raw_content:
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHLO011-203

A. BUILDING:

111 COMPTON DRIVE

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/06/2021

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

07/02/2021

Paraprofessionals

10A NCAC 27G .0204 COMPETENCIES AND
SUPERVISION OF PARAPROFESSIONALS
(a) There shall be no privileging requirements for
paraprofessionals.

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

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

(d) At such time as a competency-based
employment system is established by rulemaking,
then qualified professionals and associate
professionals shall demonstrate competence.
(e) Competence shall be demonstrated by
exhibiting core skills including:

(1) technical knowledge;

(2) cultural awareness;

(3) analytical skills;

(4) decision-making;

(5) interpersonal skills;

(6) communication skills; and

(7) clinical skills.

(f) The governing body for each facility shall
develop and implement policies and procedures

REUTER COTTAGE
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000} INITIAL COMMENTS V 000
An annual and complaint survey was completed
on July 2, 2021. The complaint was
substantiated (HNC00176033). Deficiencies were
cited.
This facility is licensed for the following service
category: 10A NCAC 27G.1700 Residential
Treatment Staff Secure for Children or
Adolescents.
V 110| 27G .0204 Training/Supervision Vv 110

Division of Health Service Regulation

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

STATE FORM

6808 K8ZJ11

TITLE

(X6) DATE

If continuation sheet 1 of 51

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/06/2021
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL011-203 07/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
111 COMPTON DRIVE
REUTER COTTAGE
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 110] Continued From page 1 Vv 110

for the initiation of the individualized supervision
plan upon hiring each paraprofessional.

This Rule is not met as evidenced by:

Based on record reviews and interviews, 2 of 3
staff (Cottage Supervisor and Residential
Director) failed to demonstrate the knowledge,
skills and abilities required by the population
served. The findings are:

Refer to Tag V112 for additional information.

Review on 6/15/21 of the Residential Director's
employee file revealed:

-hire date 1/30/17.

-promoted to current position on 10/20/20.
-11/20/19 - TCI (Therapeutic Crisis Intervention)
Trainer Associate - expires 11/20/21.

-admitted 12/23/20.

-17 years old - identified as a transgendered
male.

-diagnoses of Post-Traumatic Stress Disorder,
Major Depressive Disorder with psychotic
features, Generalized Anxiety Disorder with
Obsessive-Compulsive features, Gender
Dysphoria, Specific Learning Disorder and
Attention-Deficit Hyperactivity Disorder.
-5/11/21 - most recent Comprehensive Clinical
Assessment update - "...since admission to
Reuter he has demonstrated the following
behavior: daily self-harm that includes cutting
herself with paper or using her finger nail, she

Division of Health Service Regulation
STATE FORM

Review on 6/16/21 of Client #1's record revealed:

6809

K8ZJ11

If continuation sheet 2 of 51

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/06/2021
FORM APPROVED

(X3) DATE SURVEY

has also carved the name of her abuser into her
stomach with her finger nail, head banging,
leaving the cottage to walk around campus
without permission and reports suicidal ideation
with a plan but with no means to complete.
Property destruction including breaking windows
and has engaged in violence towards staff which
included biting, licking, hitting and kicking,
requires 1-1 support to regulate."

Review on 6/16/21 of Client #1's Crisis
Prevention and Intervention Plan initially dated
12/9/20 and last revised on 6/11/21 revealed:
-"What are some events or situations that have
caused me trouble in the past?...1 get triggered
when people touch me."

-4/6/21 - Triggers: "...[Client #1] has reported that
the gym and weight barn are triggers..."

-"What are the early warning signs that | am not
doing well?... (Prevention and Early Intervention
Strategies) | run to my room and isolate myself. |
shut the door. | stop talking."

-3/1/21 - Strategies: "Presenting a firm schedule
with alternatives if [he] doesn't like an activity.
Appealing to [his] interests..."

-4/6/21 - Strategies: "Making a plan, providing
distractions..."

Review on 6/21/21 of Residential Multidisciplinary
Team Meetings for Client #1 from March 2021
through May 2021 revealed:

-meetings on 3/30/21, 4/20/21 and 5/18/21.
-strategies to prevent future incidents/outbursts:
structured activities that allowed client to have
staff's attention - he preferred 1-1 staff.

Review on 6/15/21, 6/16/21, 6/17/21, 6/22/21,
6/23/21, and 6/24/21 of facility Incident Reports
(IR), facility Level Ill Restrictive Intervention

Division of Health Service Regulation

STATE FORM

6809

K8ZJ11

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL011-203 07/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
111 COMPTON DRIVE
REUTER COTTAGE
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 110) Continued From page 2 Vv 110

If continuation sheet 3 of 51

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/06/2021
FORM APPROVED

(X3) DATE SURVEY

Incident Reports (RI) and the North Carolina
Incident Response Improvement System (IRIS)
for Client #1 from March 2021 to June 2021
revealed:

-3/27/21 1:02 p.m. IRIS -RI Client head banged
against a concrete wall and would not allow staff
to use headboard. Staff utilized a seated restraint
for approximately 13 minutes. The summary of
incident described a situation where the client did
not want to watch the movie being played
(Hunger Games) as it was too violent.

Student re-engagement: The client was brought
back to join the rest of the movie block.

Ways to manage the identified trigger: "Proactive
alternate activity during non-preferred blocks."

-4/6/21 8:42 p.m. IRIS -RI Client attempted to
open his room window. Staff closed the window
and blocked him from it. Client ran toward the
door and staff tried to block him from leaving.
Client began to push and kick staff. Staff initiated
a "yoke" (the initiation of a RI). Staff attempted to
initiate a second RI but the client's legs were
locked. Staff released the "yoke" and tried to
block him from getting out the side door. Client
was able to run outside again.

Environmental effects: it was less structured due
to it being "choice time."

-5/8/21 1:00 p.m. IR- Self injurious. During
self-support activity, staff blocked client's room as
he attempted to go to his room after stating he
wanted to hurt himself. Two staff entered his
room as he went inside. Staff provided proximity
as client began to hit his head. Staff called for
additional staff as client began to hit his head with
increasing intensity and frequency. Staff blocked
the windows as client attempted to open them
and jump out of them.

Division of Health Service Regulation

STATE FORM

6809

K8ZJ11

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL011-203 07/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
111 COMPTON DRIVE
REUTER COTTAGE
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 110) Continued From page 3 Vv 110

If continuation sheet 4 of 51

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/06/2021
FORM APPROVED

(X3) DATE SURVEY

To prevent: discuss with clinician how to best
support client in setting appropriate boundaries
with staff and advocating to check-in with them.

-5/8/21 8:10 p.m. - IRIS - RI. Client was in the
gym and upset about mom and non-preferred
staff. He began to lightly head bang. He
transitioned back to the cottage and began head
banging in room. Client went outside and
engaged in verbal threats towards staff. His
behavior escalated and he started kicking glass
by the front door and it shattered. Client returned
to his room and began head banging. Incident
ended in a restrictive intervention.

-5/9/21 12:02 p.m. IR- Self injurious. Client was in
the gym and claimed he was lightly tapping his
head. He was transitioned to his room. Client
head banged and attempted to exit through his
window. Staff provided proximity and closed the
window. Staff utilized the "breaking up fight
technique" in order to prevent client from going
towards the staff at the side door. Staff utilized
the technique again as he tried to push past staff
in the hallway going towards the common area.
Staff continued to utilize the protective stance and
proximity as client continued trying to exit the
cottage. Staff entered client's room as he entered
and tried to leave through the window. Staff
utilized the protective stance to prevent him from
doing so. Staff continued to utilize protective
stance as client continued going from window to
window and trying to go out the door. Staff utilized
proximity as client continued to head bang and
run around his room in order to do so as staff was
preventing him. Staff set the expectation for client
to make a plan in order for him to leave his room.
To prevent: staff need to create plan before client
calls mom; increased checks during other's crisis;
continue to foster independent living skills.

Division of Health Service Regulation

STATE FORM

6809

K8ZJ11

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL011-203 07/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
111 COMPTON DRIVE
REUTER COTTAGE
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 110) Continued From page 4 Vv 110

If continuation sheet 5 of 51

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/06/2021
FORM APPROVED

(X3) DATE SURVEY

-6/23/21 4:30 p.m. IR- Self-injurious. Client was in
gym and had light head banging for
approximately 3 minutes. He was transitioned to
his room and head banged. Client transitioned to
the support room during dinner. Staff entered
support room and used headboard when staff
heard light head banging. Staff continued to use
headboards until client said he was done
because "...this isn't working," Staff set
expectation that client would have to make a plan
before leaving the support room.

To prevent: during unstructured blocks, staff can
manage by proactive check-ins to make a plan
and proximity to ensure follow through.

-5/29/21 4:25 p.m. IR- Self injurious. Safety check
of client in his room. Client was lightly tapping his
head on brick wall. Staff used a pillow between
his head and a wall. Client had a phone call with
his mother and was yelling at his mother. Staff
followed client onto porch and client returned to
common area. Staff gave client scissors to cut off
end of an anklet he was wearing. When given a
direct statement to return scissors, client
responded aggressively that he wasn't giving
scissors back. Staff provided grounding
technique of holding the client's hands which
continued until client handed over the scissors.
Client went outside and staff used proximity to
prevent client from kicking windows. Staff
informed client a restrictive intervention would be
initiated if he didn't stop hitting windows. Client
walked around the back of the cottage and lightly
tapped his knuckles on a brick wall. Staff placed
a headboard between client's fist and wall. Staff
encouraged client to hit headboard instead of wall
and provided positive encouragement for hitting
headboard with "cool karate kick." Client showed
safety, returned to cottage and then room.

Division of Health Service Regulation

STATE FORM

6809

K8ZJ11

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL011-203 07/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
111 COMPTON DRIVE
REUTER COTTAGE
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 110) Continued From page 5 Vv 110

If continuation sheet 6 of 51

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

NAME OF PROVIDER OR SUPPLIER

A. BUILDING:

MHLO011-203

111 COMPTON DRIVE

PRINTED: 08/06/2021

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

07/02/2021

REUTER COTTAGE
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 110) Continued From page 6 Vv 110

Trigger: client started day in "unusually bad
mood", client expressed bad phone call with mom
as trigger.

To prevent: staff will be very mindful of this
behavior possibly occurring when client has
phone calls with mom.

-6/2/21 5:35 p.m. - IR - Client in gym - Client was
picking at wound on his foot and punching a wall.
In the cottage, client was "weaponing forks,"
grabbed pen and ran outside.

To prevent: staff proactively monitoring for
potential triggers from peers, keeping kitchen
managed, removing the audience.

-6/5/21 12:45 p.m. IRIS -RI - Client was in the
gym, isolated himself, and said he was head
banging. In the cottage, he head banged on the
wall and the floor. This resulted in a restrictive
intervention.

To prevent: continue proactive support and
options for client. Brainstorm ideas with clinician
on how to encourage client to seek positive
attention from staff.

Review on 6/29/21 of the Reuter Cottage
Schedule Template for 2021 provided by the
Residential Director revealed:

-unstructured time of
self-reflection/self-support/choice time scheduled
4 times a day during weekdays and 5 times a day
on weekends.

-movie time was scheduled 2 times a day on
weekends.

-the gym was scheduled for weekends.

-there was no alternative plan/schedule for Client

Interview on 6/11/21 with Staff #1 revealed:
-she was the Lead Residential Counselor and

Division of Health Service Regulation
STATE FORM

6809

K8ZJ11

If continuation sheet 7 of 51

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/06/2021
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL011-203 07/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
111 COMPTON DRIVE
REUTER COTTAGE
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 110) Continued From page 7 Vv 110

typically worked the second shift.

-she learned of clients’ needs, triggers and
behaviors as "...kids will tell you..."

-there was a staff meeting each week and any
updates for a client were emailed.

-Client #1 was attention seeking, he head bangs,
but unlike other clients' who are self-injurious, he
was not harming himself, it was more attention
seeking.

-"...try to be pro-active, keep him engaged,
distractions...very kiddish kind of
engagement...behavior not predictable..."

-when he was head banging it was more like
“notice me."

-they first gave him prompts and try to redirect
him. If he keeps going they would use a
headboard to block his head from hitting the
concrete wall.

Interviews on 6/11/21 and 6/23/21 with Staff #2
revealed:

-there were meetings every Wednesday. They
met as a cottage and the supervisor would inform
them of new clients, and the counselor would
notify them of specific client strategies.

-this usually happened within a couple days of
admission.

-the client will also complete paper work
regarding what makes them angry, triggers, what
helps them, and their interest.

-Client #1: "...at beginning he was doing really
good. | don't' know what happened. He might be
scared of going home, having behavior as
avoidance...to avoid going home. When he talks
of going home, he gets anxious and see
increasing in behaviors. ..."

-she attempted to use verbal re-direction to
distract him from self-harm with drawing or
painting on his arm.

Division of Health Service Regulation
STATE FORM

-she learned about new clients when they arrived.

6809

K8ZJ11

If continuation sheet 8 of 51

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/06/2021
FORM APPROVED

(X3) DATE SURVEY

Interview on 6/24/21 with Staff #3 revealed:

-she learned about clients’ triggers, strategies,
what works, what doesn't work via a support plan
completed by intake staff.

-it was better to hear from the client what worked
and what didn't work; as they got to know the
client they could update the support plan.

-when Client #1 was self-harming "heavily,"
scratching at arms, or legs she would try to
distract him verbally or take his hands and gently
redirect him.

-physical touch was the most effective. Like just
putting her hand on the arm of the client.

Interview on 6/24/21 with the Cottage Supervisor
revealed:

-she worked on the floor with the clients. Every
Tuesday she had the client's come to the office to
check-in, see what they need from the store and
she would pick it up for them.

-the staff came together at the end of their shift to
debrief, discuss what happened on their particular
shift and if there were any incidents.

-Staff rely on intake information to know what
triggers a client and what their strategies were.
-there was a white board in the office that had the
client's initials, age, triggers, and what they liked;
they would also talk to the clients and find out.
-there was also an internal document sent out 3
times a day via email detailing how each client did
on each shift.

-when asked about training for the Psychiatric
Residential Treatment Facility (PRTF) staff
coming to the level III cottage - "theoretically it's in
a pre-service."

- if the staff do not know what interventions may
or may not be used she will sit down with that
staff and use the minutes from their team
meetings to teach them about clients’ and

Division of Health Service Regulation

STATE FORM

6809

K8ZJ11

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL011-203 07/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
111 COMPTON DRIVE
REUTER COTTAGE
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 110) Continued From page 8 Vv 110

If continuation sheet 9 of 51

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/06/2021
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL011-203 07/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
111 COMPTON DRIVE
REUTER COTTAGE
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 110) Continued From page 9 Vv 110

possible interventions to be used.

-a strategy recently used on Client #1 that
worked, was to take off marker tops, and
changed the caps as a distraction.

-the Cottage Supervisor's meet every Tuesday
and discuss other strategies and share
announcements with staff.

Interviews on 6/16/21, 6/17/21 and 6/24/21 with
the Residential Director revealed:

-his role was to oversee the staff and supervisors
of all residential programs.

-he was also one of the TCI trainers.

-the staff were aware of client's issues, triggers
and what worked best for them through the
Cottage Supervisor.

-they had team meetings once a month where
they talked about every client and the Cottage
Supervisor was a part of this meeting.

-the therapist reviews goals and gets the
progress of goals from staff and will update the
treatment plans.

-they had a milieu review every week, all direct
care staff participate, and they reviewed each
client during the meeting and the minutes were
available to staff on the home drive as well.

-the milieu review was how staff got updates, and
learned about each client.

-clients were able to find glass because windows
get broken, they get cleaned up, but as clients
walk around campus they find different items to
pick up.

-" ...we can only police it so much, kids find
things."

-a "Yoke" was part of the TCI initiation process for
aRl.

-he described "It's how you get in position...step
one of the restrictive intervention...hands on...to
get in position..."

-staff would "...approach from behind...for

Division of Health Service Regulation
STATE FORM

6809

K8ZJ11

If continuation sheet 10 of 51

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/06/2021
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL011-203 07/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
111 COMPTON DRIVE
REUTER COTTAGE
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 110) Continued From page 10 Vv 110

standing...staff would come from behind to hold
arms and then move into restrictive
intervention..."

-when a client was head banging, he looked at
what's causing this, reach out to nursing, use
head boards, or something soft; they were trying
to get away from using hands.

-they called it a "caring gesture;" there was a fine
line with head banging and how long they could
let it go on.

-" ...sometimes physical touch is used as a
grounding thing; if | am upset, let me know you
are there."

-they currently had a couple of clients threatening
to kill staff/peers; no one was currently on a
special staffing situation, or assigned a
one-on-one staff.

-at the beginning of shift, staff designate a point
person to focus more on a particular client.
-expectations of staff were to be in "eyesight and
earshot at all times when they are out of the
room."

-"| believe [Client #1] would be on eyesight, it
would be documented in email, [clinician name]
would indicate that."

-incident reports - supervisor team reviews them,
how something may have worked and try to help
staff with their documenting.

-the Quality Assurance committee looked at
incidents quarterly. They did not look at strategies
for each individual.

-incidents were randomly pulled as a peer review
and various staff were asked to review them and
give input.

-when asked about the frequency of incidents for
Client #1 -" ...would be in team minutes, if
something specific to that student, emailed to
staff."

-they staffed Client #1 on 5/8/21 and saw this
trend and initiated strategies and revisited it about

Division of Health Service Regulation
STATE FORM

6809

K8ZJ11

If continuation sheet 11 of 51

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/06/2021
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL011-203 07/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
111 COMPTON DRIVE
REUTER COTTAGE
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 110) Continued From page 11 Vv 110

a month later.

-they looked at it from a bigger perspective. They
had been trying certain interventions; tried to
determine what was working and what was not
working.

-they would usually get a lot of insight from
processing with the client; "...but [Client #1] is
lower functioning..."

-they had been looking to transition Client #1 to
another program for " ...a bit."

Interviews with the Clinician on 6/17/21, 6/24/21,
and 6/30/21 revealed:

-she was not aware of the movie that triggered
the client because it was too violent.

-she did not give input on what the 2nd shift did
for activities.

-she felt it was an inappropriate movie for the
entire milieu.

-she has told staff it was important to have
opportunities to do real life things, for example
had Client #1 mop floor and provide information
why work regulates their mood.

-she and the case manager had conversations
during the last team meeting addressing that "we
are a therapeutic plan and everything we do has
to have a therapeutic component...not something
we discuss every week but talk about it regularly."
-staff decided what activity the clients’ did in the
afternoons and evenings.

-the Cottage Supervisors might have a role but
she was not sure.

-she felt giving the client scissors would have
been ok, "if he was in a safe space, in common
area...what head space was he in, a lot of factors
would be involved in that decision."

This deficiency is cross referenced into 10A
NCAC 27G.1701 Scope (V293) for a Type A1 rule
violation for serious neglect and must be

Division of Health Service Regulation
STATE FORM

6809

K8ZJ11

If continuation sheet 12 of 51

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/06/2021
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL011-203 07/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
111 COMPTON DRIVE
REUTER COTTAGE
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 110) Continued From page 12 Vv 110
corrected within 23 days.
V 112| 27G .0205 (C-D) v112

Assessment/Treatment/Habilitation Plan

10A NCAC 27G .0205 ASSESSMENT AND
TREATMENT/HABILITATION OR SERVICE
PLAN

(c) The plan shall be developed based on the
assessment, and in partnership with the client or
legally responsible person or both, within 30 days
of admission for clients who are expected to
receive services beyond 30 days.

(d) The plan shall include:

(1) client outcome(s) that are anticipated to be
achieved by provision of the service and a
projected date of achievement;

(2) strategies;

(3) staff responsible;

(4) aschedule for review of the plan at least
annually in consultation with the client or legally
responsible person or both;

(5) basis for evaluation or assessment of
outcome achievement; and

(6) written consent or agreement by the client or
responsible party, or a written statement by the
provider stating why such consent could not be
obtained.

This Rule is not met as evidenced by:
Based on record reviews and interviews, the

Division of Health Service Regulation
STATE FORM

6809

K8ZJ11

If continuation sheet 13 of 51

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/06/2021
FORM APPROVED

(X3) DATE SURVEY

facility failed to develop and implement effective
goals and strategies to meet the client's needs
affecting 1 of 3 clients audited (Client #1). The
findings are:

Review on 6/16/21 of Client #1's record revealed:
-admitted 12/23/20.

-17 years old - identified as a transgendered
male.

-diagnoses of Post-Traumatic Stress Disorder,
Major Depressive Disorder with psychotic
features, Generalized Anxiety Disorder with
Obsessive-Compulsive features, Gender
Dysphoria, Specific Learning Disorder and
Attention-Deficit Hyperactivity Disorder.

Review on 6/16/21 of Client #1's Comprehensive
Clinical Assessment (CCA) dated 12/9/20 with
updates of 4/19/21, 4/23/21, 5/3/21 and 5/11/21
revealed:

-he was admitted from a Psychiatric Residential
Treatment Facility (PRTF).

-history of sexual abuse, parental divorce, and
incarcerated household member.

-history of self-injurious behaviors, poor insight
and control over emotions; had not engaged in
self-harm for over a month.

-he continued to need assistance in coping skills
for hallucinations, depression and anxiety.

-had displayed significant progress with decline in
Suicidal Ideations/Self-Injurious Behaviors
(SI/SIB) in PRTF.

-5/11/21 - most recent CCA update -
demonstrated the following behaviors since
admission to Reuter - daily self-harm to include:
cutting self with paper or fingernail, carving name
of abuser onto stomach with fingernail, head
banging, leaving the cottage without permission
and walking around campus, property destruction
to include breaking windows, suicidal ideations,

Division of Health Service Regulation

STATE FORM

6809

K8ZJ11

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL011-203 07/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
111 COMPTON DRIVE
REUTER COTTAGE
ASHEVILLE, NC 28806
(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 112) Continued From page 13 Vv 112

If continuation sheet 14 of 51

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/06/2021
FORM APPROVED

(X3) DATE SURVEY

violence towards staff in the form of biting, hitting
and kicking.

-required 1-1 support to regulate.

-experiencing nightmares and flashbacks - he
referred to as "voices."

-recently beginning to refuse therapy.

-as of 5/10/21 - his ability to remain safe appears
to be more difficult.

-reported suicidal thoughts that he "just wants to
die."

-"...had difficulty partnering with staff and clinical
providers to identify ways to support her to reduce
self-harm ...currently demonstrates behaviors that
are more appropriate for a PRTF level of care,
which is the current recommendation."

Review on 6/16/21 of Client #1's
Person-Centered Profile (PCP) dated 12/9/20 and
updated 1/11/21, 2/2/21, 3/1/21, 4/6/21, 5/13/21
and 6/11/21 revealed:

-12/9/20 -goals: 1. Exhibits poor impulse control
and 2. History of SI/SIB.

-6/11/21 - most recent update - goal: 1.
"...Struggles to manage flashbacks and emotion
regulation...will demonstrate an improvement in
trauma symptoms..."

-"...will practice the use of mindfulness activities
once each shift as a way to decrease [his]
flashbacks with the assistance of staff and
clinician...will practice using effective
communication skills with [his] mom with the
assistance of clinician during family therapy
sessions..."

-How (Support/Intervention) -"...will participate in
assessments to help with treatment planning and
identification of strengths, triggers, and preferred
coping skills. Participate in individual, family (if
applicable), and group therapies. Attend and
participate in Child and Family Team
Meetings....utilizing co-regulation with staff along

Division of Health Service Regulation

STATE FORM

6809

K8ZJ11

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL011-203 07/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
111 COMPTON DRIVE
REUTER COTTAGE
ASHEVILLE, NC 28806
(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 112) Continued From page 14 Vv 112

If continuation sheet 15 of 51

PRINTED: 08/06/2021

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL011-203 TT 07/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
111 COMPTON DRIVE
REUTER COTTAGE
ASHEVILLE, NC 28806
(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 112) Continued From page 15 Vv 112

with self-regulation when planning safety goals
with [him]. [Client #1] will be encouraged to utilize
disengagement from situations that aren't in-line
with [his] treatment goals. Staff will utilize
proactive check-ins for [Client #1] in order to
develop healthy coping skills in an effort to
decrease flashbacks."

-How continued: "Level III Residential with
planned use of restrictive intervention: ...Provide
recreation and exercise opportunities such as
basketball, football...use of exercise room/gym.
Provide therapeutic daily schedule/routine to
reduce arousal levels, and prepare students for
transitions..."

-goal: 2. Struggles with depressive symptoms -
"...demonstrate an improvement in mood
regulation as evidenced by the following:...will
continue to use writing as a way to process [his]
emotions and then share them during individual
therapy sessions for guidance in reframing
negative cognitions..."

-How - same as first goal with addition of "...
[Client #1] will be encouraged by staff to utilize
co-regulation and staff support surrounding the
regulation of [his] mood. Staff will ask [Client #1]
to be mindful of boundaries with staff in order for
[him] to get [his] needs met. Staff will provide
[Client #1] praise for sharing truthful stories to
staff and peers and provided with feedback in
[his] attempts to discuss [his] trauma during
inappropriate settings."

-How continued: "...Level III staff will assist [Client
#1] with mood regulation as evidenced by:
leadership roles in the cottage, praise for
appropriate group sharing, staff co-regulation,
redirection from peer crisis, feedback about their
treatment progress, and goal centered check-ins.
Staff will provide a minimum risk schedule and
cottage environment to assist [Client #1] in [his]
processing ability and peer relations."
Division of Health Service Regulation

STATE FORM 6899 K8ZJ11 If continuation sheet 16 of 51

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/06/2021
FORM APPROVED

(X3) DATE SURVEY

-There were no specific strategies to address the
difficulty of staff and clinical partnering to identify
ways to support the client in reducing self-harm.
-The client's self-harm of head banging and
cutting continued and escalated to property
destruction, hitting and kicking staff.

-Strategies to support the client and staff during
times the client was triggered by his mom were
not identified.

-Alternative strategies were not provided when
the client identified the gym/weight barn were
triggers.

-Strategies were not developed to address the
identified need that 1-1 support was required to
regulate the client.

-Strategies were not developed to address the
client when he began to refuse therapy.

Review on 6/16/21 of Client #1's Crisis
Prevention and Intervention Plan initially dated
12/9/20 and last revised on 6/11/21 revealed:
-"What are some events or situations that have
caused me trouble in the past?...1 get triggered
when people touch me."

-3/1/21 - Triggers: topic of safety, his abuser,
being bored, feeling unsafe when returning home,
staff not paying attention to him.

-4/6/21 - Triggers: topic of safety or needing to be
safe. "...[He] has reported that the gym and
weight barn are triggers, not receiving attention
by preferred staff or check-ins from preferred
staff."

-5/13/21- "Banging [his] head as a form of stress
relief...Fabricating stories. Glorifying self-harm.
Talking about self-harm in the common area. Will
refuse to process incident or will process very
superficially...pick up objects from outside and
report [he] will kill [himself] with the object. Will
refuse to process with non-preferred staff."
-6/2/21 - Triggers: peers in crisis, phone calls with

Division of Health Service Regulation

STATE FORM

6809

K8ZJ11

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL011-203 07/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
111 COMPTON DRIVE
REUTER COTTAGE
ASHEVILLE, NC 28806
(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 112) Continued From page 16 Vv 112

If continuation sheet 17 of 51

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/06/2021
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL011-203 07/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
111 COMPTON DRIVE
REUTER COTTAGE
ASHEVILLE, NC 28806
(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 112) Continued From page 17 Vv 112

mom, over stimulated when given too much or
too little attention, seeing preferred staff give
other peers attention, internalizing and/or
imitating other peers' crisis situations.

-"What are the early warning signs that | am not
doing well?... (Prevention and Early Intervention
Strategies) | run to my room and isolate myself. |
shut the door. | stop talking."

-3/1/21 - Strategies: "Presenting a firm schedule
with alternatives if [he] doesn't like an activity.
Appealing to [his] interests. Using humor and real
talk work well."

-4/6/21 - Strategies: "Making a plan, providing
distractions, redirection and caring gestures."
-5/13/21 - Strategies: Allow to set own goals for
safety. Provide neutral staff and hold firm
expectations. Provide positive feedback.

-6/2/21 - Strategies: Proactive check-in with
preferred staff, one-on-one attention, give specific
invitations to participate in activities, challenge
some of his stories.

-"If lam in crisis, what are ways that others can
help me and how can | help myself? What
strategies do not work well for me? Staff should
talk to me in a calm way. Remind me of my family
and that they think | am important. If | have to be
restrained, | prefer women...| don't like to be
touched when | am upset."

-3/1/21 - Strategies: "Being around [him] but not
talking until [he] is ready for a check-in."

-4/6/21 - Strategies: Humor, role playing with
staff.

-5/13/21 - no strategies listed.

-6/2/21 - Strategies: one-on-one attention, make
plans for check-in and safety.

-"Additional strategies for [client] can be found in
the following documents: Clinical Case review
minutes, Multi-disciplinary treatment team

Division of Health Service Regulation
STATE FORM

6809

K8ZJ11

If continuation sheet 18 of 51

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/06/2021
FORM APPROVED

(X3) DATE SURVEY

minutes, Direct care staff shift notes, Child and
family treatment team meeting minutes, Individual
Crisis Management Plans, and incident reports."

Review on 6/17/21 of Individual Crisis
Management Plans (ICMP) for Client #1 from
March 2021 to present revealed:

-meetings held 3/17/21, 4/2/21, 4/28/21, 5/5/21,
5/8/21, 6/3/21, 6/5/21, 6/10/21 and 6/15/21.
-issues/triggers identified: "...Mother, being called
[birth name], talking about safety or needing to be
safe. [Client #1] has reported that the gym and
weight barn are triggers, not receiving enough
attention by preferred staff or receiving check-ins
from preferred staff...", phone calls with mom,
and peers being in crisis.

-high risk behaviors identified: self harming, head
banging, picking at skin, scratching, writing name
of abuser on head and arms, "flashbacks," raising
voice, rapid and loud transitions, isolating in
room, defiance, name calling and screaming,
attempting to open window, attempting to trigger
peers, tear at staff clothing, attempting to cut staff
or self with cardboard from puzzle box or pieces
of glass, ingesting soap and broke markers to
self -harm, running out of cottage, breaking
window, threatening and instigating peers;
opening window or side door triggering the alarm,
breaking window, drawing several pictures
depicting guns and shooting people and voiced
his plan to kill peers, staff, his mom and himself.
-strategies identified: make a plan, provide
distractions, redirection and caring gestures,
neutral staff, silence with "proximity" (being
around him but not talking until he is ready),
humor, role playing with staff, surprise him with a
random saying, "...support screams (going
outside and screaming), temperature changes for
grounding (warm wash cloth), running laps...."
one-on-one attention, set expectations and then

Division of Health Service Regulation

STATE FORM

6809

K8ZJ11

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL011-203 07/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
111 COMPTON DRIVE
REUTER COTTAGE
ASHEVILLE, NC 28806
(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 112) Continued From page 18 Vv 112

If continuation sheet 19 of 51

PRINTED: 08/06/2021

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL011-203 07/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
111 COMPTON DRIVE
REUTER COTTAGE
ASHEVILLE, NC 28806
(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 112) Continued From page 19 Vv 112

disengage, use "real talk", provide firm
expectation, provide with options so can feel
sense of control, set clear consequences and
then let him make decision, physical touch (i.e.
tapping back, hand pressure on back, wedging
body between client and wall to prevent head
banging), allow him to paint a staff hand/arm,
disengage during crisis and have a side
conversation that he will want to engage in,
remove the audience by separating him from the
milieu, proactively ensure safety by managing the
environment, and offer positive feedback when
client discloses SI/HI to staff or clinician rather
than harming others.

-there were no strategies to address the gym and
weight barn, his mom and not liking to be touched
that were identified triggers.

Review on 6/18/21 of Child and Family Team
(CFT) Meeting Minutes from March 2021 through
May 2021 revealed:

-meetings held on 3/1/21, 4/6/21, and 5/13/21.
-strategies identified: corrective logic, keep in
eyesight when unsafe behavior demonstrated,
ask for help with a task, and provide leadership
opportunities.

-5/13/21 - struggles to remain safe, behavior
increasing, revisit transition plan to PRTF.

Review on 6/18/21 of Clinical Case Review notes
from 3/10/21 through 6/2/21 revealed:

-meetings on 3/10/21, 4/7/21, 5/5/21, and 6/2/21.
-how/interventions: support walk, activities during
day, staff tell him they like spending time with him
and encourage him to demonstrate appropriate
behaviors, exaggerated praise, lowering
expectations, and challenge to use coping skills
by asking him to write a song about it.

Review on 6/21/21 of Residential Multidisciplinary

Division of Health Service Regulation

STATE FORM

6809

K8ZJ11

If continuation sheet 20 of 51

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/06/2021
FORM APPROVED

(X3) DATE SURVEY

Team Meetings for Client #1 from March 2021
through May 2021 revealed:

-meetings on 3/30/21, 4/20/21 and 5/18/21.
-restrictive interventions and self-harm incidents
reviewed.

-alternatives identified: short term goals were
"...somewhat effective..." depending on his "head
space" at the time, structured activities that
allowed client to have staff's attention - he
preferred 1-1 staff.

Review on 6/18/21 of Special Staffing's for Client
#1 dated 5/10/21 and 6/8/21 revealed:

-5/10/21 Reason for Special Staffing: Client #1
had gradual increase in acuity through self-injury
behaviors, property destruction, and running
behavior.

Identified Triggers: "Everything with Mom,
Inconsistency with mom-lies and support. Talking
to mom, or feeling like mom is avoiding [him].
Feeling unwanted by mother. Not being
recognized to the degree [he] feels is necessary.
The word Safety."

Preventative Strategies: same as mentioned in all
the above documents.

-6/8/21 - Reason for Special Staffing: Concerns
of self-injurious behaviors. Thirty day follow-up
meeting to determine appropriate strategies and
transition plan.

Preventative Strategies: "The strategies above
are still relevant and working... Staff call mom
before hand and discuss the current space of
[Client #1] to support the phone call and avoid
triggering a crisis."

-mom was an identified trigger as early as
3/17/21.

Review on 6/15/21, 6/16/21, 6/17/21, 6/22/21,
6/23/21, and 6/24/21 of facility Incident Reports
(IR), facility Level Ill Restrictive Intervention

Division of Health Service Regulation

STATE FORM

6809

K8ZJ11

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL011-203 07/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
111 COMPTON DRIVE
REUTER COTTAGE
ASHEVILLE, NC 28806
(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 112) Continued From page 20 Vv 112

If continuation sheet 21 of 51

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/06/2021
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL011-203 07/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
111 COMPTON DRIVE
REUTER COTTAGE
ASHEVILLE, NC 28806
(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 112) Continued From page 21 Vv 112

Incident Reports (RI) and the North Carolina
Incident Response Improvement System (IRIS)
for Client #1 from March 2021 to June 2021
revealed:

-incidents continued with mom being his trigger;
18 from 3/4/21 through 6/10/21.

-the client continued to be taken to the
gym/weight barn after he identified this as a
trigger.

-3/4/21 8:12 p.m. IR- Self injurious- head banging
on concrete wall in his room, threatened to open
window.

Trigger: phone with mom calling client by his legal
name.

Ways to manage the identified trigger to prevent
future incidents: Staff can continue to work on
support plan prior to calling mother, clinician can
speak with mother to further support plan.

-3/18/21 8:25 p.m. IR- Self-injurious. Client
scratched his arm, head banged on a concrete
wall in his room, threatened, scratched, kicked
and pushed staff.

Trigger: family situation, feeling like mom doesn't
care.

To prevent: talk with clinician about having
conversation with mother about communication
with client.

-3/19/21 5:00 p.m. IR- Self-injurious. Head
banged in room on concrete wall, and tried to
open window.

Trigger: by "internal family situations."

To prevent: proactive check-in between activities,
and clinician getting in contact with guardian
(mom).

-3/20/21 12:30 p.m. IRIS- Self injurious. Head
banged in room for close to 30 minutes. Sent to

Division of Health Service Regulation
STATE FORM

6809

K8ZJ11

If continuation sheet 22 of 51

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/06/2021
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL011-203 07/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
111 COMPTON DRIVE
REUTER COTTAGE
ASHEVILLE, NC 28806
(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 112) Continued From page 22 Vv 112

hospital due to prolonged head banging.
Triggers: client identified internal thoughts
bothering him but would not disclose specifics to
staff.

To prevent: by communication with clinical to get
in contact with mother.

-3/20/21 7:00 p.m. IRIS -RI Escalation episode
lasting approximately 2 hours. Client head
banging. Client was physically restrained 3 times
during this incident.

Triggers: Mom visited this day - update to
treatment plan recommended.

Ways to manage the identified trigger to prevent
future incidents: by providing one-on-one staffing
to keep client engaged.

Did not respond to attempted interventions.
Triggers: mom not answering phone, and him not
getting enough attention - update to treatment
plan recommended.

Ways to manage the identified trigger: proactive
check-ins during or after each activity and inviting
him to play cards.

-3/24/21 7:36 p.m. IR- Self injurious. Client
scratched self with soap dispenser.

Triggers: phone call with mom who called him by
his legal name.

To prevent: create a plan before starting a call
with mom.

-3/27/21 1:02 p.m. IRIS -RI Client head banged
against concrete wall.

Triggers: did not want to watch movie (Hunger
Games) saying it was too violent.

Ways to manage the identified trigger: "Proactive
alternate activity during non-preferred blocks."

Division of Health Service Regulation
STATE FORM

-3/21/21 10:00 a.m. IRIS - RI Client head banged.

6809

K8ZJ11

If continuation sheet 23 of 51

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

A. BUILDING:

MHLO011-203

111 COMPTON DRIVE

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

PRINTED: 08/06/2021

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

07/02/2021

-3/29/21 7:20 p.m. IR- Head banged and ran out
of cottage.

Trigger: staff redirecting client from having journal
in common area; anniversary of friends
anniversary; a peer off task.

Client stated he was stressed and confused
because mom was supposed to visit but
cancelled again.

To prevent: staff should refrain from offering
support walks while peers were off task.

-3/30/21 8:00 p.m. IRIS -RI Client was head
banging in his room. He refused to stop.
Proximity, caring gesture, physical outlets, staff
support, real talk, open-ended questions, coping
skills, and prompts were all ineffective.
Triggers: voices and flashbacks.

Ways to manage the identified trigger: proactive
check-ins, separate from milieu when he
becomes escalated.

-4/2/21 11:40 a.m. IR- Self injurious. Client
scratched his arm with a broken marker cap,
attempted to scratch stomach, and ingested

Triggers: Client having intrusive thoughts of peer
who died by suicide; per client the identified
trigger was lack of attention from preferred staff.
To prevent: manage the restroom; provide
positive and consistent feedback for healthy
behaviors.

-4/6/21 8:42 p.m. IRIS -RI Threatened to kill self,
attempted to open window, ran out of cottage,
and head banged.

Triggers: Client identified hearing voices, wanting
to kill himself when hears voices, losing control
over his life, mom having guardianship when he
turned 18.

Environmental effects: it was less structured due

Division of Health Service Regulation
STATE FORM

6809

K8ZJ11

REUTER COTTAGE
ASHEVILLE, NC 28806
(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 112) Continued From page 23 Vv 112

If continuation sheet 24 of 51

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/06/2021
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL011-203 07/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
111 COMPTON DRIVE
REUTER COTTAGE
ASHEVILLE, NC 28806
(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 112) Continued From page 24 Vv 112

to it being "choice time."

-4/12/21 7:50 p.m. IRIS -RI_ Head banged, ran
out of cottage, threatened to kill self. Client was
physically restrained 2 times during this incident.
Triggers: client upset his mother did not visit
when she said she would, feeling lied to by mom.
Ways to manage: provide a structured activity
outside client's room until at baseline.

-4/14/21 3:00 p.m. IR- Self injurious. Client
expressed wanting to die, scratched self with
rock/stick and head banged.

Trigger: student identified feeling controlled by
mom.

To prevent: staff will continue to provide proactive
check-ins and encourage client to use coping
skills.

-4/15/21 7:00 p.m. IR -Self injurious. Head
banged on ground.

Trigger: phone call with mom. Update to crisis
plan recommended.

To prevent: staff will switch out with preferred staff
for neutral staff upon escalation.

-4/29/21 6:00 p.m. IR- Self injurious. Head
banged in room, wanted to choke self, attempted
to open window.

Triggers: staff holding firm expectations while
completing chores while waiting for a phone call
after his peer; client identified feeling anxious to
go home and almost being 18.

To prevent: proactive support and redirect to
alternative preferred activities when client
requests were unable to be facilitated.

-4/30/21 6:40 p.m. IRIS -RI Client threw cups of
water at staff, grabbed trays and pots to hit staff,
began to grab staff's radios, keys and clothing

Division of Health Service Regulation
STATE FORM

6809

K8ZJ11

If continuation sheet 25 of 51

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/06/2021
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL011-203 07/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
111 COMPTON DRIVE
REUTER COTTAGE
ASHEVILLE, NC 28806
(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 112) Continued From page 25 Vv 112

items. Grabbed staff arms and choked staff.
Triggers: client not able to call mom on-time, staff
split doing a room search.

To prevent: staff to manage with proximity and
proactive engagement.

-5/7/21 5:30 p.m. IRIS -RI Scratched arms with
sticks and rocks, attempted to open cottage, ran
from the cottage, head banged on brick wall and
inside on concrete wall. Client was not receptive
to behavior support techniques.

Triggers: not having constant one-on-one staff
support; debriefing of incident indicated client
drained emotions about mom and not wanting to
go home.

To prevent: set mini-motivator to check in with
preferred staff.

-5/8/21 1:00 p.m. IR- Self injurious. Head banged
on concrete wall, attempted to open window, and
ran from cottage.

Trigger: client wanting preferred staff support;
student stated trigger was his brain telling him to
hurt himself.

To prevent: discuss with clinician how to best
support client in setting appropriate boundaries
with staff and advocating to check-in with them.

-5/8/21 8:10 p.m. IRIS -RI Client was in gym and
began head banging. This continued once in
room, and he also kicked window at front door of
cottage and broke it.

Trigger: client stated when he was in gym he
talked with staff about another peer and he was
getting escalated. Staff identified trigger as client
finding out Mother's Day was tomorrow.
Environment effects: having unlocked cottage
enabling client to go outside and less staff
available. Preferred staff was helping other peers
which was triggering. "There were multiple

Division of Health Service Regulation
STATE FORM

6809

K8ZJ11

If continuation sheet 26 of 51

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/06/2021
FORM APPROVED

(X3) DATE SURVEY

non-consistent staff on the floor." Update to
treatment plan recommended.

To prevent: continue to assist client in making
support plan for self-supporting blocks.

-5/9/21 12:02 p.m. IR- Self injurious. While in
gym, client claimed he was lightly tapping his
head, continued head banging in cottage,
attempted to open window, ran from cottage
through front door.

Trigger: client identified mom not answering
phone consistently as trigger; staff identified client
struggles during less structured activities like
choice and lunch/movie.

To Prevent: Staff to discuss with clinician how to
best support client. Update to crisis plan
recommended.

-5/23/21 4:30 p.m. IR- Self-injurious. In gym,
client head banged and this continued in his
room.

Trigger: staff identified a phone call with mom as
well as less structured blocks during schedule
when preferred staff stepped off floor; client
identified being upset about his brother being
bullied at school and hearing voices, and staff
suggesting "support walks" and advocated for
them to say "flower picking."

To prevent: during unstructured blocks, staff can
manage by proactive check-ins to make a plan
and proximity to ensure follow through.

-6/29/21 4:25 p.m. IR- Self injurious. Client head
banged in room, walked out of the cottage, kicked
windows, and hit brick wall.

Trigger: client started day in "unusually bad
mood"; client expressed bad phone call with mom
as trigger.

To prevent: staff will be very mindful of this
behavior possibly occurring when client has

Division of Health Service Regulation

STATE FORM

6809

K8ZJ11

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL011-203 07/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
111 COMPTON DRIVE
REUTER COTTAGE
ASHEVILLE, NC 28806
(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 112) Continued From page 26 Vv 112

If continuation sheet 27 of 51

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/06/2021
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL011-203 07/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
111 COMPTON DRIVE
REUTER COTTAGE
ASHEVILLE, NC 28806
(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 112) Continued From page 27 Vv 112

phone calls with mom.

-6/1/21 4:00 p.m. IR- Self injurious. Client threw
water at staff, attempted to hit his staff, punching
wall, walked out of cottage.

Trigger: client identified peer walking out of gym,
and peer playing triggering song

To prevent: staff monitoring songs more closely
that are being played in common area.
Redirecting client when someone else gets
triggered.

-6/2/21 5:35 p.m. IR- Self injurious. Client was in
the gym and picked at wound on foot, punched
wall. In the cottage, he was "weaponing forks,
grabbed pen, ran outside."

Trigger: client identified being in negative head
space from start of shift and a peer talking about
Father's Day.

To prevent: staff proactively monitoring for
potential triggers from peers, keeping kitchen
managed, removing the audience.

-6/5/21 12:45 p.m. IRIS -RI Client was in the gym
- isolated self, and said he was head banging. In
cottage, he head banged on the wall and floor.
Triggers: Client's point of view: he felt sad and
overwhelmed; referenced his mom, brother,
abuser, and friends. Staff identified trigger as
client not having preferred staff attention. He was
annoyed with a peer while in the gym.

To prevent: continue proactive support and
options for client. Brainstorm ideas with clinician
on how to encourage client to seek positive
attention from staff.

-6/5/21 1:30 p.m. IR-Self injurious. Cut self with
glass, head banged on wall and floor.

Trigger: staff identified client being triggered by
his peers in common area; not receiving

Division of Health Service Regulation
STATE FORM

6809

K8ZJ11

If continuation sheet 28 of 51

PRINTED: 08/06/2021

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL011-203 07/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
111 COMPTON DRIVE
REUTER COTTAGE
ASHEVILLE, NC 28806
(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 112) Continued From page 28 Vv 112

preferred staff attention; being in escalated state
for multiple hours. The description identified him
being frustrated by a phone call. Crisis plan
update recommended.

-6/10/21 11:30 a.m. IRIS - Client drew 9 pictures
of nooses and guns illustrating him killing two
staff, three peers and himself. He also drew
himself, staff, and peers in the hospital in critical
condition with the names of staff and peers. The
clinician checked-in with client who confirmed he
intended to harm staff, peers and himself. It was
determined an Involuntary Commitment was
necessary and client was transported to hospital
by police.

Incident prevention: "Mediation and separation
from the group when conflict occurs."

Review on 6/17/21 of a Contact Log and Nursing
Report dated 6/10/21 and 6/12/21 revealed:
-6/10/21- Client #1 was approved for Involuntary
Commitment (IVC) and police arrived to take
client to the hospital.

-6/12/21 - returned from the hospital with no new
orders or discharge summary; called hospital to
obtain information and they reported Client #1
was not in their system.

Review on 6/28/21, 6/29/21 and 6/30/21 of
Clinical Service Notes (individual and family
therapy) for Client #1 from 3/3/21 through 6/10/21
revealed:

-there was no reference for a support plan,
guidance or brainstorming with the client and staff
to use prior to client calling his mom referenced in
the 3/4/21, 3/24/21, 5/8/21, 5/9/21, and 6/5/21
incidents as ways to prevent future incidents.
-incidents of self-injurious behaviors continued of
being triggered by mom, by mom's calls, mom
not answering the phone, or mom not coming to

Division of Health Service Regulation

STATE FORM

6809

K8ZJ11

If continuation sheet 29 of 51

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/06/2021
FORM APPROVED

(X3) DATE SURVEY

visit when scheduled on 3/4/21, 3/18/21, 3/19/21,
3/20/21, 3/21/21, 3/24/21, 3/29/21, 4/6/21,
4/14/21, 4/15/21, 4/29/21, 4/30/21, 5/7/21, 5/9/21,
5/23/21, 5/29/21 and 6/5/21.

Interview on 6/15/21 with Client #1 revealed:

-he denied ever being physically restrained.

-he tried to run; "...get mad so typically | try and
run away but always come back, just campus
wide."

-staff always knew when he ran because alarms
went off or they saw him.

-the staff ran after him, try to talk to him, he
denied they put hands on him.

-his goals were "to go home, safety is involved in
that, | stay safe most of the time ... draw my
emotions."

-he admitted safety issues were "cutting... maybe
1 time a week...haven't done it since Thursday."
-when questioned about head banging, he said
"...only ever done it once...haven't done it since.
-he denied ever having to go to the hospital as a
result of hurting himself.

Interviews with the Clinician on 6/17/21, 6/24/21,
and 6/30/21 revealed:

-she has "definitely seen" Client #1's behavior
which included self-harm, superficial cutting and
head banging.

-his behavior had "always been there but it is
increasing."

-he has shifted to no longer wanting to use
strategies that once worked.

-she checked-in with Client #1 to address his self
harm/suicidal ideation but did not complete notes
for these "check-ins."

-staff knew Client #1 was on eyesight via email
and the Cottage Supervisor would communicate
this face-to-face.

-she was aware the weight barn and gym were

Division of Health Service Regulation

STATE FORM

6809

K8ZJ11

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL011-203 07/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
111 COMPTON DRIVE
REUTER COTTAGE
ASHEVILLE, NC 28806
(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 112) Continued From page 29 Vv 112

If continuation sheet 30 of 51

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/06/2021
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL011-203 07/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
111 COMPTON DRIVE
REUTER COTTAGE
ASHEVILLE, NC 28806
(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 112) Continued From page 30 Vv 112

triggers for Client #1; she discussed this with him
but couldn't determine if it was the "space or
something that happened within those spaces
that were triggers."

-Staff took client outside of weight barn when he
was triggered.

-Staff discussed engaging client in another activity
rather than going to the weight barn or gym but
alternate activity depended on the number of staff
available to do this; she was not sure that would
have been possible.

-she was aware another trigger for client was
being touched; she gave staff information about
Client #1's triggers.

-it was "always a discussion to be having" if a
client should be restrained or not.

-the goal of SI/SIB was removed from the client's
treatment plan in response to "something that
came up during another licensure or something
about goals."

-the goal was individualized to address
flashbacks; "flashbacks are typically what cause
self-harm and if we can get a hold on flashbacks,
we can get a hold of other behaviors... there is
direct correlation between flashbacks and self
harm...flashbacks of the trauma and hearing
these voices of the specific people who abused
him."

-within the first two weeks of admission, she
created the individualized goals based on what
staff/clinician notices, feedback from team
meeting, and what the client reported.

-she then sent the goals to the staff in an email.
-she was responsible for updating goals.
-updates to strategies to address behaviors
“usually go in the ICMP, may not write goal, but
will update ICMP...so any staff coming into
cottage would know."

Review on 7/1/21 and 7/2/21 of a copy of the

Division of Health Service Regulation
STATE FORM

6809

K8ZJ11

If continuation sheet 31 of 51

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

A. BUILDING:

MHLO011-203

111 COMPTON DRIVE

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

PRINTED: 08/06/2021

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

07/02/2021

recording provided by the facility revealed
excerpts of the following:

-on 7/1/21 - surveyor notified facility of a Type A1
rule violation in the areas of scope with cross
references in competency of paraprofessionals,
assessment and treatment plans and training in
restrictive interventions.

-a Plan of Protection (PoP) for immediate actions
in these areas was requested.

-the Chief Executive Office (CEO), Chief
Operations Officer (COO), PQI (Performance and
Quality Improvement) Director, Clinical Director,
and Residential Director were present.

-surveyor requested at this time if there was more
information regarding the areas of
non-compliance the facility would like to provide
this would be accepted and reviewed prior to exit.
-asked if had one-on-one staff assigned - CEO -
"Oh not like an individual service provider, no we
don't do that unless we are in a seriously
dangerous situation, this means having someone
doing a support walk with him...not 1:1
assignment...let's clear that up."

-surveyor gave examples of restrictive
interventions that were not determined to be as
such; anything that restricts the client's
movement.

-COO - "We have kept [Client #1] safe this entire
time...we have kept him alive...we have kept him
secure within his own body with him being
transgender, no other PRTF will take him but he
is at imminent risk with us...is that what you are
saying?"

This deficiency is cross referenced into 10A
NCAC 27G.1701 Scope (V293) for a Type A1 rule
violation for serious neglect and must be
corrected within 23 days.

Division of Health Service Regulation
STATE FORM

6809

K8ZJ11

REUTER COTTAGE
ASHEVILLE, NC 28806
(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 112) Continued From page 31 Vv 112

If continuation sheet 32 of 51

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/06/2021
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL011-203 07/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
111 COMPTON DRIVE
REUTER COTTAGE
ASHEVILLE, NC 28806
(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 293] Continued From page 32 V 293
V 293] 27G .1701 Residential Tx. Child/Adol - Scope V 293

10A NCAC 27G .1701 SCOPE

(a) Aresidential treatment staff secure facility for
children or adolescents is one that is a
free-standing residential facility that provides
intensive, active therapeutic treatment and
interventions within a system of care approach. It
shall not be the primary residence of an individual
who is not a client of the facility.

(b) Staff secure means staff are required to be
awake during client sleep hours and supervision
shall be continuous as set forth in Rule .1704 of
this Section.

(c) The population served shall be children or
adolescents who have a primary diagnosis of
mental illness, emotional disturbance or
substance-related disorders; and may also have
co-occurring disorders including developmental
disabilities. These children or adolescents shall
not meet criteria for inpatient psychiatric services.
(d) The children or adolescents served shall
require the following:

(1) removal from home to a
community-based residential setting in order to
facilitate treatment; and

(2) treatment in a staff secure setting.

(e) Services shall be designed to:

(1) include individualized supervision and
structure of daily living;

(2) minimize the occurrence of behaviors
related to functional deficits;

(3) ensure safety and deescalate out of

control behaviors including frequent crisis
management with or without physical restraint;
(4) assist the child or adolescent in the
acquisition of adaptive functioning in self-control,
communication, social and recreational skills; and
(5) support the child or adolescent in

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/06/2021
FORM APPROVED

(X3) DATE SURVEY

gaining the skills needed to step-down to a less
intensive treatment setting.

(f) The residential treatment staff secure facility
shall coordinate with other individuals and
agencies within the child or adolescent's system
of care.

This Rule is not met as evidenced by:

Based on record reviews and interviews, the
facility failed to ensure services were designed to
minimize the occurrence of behaviors related to
functional deficits and ensure safety and
deescalate out of control behaviors including
frequent crisis management with or without
physical restraint affecting 1 of 3 clients audited
(Client #1). The findings are:

Cross Reference: 10A NCAC 27G.0204
COMPETENCIES AND SUPERVISION OF
PARAPROFESSIONALS (V110) Based on record
reviews and interviews, 2 of 3 staff (Cottage
Supervisor and Residential Director) failed to
demonstrate the knowledge, skills and abilities
required by the population served.

Cross Reference: 10A NCAC 27G.0205
ASSESSMENT AND
TREATMENT/HABILITATION OR SERVICE
PLAN (V 112) Based on record reviews and
interviews, the facility failed to develop and
implement effective goals and strategies to meet

Division of Health Service Regulation

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AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL011-203 07/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
111 COMPTON DRIVE
REUTER COTTAGE
ASHEVILLE, NC 28806
(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 293] Continued From page 33 V 293

If continuation sheet 34 of 51

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/06/2021
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL011-203 07/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
111 COMPTON DRIVE
REUTER COTTAGE
ASHEVILLE, NC 28806
(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 293] Continued From page 34 V 293

the client's needs affecting 1 of 3 clients audited
(Client #1).

Cross Reference: 10A NCAC 27E.0108
TRAINING IN SECLUSION, PHYSICAL
RESTRAINT AND ISOLATION TIME-OUT (V537)
Based on record reviews and interviews, facility
staff (Director of Residential Services) failed to
demonstrate competency in the proper use of
restrictive intervention procedures.

Review on 7/1/21 of the Plan of Protection dated
7/1/21 written by the Chief Executive Officer
revealed:

What immediate action will the facility take to
ensure the safety of the consumers in your care?

"Effective @ 1PM today in response to this
request for a POP, the following immediate
actions have been completed. [Client #1] will
have a staff dedicated during waking hours to
monitor this student. [Client #1] will also have
support walks as requested, unless there is a
safety reason why this cannot occur. During
sleeping hours all staffing and safety protocols
will be maintained.

Arisk assessments of [Client #1] and all other
students on campus within residential services to
include EAC [Eliada Assessment Center] and
Reuter students were completed at 1PM.
Following this initial assessment, to further
ensure safety, additional risk assessments will be
completed following any concerning behaviors.
With risk assessments that indicate concern, the
clinician will contact the Clinical Director and
immediately implement appropriate safety
measures.

In addition to the risk assessments to further
ensure safety and monitor for any changes in

Division of Health Service Regulation
STATE FORM

6809

K8ZJ11

If continuation sheet 35 of 51

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/06/2021
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL011-203 07/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
111 COMPTON DRIVE
REUTER COTTAGE
ASHEVILLE, NC 28806
(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 293] Continued From page 35 V 293

safety levels, clinical check ins will be conducted
daily with each student and 2 times per day with
[Client #1]. During weekend hours the onsite
supervisor will conduct these check ins and report
any concerning findings to the clinician on call.
In addition to the items identified above the
agency will maintain current protocols to include
wanding students upon entry and exit of day
treatment services, managing the common area
each shift for items that could be utilized for self
injurious behavior, and managing student rooms
for any hidden items.

In addition to medication administration, nursing
will conduct daily wellness checks with the
students in each cottage.

On call leadership to include clinical staff,
residential leadership staff and senior staff are
available to staff by phone or come to campus
24/7.

All nursing staff, cottage staff, clinical staff and
case managers in addition to expanded and
senior leadership will be notified today July 1 by
5PM of the enhanced safety protocols to include
clinical check ins, risk assessments and nursing
wellness rounds.

Daily call scheduled between PQI [Performance
and Quality Improvement] and Residential to
monitor safety protocols and update strategies as
needed."

Describe your plans to make sure the above
happens.

"Layered levels of oversight will occur each day to
include review of daily clinical check in forms by
the PQI Director, risk assessment reviews by the
Clinical Director, follow up on daily wellness
checks by Nursing Manager, and Residential
Leadership to check in with cottage leadership
daily to assess students and any need for special

Division of Health Service Regulation
STATE FORM

6809

K8ZJ11

If continuation sheet 36 of 51

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/06/2021
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL011-203 07/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
111 COMPTON DRIVE
REUTER COTTAGE
ASHEVILLE, NC 28806
(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 293] Continued From page 36 V 293

staffing.

Senior Leadership will meet weekly to review all
identified items in this plan to ensure
compliance."

Review on 7/2/21 of a revised Plan of Protection
dated 7/2/21 written by the Chief Executive
Officer revealed:

What immediate action will the facility take to
ensure the safety of the consumers in your care?

"Effective @ 1PM today July 1, 2021 in response
to this request for a POP, the following immediate
actions have been completed. As of July 1, 2021
[Client #1] will have a staff dedicated during
waking hours to monitor (defined as constant
eyes on and proximity supervision of student by
assigned Residential Counselor) (cottage staff).
The cottage shift lead will be responsible to
ensure this occurs each day. [Client #1] will also
have support walks as requested, unless there is
a safety reason why this cannot occur. During
sleeping hours all staffing and safety protocols
will be maintained.

Arisk assessments of [Client #1] and all other
students on campus within residential services to
include EAC and Reuter students were
completed at 1PM on July 1, 2021. Following this
initial assessment, to further ensure safety,
additional risk assessments will be completed
following any concerning behaviors- (defined as
any behavior that compromises the safety of the
student to include self harm or harm to others).
With risk assessments that indicate concern (as
defined above), the clinician will contact the
Clinical Director and immediately implement
appropriate safety measures.

"In addition to the risk assessments to further
ensure safety and monitor for any changes in

Division of Health Service Regulation
STATE FORM

6809

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If continuation sheet 37 of 51

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/06/2021
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL011-203 07/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
111 COMPTON DRIVE
REUTER COTTAGE
ASHEVILLE, NC 28806
(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 293] Continued From page 37 V 293

safety levels, clinical check ins (a series of
questions to assess current levels of safety) will
be conducted daily by a Licensed Therapist with
each student and 2 times per day with [Client #1].
During weekend hours the onsite cottage
supervisor will conduct these check ins and report
findings to the clinician on call.

In addition to the items identified above the
agency will maintain current protocols in place
prior to today's date of July 1, 2021 to include
wanding students upon entry and exit of day
treatment services, managing the common area
each shift for items that could be utilized for self
injurious behavior, and managing student rooms
for any hidden items.

In addition to medication administration, nursing
has been conducting and continues as of today
July 1, 2021 daily wellness checks with the
students in each cottage.

On call leadership to include clinical staff,
residential leadership staff and senior staff are
available to staff by phone or come to campus
24/7. Support Staff is available within 15 minutes,
residential leadership can be on campus as
quickly as 15 minutes, senior leadership are
available within 30 minutes, clinical staff could be
on campus within 15 minutes. Members of
Clinical and senior leadership staff are on call
24/7 365.

All nursing staff, cottage staff, clinical staff and
case managers in addition to expanded and
senior leadership were notified yesterday July 1
by 5PM of the new enhanced safety protocols as
of July 1, 2021 to include daily documented
clinical check ins, and risk assessments.

Daily call scheduled between PQI and Residential
to review safety protocols and update strategies
as needed.

The PQI Director and PQI Coordinator will meet
weekly to review trends, patterns and risks

Division of Health Service Regulation
STATE FORM

6809

K8ZJ11

If continuation sheet 38 of 51

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/06/2021
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL011-203 07/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
111 COMPTON DRIVE
REUTER COTTAGE
ASHEVILLE, NC 28806
(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 293] Continued From page 38 V 293

related to incidents including restrictive
interventions effective July 2, 2021.

We will identify any intervention that restricts the
movements of students in any way will be
identified in our documentation as a restrictive
intervention and reported to all required bodies
including any caring gesture that restricts
movement in any way.

The treatment plan is written and updated within
the CFT [Child Family Team] with all partners to
include family members, the student, Care
Coordinator if assigned, Guardian Ad Lietum if
assigned, DSS [Department of Social Services] if
involved, Eliada CM [Case Manager] and
Clinician and implemented by Case Managers,
Clinicians, and Residential staff of Eliada Homes.
Between monthly treatment plan updates,
interventions and strategy updates can be found
in the CCR [Clinical Case Reviews], MDT
[Multi-disciplinary Team], Team Meeting minutes,
shift notes, nursing report, and Individual Crisis
Management Plan (ICMP). Staff are made aware
of any updates the debrief that occurs between
shifts, update emails, team minutes.

If a student identifies a trigger related to a
particular activity on campus to include recreation
spaces, cottage staff will identify coping
strategies with the student and/or identify
alternative activities to participate in.

Prior to movie time, staff will review potential
triggers from a movie with students to ensure
they are comfortable watching the movie. Staff
will provide alternative activities to the movie to
support their engagement needs.

Clinicians meet with students individually for their
individual therapy in addition to time spent with
them with the equine program at which time the
clinician works with the students on their
self-identified goals for their PCP
[Person-Centered Profile]. Clinicians also provide

Division of Health Service Regulation
STATE FORM

6809

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If continuation sheet 39 of 51

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/06/2021
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL011-203 07/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
111 COMPTON DRIVE
REUTER COTTAGE
ASHEVILLE, NC 28806
(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 293] Continued From page 39 V 293

group therapy to support students receiving
treatment for their identified goals. Clinicians are
in constant contact via email and meetings to
update staff on any new triggers, symptoms, and
supports."

Describe your plans to make sure the above
happens.

"As of July 1, 2021, layered levels of oversight will
occur each day. Review of daily clinical check in
forms for completion by the [PQI Director], MPA,
risk assessment to be reviewed by the [Clinical
Director] LCMHC, review of daily wellness checks
completion by [Nursing Manager], RN, and
[Residential Director], or [Assistant Residential
Director], to check in with Cottage Supervisor
Team daily to assess students and any need for
special staffing.

Senior Leadership to include [Chief Executive
Officer], [Chief Operations Officer], will meet
weekly to review all identified items in this plan to
ensure compliance."

Reuter Cottage is a 6 bed Residential Treatment
facility that is Staff Secure for Children or
Adolescents. Diagnoses included: Post-Traumatic
Stress Disorder, Major Depressive Disorder,
Generalized Anxiety Disorder with
Obsessive-Compulsive features, Gender
Dysphoria, Specific Learning Disorder,
Attention-Deficit Hyperactivity Disorder, and
Unspecified Trauma and Stressor Related
Disorder. Client #1, 17 years old, had a history of
sexual abuse, self-injurious behaviors, poor
insight, hallucinations, and needed assistance
with coping skills. His behaviors since being at
the facility included head banging against a
concrete or brick wall, cutting himself with plastic,
glass, and fingernails, leaving the cottage without

Division of Health Service Regulation
STATE FORM

6809

K8ZJ11

If continuation sheet 40 of 51

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/06/2021
FORM APPROVED

(X3) DATE SURVEY

permission, breaking a window, pushing, hitting,
and kicking staff, to recently drawing pictures
depicting homicidal and/or suicidal ideations of
staff, peers, his mom and himself. Triggers
identified were anything having to do with his
mom, going to the gym/weight barn, and being
touched. There were no strategies to address the
inability of staff and clinician to partner in
managing these triggers. Staff continued to take
the client to the gym/weight barn where he had 5
additional incidents of head banging and
self-harm, 2 of which ended in a restrictive
intervention. Added to his plan was to provide a
physical touch as a way to calm him after the
client identified he did not like to be touched when
he was upset. Strategies to prevent future
incidents were to be proactive and have planned
activities of interest for the client. This would also
give the client 1-1 attention that was proven to be
an effective prevention of incidents. There was no
proactive planning for the client during activities
he did not prefer, and he did not receive 1-1
attention on a planned or consistent basis. He
told staff he did not want to watch a movie that he
felt was too violent. Directly after an incident of
head banging, leaving the cottage and having to
be physically restrained, staff brought him back to
watch the end of the movie. The client was
escalated after a phone call with his mom, and
began head banging. Just after the client had
calmed down, he was handed a pair of scissors
to cut a bracelet off his ankle. The client struggled
to give the scissors back. As a result of the
client's triggers not being managed his behaviors
continued to escalate to the point of having to be
physically restrained, thus touched, 11 times
during the above timeframe. When the client
attempted to leave the facility either by the
window or the doors he was prevented from
moving by staff blocking him. He had his

Division of Health Service Regulation

STATE FORM

6809

K8ZJ11

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL011-203 07/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
111 COMPTON DRIVE
REUTER COTTAGE
ASHEVILLE, NC 28806
(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 293] Continued From page 40 V 293

If continuation sheet 41 of 51

Division of Health Service Regulation

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

MHLO011-203

NAME OF PROVIDER OR SUPPLIER

A. BUILDING:

111 COMPTON DRIVE
ASHEVILLE, NC 28806

REUTER COTTAGE

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/06/2021
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

07/02/2021

STREET ADDRESS, CITY, STATE, ZIP CODE

(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 (xs)
(EACH CORRECTIVE ACTION SHOULD BE. COMPLETE

CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

V 293] Continued From page 41

arms/hands held when he was attempting to
self-harm. These techniques restricted the client's
movements but were not identified as restrictive
interventions. The continued action of putting
Client #1 in situations that were either identified
by him and/or by the facility as triggers and not
planning strategies to manage this constitutes a
Type A1 rule violation for serious neglect and
must be corrected within 23 days. An
administrative penalty of $2,000 is imposed. If the
violation is not corrected within 23 days, an
additional administrative penalty of $500.00 per
day will be imposed for each day the facility is out
of compliance beyond the 23rd day.

V 537] 27E .0108 Client Rights - Training in Sec Rest &
ITO

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

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

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

(c) Apre-requisite for taking this training is

Division of Health Service Regulation
STATE FORM

V 293

V 537

6809

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If continuation sheet 42 of 51

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/06/2021
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL011-203 07/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
111 COMPTON DRIVE
REUTER COTTAGE
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 537 Continued From page 42 V 537

demonstrating competence by completion of
training in preventing, reducing and eliminating
the need for restrictive interventions.

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

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

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

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

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

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

(3) emphasis on safety and respect for the
rights and dignity of all persons involved (using
concepts of least restrictive interventions and
incremental steps in an intervention);

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

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

(6) prohibited procedures;

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

(8) documentation methods/procedures.

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/06/2021
FORM APPROVED

(X3) DATE SURVEY

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

(1) Documentation shall include:

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

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

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

(i) Instructor Qualification and Training
Requirements:

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

(2) Trainers shall demonstrate competence
by scoring 100% on testing in a training program
teaching the use of seclusion, physical restraint
and isolation time-out.

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

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

(5) The content of the instructor training the
service provider plans to employ shall be
approved by the Division of MH/DD/SAS pursuant
to Subparagraph (j)(6) of this Rule.

(6) Acceptable instructor training programs
shall include, but not be limited to, presentation
of:
(A)
(8)

course;

understanding the adult learner;
methods for teaching content of the

Division of Health Service Regulation
STATE FORM

6809

K8ZJ11

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL011-203 07/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
111 COMPTON DRIVE
REUTER COTTAGE
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 537 Continued From page 43 V 537

If continuation sheet 44 of 51

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

A. BUILDING:

MHLO011-203

111 COMPTON DRIVE

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

PRINTED: 08/06/2021

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

07/02/2021

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

in teaching the use of restrictive interventions at
least two times with a positive review by the

use of restrictive interventions at least once
annually.

instructor training at least every two years.

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

outcome (pass/fail);

review/request this documentation at any time.
(!) Qualifications of Coaches:

requirements as a trainer.

times, the course which is being coached.
competence by completion of coaching or
train-the-trainer instruction.

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

evaluation of trainee performance; and
documentation procedures.
Trainers shall be retrained at least

Trainers shall be currently trained in

Trainers shall have coached experience

Trainers shall teach a program on the

Trainers shall complete a refresher

Documentation shall include:
who participated in the training and the

when and where they attended; and
instructor's name.

The Division of MH/DD/SAS may
Coaches shall meet all preparation

Coaches shall teach at least three

Coaches shall demonstrate

Division of Health Service Regulation
STATE FORM

6809

K8ZJ11

REUTER COTTAGE
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 537 Continued From page 44 V 537

If continuation sheet 45 of 51

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHLO011-203

A. BUILDING:

111 COMPTON DRIVE

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/06/2021

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

07/02/2021

This Rule is not met as evidenced by:

Based on record reviews and interviews, facility
staff (Residential Director) failed to demonstrate
competency in the proper use of restrictive
intervention procedures. The findings are:

Review on 6/16/21 of Client #1's record revealed:
-admitted 12/23/20.

-17 years old - identified as a transgendered
male.

-diagnoses of Post-Traumatic Stress Disorder,
Major Depressive Disorder with psychotic
features, Generalized Anxiety Disorder with
Obsessive-Compulsive features, Gender
Dysphoria, Specific Learning Disorder and
Attention-Deficit Hyperactivity Disorder.

Review on 6/15/21, 6/16/21, 6/17/21, 6/22/21,
6/23/21, and 6/24/21 of facility Incident Reports
(IR) for Client #1 revealed:

3/18/21- staff used strategic proximity to keep
client from rejoining peers in common area until
he could be safe for 2 minutes.

4/2/21- strategic proximity used to block marker
cap from scratching client's skin.

5/8/21- staff blocked client's door to his room as
he attempted to go in; and blocked windows as
he tried to climb out.

5/9/21- multiple attempts to block client from
leaving cottage; client had to make a plan before
he was allowed to leave his room.

§/23/21- client would have to make a plan before
leaving the support room.

5/29/21- provided grounding technique of holding
the client's hands which continued until client
handed over scissors.

REUTER COTTAGE
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 537] Continued From page 45 V 537

Division of Health Service Regulation
STATE FORM

6809

K8ZJ11

If continuation sheet 46 of 51

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/06/2021
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL011-203 07/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
111 COMPTON DRIVE
REUTER COTTAGE
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 537 Continued From page 46 V 537

-none of the above incidents were documented
as restrictive interventions.

Review on 6/11/21 and 6/15/21 of Client #2's
record revealed:

-admitted 2/26/21.

-13 years old.

-diagnoses of Unspecified Trauma and Stressor
Related Disorder, Cannabis Use Disorder,
Amphetamine Type Substance Use Disorder, and
Major Depressive Disorder.

Review on 7/6/21 of incident reports from March
2021 through June 2021 for Client #2 revealed:
3/28/21- staff tried to cover client's forearm to
prevent her from scratching.

5/4/21- staff used caring gesture of holding
client's arms when client scratched her legs
harder.

-none of the above incidents were documented
as restrictive interventions.

Review on 6/15/21 of excerpts from the TCI
(Therapeutic Crisis Intervention) Student
Workbook provided by the Residential Director
revealed:

-Behavior Support Techniques: caring gesture,
redirection and distractions, proximity, managing
the environment, prompting, hurdle help, directive
statement, and time away.

-Caring Gesture - "...Nonverbal expressions of
caring include a pat on the arm or a quick hug...."
-Redirection and distractions - "...involves turning
a young person's attention away from an
undesirable or inappropriate activity...redirection
is asking the child to go to a different activity, not
redirecting them back to the same activity that
was causing the stress..."

-Proximity - "... means nearness...moves closer to
the young person who is struggling to stay in

Division of Health Service Regulation
STATE FORM

6809

K8ZJ11

If continuation sheet 47 of 51

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

A. BUILDING:

MHLO011-203

111 COMPTON DRIVE

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

PRINTED: 08/06/2021

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

07/02/2021

control...touch is a powerful intervention and, if
used at the wrong time by the wrong person, can
easily escalate the situation. Any use of touch
should be done before the child escalates and
within the context of a trusting and therapeutic
relationship...The use of touch requires
knowledge of how the young person will interpret
the touch...A young person who has been
sexually assaulted may misperceive the
intentions of a touch....It is also very important
never to touch a young person who has escalated
beyond irritation to anger. This will more often
than not escalate the situation...."

Interview on 6/11/21 with Staff #1 revealed:

-if Client #1 wanted us to leave him alone, we
have to remind him to "show us some safety."
-if he continued to get aggressive, and not
showing safety, we have to do a restrictive
intervention.

-if he was trying to leave she would put herself
between the client and the door to block him from
leaving.

-she was not sure if this was a part of TCI
technique, but when she was trying to get Client
#1 (not sure of date), staff tried to use blocking
technique, with the help of the Cottage
Supervisor, and then he ended up having to be
restrained.

Interviews on 6/11/21 and 6/23/21 with Staff #2
revealed:

-she had not had to use a restrictive intervention
on anyone for over a year.

-if Client #1 attempted to open a door or window
to leave she would not block him and allow him to

-restrictive interventions were not planned, but if
client was a danger to himself or others she
would have to initiate one.

Division of Health Service Regulation
STATE FORM

6809

K8ZJ11

REUTER COTTAGE
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 537 Continued From page 47 V 537

If continuation sheet 48 of 51

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/06/2021
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL011-203 07/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
111 COMPTON DRIVE
REUTER COTTAGE
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 537 Continued From page 48 V 537

Interview on 6/24/21 with Staff #3 revealed:

-she had not used a restrictive intervention on
Client #1; they do not see as many behaviors on
the 1st shift.

-when client's self-harmed "heavily," scratching at
arms, or legs she would try to distract him/her
verbally or take his/her hands and gently redirect
them.

-physical touch was the most effective - like
putting her hand on the arm of the client.

-this was not considered a restrictive intervention.
-if the client was cutting, would want to take the
object away; but mostly she would try
distractions.

-if the client was trying to get out the door ora
window she would use a protective stance
(standing with palms open).

-if the client was attacking her she would have to
weigh the risk of her getting hurt vs. the client
leaving.

-if you know that client has never left campus,
sometimes it was safer to let the client walk out.
-if someone is going off campus or engaging in
dangerous behavior may have to initiate a
restrictive intervention, but never plan it.
-restrictive intervention was the last option.

Interview on 6/24/21 with the Cottage Supervisor
revealed:

-it was never a plan to restrain a client,
sometimes it had to be done for safety reasons.
-the front door was never blocked if a client was
trying to leave; she would stand in front of the
side door to prevent the client from going out
because an alarm went off when it was opened.
-if a client was really trying to get out, she was not
going to stop them.

-we just talked about this yesterday in team, we
don't do blocks, we stand in front of the door in a

Division of Health Service Regulation
STATE FORM

6809

K8ZJ11

If continuation sheet 49 of 51

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/06/2021
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL011-203 07/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
111 COMPTON DRIVE
REUTER COTTAGE
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 537 Continued From page 49 V 537

non-threatening way.

-we have used a lot of staff from the PRTF
building and they do things a little differently.
-when asked about training for the PRTF staff
coming to the level III cottage - "theoretically it's in
a pre-service."

-if the staff do not know what interventions may or
may not be used she will sit down with that staff
and use the minutes from their team meetings to
teach them about clients' and possible
interventions to be used.

-she described body blocking as staff standing
with their arms down and palms facing up.

Interviews on 6/16/21, 6/17/21 and 6/24/21 with
the Residential Director revealed:

-his role was to oversee the staff and supervisors
of all residential programs.

-he was also one of the TCI trainers.

-when a client was head banging, we look at the
front end, what's causing this, reach out to
nursing, we use head boards, or something soft,
trying to get away from using hand.

-we Call it a caring gesture; there is a fine line with
head banging and how long we can let it go on.
-" ...sometimes physical touch is used as a
grounding thing, if | am upset, let me know you
are there."

-if a client was trying to exit, and staff blocked the
doorway, this was not a restrictive intervention.
-this was not a restrictive intervention since the
client had 3 other directions they could go.

-if the client kept trying to exit and pushed staff,
would depend on what pushing looked like, if
aggressive, would initiate a restrictive
intervention.

This deficiency is cross referenced into 10A
NCAC 27G.1701 Scope (V293) for a Type A1 rule
violation for serious neglect and must be

Division of Health Service Regulation
STATE FORM

6809

K8ZJ11

If continuation sheet 50 of 51

PRINTED: 08/06/2021

FORM APPROVED
Division of Health Service Re
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL011-203 — 07/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
111 COMPTON DRIVE
REUTER COTTAGE
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 537 Continued From page 50 V 537

corrected within 23 days.

Division of Health Service Regulation
STATE FORM 6809 K8ZJ11 If continuation sheet 51 of 51