. Ww thats WA be EN Stal t Alt a
~-Describe your plans to make sure the above € Crm . home wells
ha he entire
ippens. oughour \
PROVIDER LICENSEE OR LICENSEE DESIGNEE'S SIGNATURE TITLE The Qseas DATE Wore

Cea
the Common ie oF Cleat Lous
STATE FORM — DHSR LIMITED USE STATEMENT OF DEFICIENCIES ttre EL eftion
[((4(2*

OHSR LIMITED USE STATEMENT OF
DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLL
IDENTIFICATION NUMBER:

MHL002-028

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

B.WING _

(%3) DATE SURVEY
COMPLETED

Cc
10/10/22

NAME OF PROVIDER OR SUPPLIER

Luca's Hope III 243 Liledoun Road

Taylorsville, NC 28681

STREET ADDRESS, CITY, STATE, ZIP CODE

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

(4) 1D
PREFIX
TAG

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

(x5)
COMPLETE
DATE

V110 Luca’s Hope will hire a house manager that will
assist with monitoring all staff that work and
engage with all clients that are enrolled in the
Program. The home will contact and schedule a
trainer to be a part of the next staff meeting so
that additional training can be offered to all staff
that engage with the clients. The home will focus
more on client incident de-escalation. Luca’s Hope
| will also have camera's installed and will they will
be monitored ona regular basis ensuring client
safety. Luca's Hope will have all cameras installed
immediately.”

V110

Review on 10/10/22 of a Plan of Protection
addendum dated 10/10/22 written by the
Director/CEO revealed:

~The facility suspended staff on 9/13/2022 and
staff has not worked at the facility since that date.
| The facility will be meeting in the next 2 weeks to
determine whether staff will be permanently
suspended/terminated...The facility will also
schedule additional training on Effective
Communication Skills based on the fact that this
incident was not Communicated to the Director
immediately. The Director was not informed about
this incident and did not learn about the incident
until the following day. The Director was informed
about the incident by another staff member the

| following day that the incident happened...

-The Director will monitor staff and clients to
ensure that safe services are being provided by all
Staff. Luca's Hope will be hiring a house manager
that will assist the Director with monitoring all staff
that work and engage with all clients that are
enrolled in the program moving forward...The
meeting, training and cameras will all be in place
within the next two weeks no later than
10/31/2022...All cameras will be monitored on a
regular basis ensuring client safety.”

This is a residential facility for adolescents with
diagnoses including Attention-Deficit Hyperactivity
Disorder, Disruptive Mood Dysregulation Disorder,
Anxiety Disorder, Depression and Autism
PROVIDER LICENSEE OR LICENSEE DESIGNEE'S SIGNATURE

TITLE

oN Anciderk de - t5Calakien
by Emprevi\ how the home
wd monloued b Stn FE Pespon

4o Clients F Sibeuttns,

mare he ar

STATE FORM — DHSR LIMITED USE STATEMENT OF DEFICIENCIES

OHSR LIMITED USE STATEMENT OF (x1) PROVIDER/SUPPLIER/CLI

DEFICIENCIES IDENTIFICATION NUMBER:
AND PLAN OF CORRECTION

+ —

(X4) 1D
PREFIX
TAG

Vv110

PROVIDER LICENSEE OR LICENSEE DESIGNEE'S SIGNATURE

NAME OF PROVIDER OR SUPPLIER

Luca's Hope Ill

MHL002-028

B. WING _

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

Taylorsville, NC 28681

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

STREET ADDRESS, CITY, STATE, ZIP CODE
243 Liledoun Road

ID
PREFIX
TAG

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

) DATE SURVEY
COMPLETED

c
10/10/22

(x5)
COMPLETE
DATE

Spectrum Disorder. Client #1 tended to be defiant
and fight other clients and staff. Staff #1 was not
able to de-escalate the situation in at least two
incidents when Client #1 had locked himself in the
bathroom on an unknown date and when he was
fighting with other clients on 9/12/22. During both
incidents Staff #1 physically intervened by
grabbing Client #1 on the ankles to pull him out of
the bathroom and by grabbing his wrist/forearm to
get him off the floor. This deficiency constitutes a
Type B rule violation which is detrimental to the
health, safety, and welfare of the clients. If the
violation is not corrected within 45 days, an
administrative penalty of $200.00 per day will be
imposed for each day the facility is out of
compliance beyond the 45t day.

TITLE

STATE FORM ~ DHSR LIMITED USE STATEMENT OF DEFICIENCIES

DATE /{ g/29-

ROY COOPER - Governor
KODY H. KINSLEY ~ Secretary
MARK PAYNE » Director, Division of Health Service Regulation

November 1, 2022

P.O. Box 442, Suite 307
Sherrills Ford, NC 28673

Re: Revised Letter
Complaint Survey completed October 10, 2022
Luca’s Hope III, 243 Liledoun Road, Taylorsville, NC 28681

MHL #002-028
E-mail Address: yalariestanback@yahoo.com
Intake #NC00193246

Dear Ms, Stanback:

Thank you for the cooperation and courtesy extended during the complaint survey completed October 10, 2022. The
complaint was substantiated.

Enclosed are your findings listed on a Limited Use Statement of Deficiencies Form. The purpose of these findings
is to provide you with specific details of the practice that does not comply with state regulations. Once we have
access to our IT System, we will send out the official Statement of Deficiencies. You must develop one Plan of
Correction that addresses each deficiency listed on the State Form and return it to our office within ten days of

receipt of this letter. Below you will find details of the type of deficiencies found, the time frames for compliance
plus what to include in the Plan of Correction.

Type of Deficienc’ ‘0

e Type B rule violation is cited for 10A NCAC 27G.0204 Competencies and Supervision of
Paraprofessionals (V110).

Time Frames for Compliance
e Type B violation must be corrected within 45 days from the exit date of the survey, which is November
24, 2022. Pursuant to North Carolina General Statute § 122C-24.1, failure to correct the enclosed
deficiency by the 45" day from the date of the survey may result in the assessment of an administrative

penalty of $200.00 (Two Hundred) against Luca’s Hope, LLC for each day the deficiency remains out of
compliance.

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

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

MAILING ADDRESS: 2718 Mail Service Center, Raleigh, NC 27699-2718
www.ncdhhs.gov + TEL: 919-855-4619 » FAX: 919-715-8078

AN EQUAL OPPORTUNITY / AFFIRMATIVE ACTION EMPLOYER

November 1, 2022
irector
uuca’s Hope, LLC

Make a copy of the Statement of Deficiencies with the Plan of Correction to retain for your records. Please do not

include confidential information in your plan of correction and please remember never to send confidential
information (protected health information) via email.

Send the original completed form to our office at the following address within 10 days of receipt of this letter.
Mental Health Licensure and Certification Section
NC Division of Health Service Regulation
2718 Mail Service Center
Raleigh, NC 27699-2718

If we can be of further assistance, please call Lynn Grier, Team Leader at 336-247-1723.

Sincerely,

Facility Compliance Consultant I
Mental Health Licensure & Certification Section

Ce: dhhs@vayahealth.com
Pam Pridgen, Administrative Supervisor