summary: Statement of Deficiency - MHLCS Annual

raw_content:
PRINTED: 09/29/2025
FORM APPROVED
Division of Health Service Regulation

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

MHL001-155 B. WING _____ 09/25/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
813 TRAIL ONE
BURLINGTON, NC 27215

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

DEFICIENCY)

NEW POSSIBILITIES HOME FOR CHILDREN, L

V 000} INITIAL COMMENTS Vv 000

An annual survey was completed on
September 25, 2025. Deficiencies were cited.

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

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

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

10A NCAC 27G .0209 MEDICATION
REQUIREMENTS

(c) Medication administration:

(1) Prescription or non-prescription drugs shall
only be administered to a client on the written
order of a person authorized by law to prescribe
drugs.
(2) Medications shall be self-administered by
clients only when authorized in writing by the
client's physician.
(3) Medications, including injections, shall be
administered only by licensed persons, or by
unlicensed persons trained by a registered nurse,
pharmacist or other legally qualified person and
privileged to prepare and administer medications.
(4) A Medication Administration Record (MAR) of
all drugs administered to each client must be kept
current. Medications administered shall be
recorded immediately after administration. The
MAR is to include the following:

(A) client's name;

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

(C) instructions for administering the drug;

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

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

STATE FORM 6899 £63811 If continuation sheet 1 of 16

PRINTED: 09/29/2025

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL001-155 B. WING 09/25/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
813 TRAIL ONE
NEW POSSIBILITIES HOME FOR CHILDREN, L
BURLINGTON, NC 27215
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118] Continued From page 1 V 118

drug.

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

This Rule is not met as evidenced by:

Based on interviews and record reviews the
facility failed to keep the MAR current affecting
two of three audited clients (#2 and #3). The
findings are:

Review on 9/25/25 of Client #2's record revealed:
-Admission date of 2/13/24.

-She was 18 years old.

-Diagnoses of Post Traumatic Stress Disorder;
Attention Deficit Hyperactivity Disorder;
Oppositional Defiant Disorder; Generalized
Anxiety Disorder, Disinhibited Social Engagement
Disorder, and Reactive Attachment Disorder.
-Physician order dated 4/8/25 for Buspirone 5
milligrams (mg)(anti-anxiety)- Take one tablet
daily.

Observation on 9/25/25 at 11:20 am of Client #2's
medications revealed:
-Buspirone 5 mg was available.

Review on 9/17/25 of Client #2's MARs for the
month of September 2025 revealed:
-Staff did not sign off on the MAR indicating
medication had been administered for the
following:

-Buspirone 5 mg- on 9/7 and 9/14.
Division of Health Service Regulation
STATE FORM

6899 £63811

If continuation sheet 2 of 16

PRINTED: 09/29/2025

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL001-155 B. WING 09/25/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
813 TRAIL ONE
NEW POSSIBILITIES HOME FOR CHILDREN, L
BURLINGTON, NC 27215
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118| Continued From page 2 V 118

Review on 9/25/25 of Client #3's record revealed:
-Admission date of 6/25/25.
-She was 17 years old.
-Diagnoses of Major Depressive Disorder,
Recurrent Episode with Psychotic Features;
Attention Deficit/ Hyperactivity Disorder,
Predominantly Inattentive; Unspecified Trauma
and Stressors-Related Disorder.
-Physician order dated 6/24/24:

-Oxcarbazepine 300 mg (antiepileptic)- Take
one tablet twice a day.

-Metformin 750 mg (weight management)-
Take one tablet daily.

Observation on 9/25/25 at 11:20 am of Client #3's
medications revealed:
-Medications mentioned were available.

Review on 9/25/25 of Client #3's MARs for the
month of September 2025 revealed:

-Staff did not sign off on the MAR indicating
medication had been administered for the
following:

-Oxcarbazepine 300 mg- 9/4 @ 8pm, 9/6 @
8pm, 9/7 @ 8pm, 9/14 @ 8pm, 9/15 @ 8pm, 9/22
@ 8pm.

-Metformin 750 mg- 9/6, 9/7, 9/15, 9/21,
9/22, 9/24.

Interview on 9/25/25 with Client #3 revealed:

-She had never had an issue in receiving her
medications.

-She had never skipped her medications.

-Staff would always hand her the medications that
she needed to take.

Interview on 9/25/25 with the Program
Coordinator revealed:

-She was not aware that some of the client's
Division of Health Service Regulation

STATE FORM

6899 £63811

If continuation sheet 3 of 16

Division of Health Service Regulation

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

MHL001-155 B. WING

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

NEW POSSIBILITIES HOME FOR CHILDREN, L BURLINGTON, NC 27215

PRINTED: 09/29/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

09/25/2025

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

(X4) ID
PREFIX
TAG

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

COMPLETE
DATE

DEFICIENCY)

V 118| Continued From page 3 V 118

medications had not been logged properly on
their MARs.

-She did not know why staff did not mark some
medications as given.

-Client's medications came in "bubble packs."
-She knew that the medications were given
because they were inside the bubble pack.
-She would be reviewing with staff that
administered medication to make sure they
marked the MARs appropriately.

-She acknowledged that staff failed to maintain
Client #2 and Client #3's MARs current.

Due to the failure to accurately document
medication administration for clients #1 and #2, it
could not be determined if they received
medication as ordered by their physicians.

V 298] 27G .1706 Residential Tx. Child/Adol - V 298

Operations

10A NCAC 27G .1706 OPERATIONS

(a) Each facility shall serve no more than a total
of 12 children and adolescents.

(b) Family members or other legally responsible
persons shall be involved in development of plans
in order to assure a smooth transition to a less
restrictive setting.

(c) The residential treatment staff secure facility
shall coordinate with the local education agency
to ensure that the child's educational needs are
met as identified in the child's education plan and
the treatment plan. Most of the children will be
able to attend school; for others, the facility will
coordinate services across settings such as
alternative learning programs, day treatment, or a
job placement.

(d) Psychiatric consultation shall be available as
needed for each child or adolescent.

Division of Health Service Regulation

STATE FORM 6899 £63811

If continuation sheet 4 of 16

Division of Health Service Regulation

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

(X2) MULTIPLE CONSTRUCTION

A. BUILDING:
MHL001-155 B. WING
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
813 TRAIL ONE
NEW POSSIBILITIES HOME FOR CHILDREN, L BURLINGTON, NC 27215

PRINTED: 09/29/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

09/25/2025

(e) If an adolescent has his 18th birthday while
receiving treatment in the facility, he may remain
for six months or until the end of the state fiscal
year, whichever is longer.

(f) Each child or adolescent shall be entitled to
age-appropriate personal belongings unless such
entitlement is counter-indicated in the treatment
plan.

(g) Each facility shall operate 24 hours per day,
seven days per week, and each day of the year.

This Rule is not met as evidenced by:

Based on record review and interviews, the
facility allowed a client to remain in the facility in
excess of the maximum allowed time of six
months following clients 18 th birthday or until end
of the state fiscal year affecting one of three
audited current client (#2). The findings are:

Review on 9/25/25 of Client #2's record revealed:
-Admission date of 2/13/24.

-Date of Birth: 1/9/07. She was 18 years and 8
months old.

-Client #2 was her own guardian.

Interview on 9/25/25 with the Program
Coordinator revealed:

-She thought Client #2 was able to remain at the
facility until she was 21 due to her diagnoses.
-Facility had tried to find placement for Client #2,
but it did not fall through due to her Supplemental
Security Income (SSI).

-Client #2's SSI would not have covered the
services at the other facility.

Division of Health Service Regulation

STATE FORM 6899

£63811

(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 298] Continued From page 4 V 298

If continuation sheet 5 of 16

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL001-155 B. WING

NAME OF PROVIDER OR SUPPLIER
813 TRAIL ONE

NEW POSSIBILITIES HOME FOR CHILDREN, L BURLINGTON, NC 27215

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 09/29/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

09/25/2025

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

(X4) ID
PREFIX
TAG

ID
PREFIX
TAG

CROSS-REFERENCED TO THE APPROPRIATE

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

(x5)
COMPLETE
DATE

DEFICIENCY)

V 298 V 298

Continued From page 5

Interview on 9/25/25 with the Program Director
revealed:

-She was not aware that she needed to have an
age waiver in order for Client #2 to be able to
remain at the facility.

-Client #2 was not under the Department of
Social Services custody.

-Client #2 became her own guardian when she
turned 18 years old.

-They had been trying to get Client #2 into a
group home, but because her SSI had not been
approved yet, she was not able to go.

-They had been looking into placing Client #2 ina
level 2 group home.

-Client #2's SSI would not had covered room and
board.

-They were also trying to have family counseling
with Client #2's adoptive mother.

-lf things would work out, they would be able to
place Client #2 with her family.

V 536] 27E .0107 Client Rights - Training on Alt to Rest. | V 536

Int.

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

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

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

Division of Health Service Regulation

STATE FORM 6899

£63811

If continuation sheet 6 of 16

PRINTED: 09/29/2025

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL001-155 B. WING 09/25/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
813 TRAIL ONE
NEW POSSIBILITIES HOME FOR CHILDREN, L
BURLINGTON, NC 27215
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 536} Continued From page 6 V 536

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

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

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

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

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

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

(2) recognizing and interpreting human
behavior;

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

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

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

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

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

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

Division of Health Service Regulation

STATE FORM 6899

£63811

If continuation sheet 7 of 16

PRINTED: 09/29/2025

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL001-155 B. WING 09/25/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
813 TRAIL ONE
NEW POSSIBILITIES HOME FOR CHILDREN, L
BURLINGTON, NC 27215
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 536} Continued From page 7 V 536

(9) positive behavioral supports (providing
means for people with disabilities to choose
activities which directly oppose or replace
behaviors which are unsafe).

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

(1) Documentation shall include:

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

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

review/request this documentation at any time.

(i) Instructor Qualifications and Training
Requirements:

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

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

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

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

(5) Acceptable instructor training programs
shall include but are not limited to presentation of:

(A) understanding the adult learner;

(B) methods for teaching content of the
course;

(C) methods for evaluating trainee

Division of Health Service Regulation

STATE FORM 6899

£63811

If continuation sheet 8 of 16

Division of Health Service Regulation

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

(X2) MULTIPLE CONSTRUCTION

A. BUILDING:
MHL001-155 B. WING
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
813 TRAIL ONE
NEW POSSIBILITIES HOME FOR CHILDREN, L BURLINGTON, NC 27215

PRINTED: 09/29/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

09/25/2025

performance; and

(D) documentation procedures.

(6) Trainers shall have coached experience
teaching a training program aimed at preventing,
reducing and eliminating the need for restrictive
interventions at least one time, with positive
review by the coach.
(7) Trainers shall teach a training program
aimed at preventing, reducing and eliminating the
need for restrictive interventions at least once
annually.
(8) Trainers shall complete a refresher
instructor training at least every two years.

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

(1) Documentation shall include:

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

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

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

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

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

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

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

Division of Health Service Regulation

STATE FORM 6899

£63811

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 536} Continued From page 8 V 536

If continuation sheet 9 of 16

PRINTED: 09/29/2025

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL001-155 B. WING 09/25/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
813 TRAIL ONE
NEW POSSIBILITIES HOME FOR CHILDREN, L
BURLINGTON, NC 27215
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 536} Continued From page 9 V 536

This Rule is not met as evidenced by:

Based on record reviews and interview, the
acility failed to ensure two of three staff (Staff #4
and the Licensed Professional) received annual
raining updates in alternatives to restrictive
interventions. The findings are:

Review on 9/25/25 of Staff #4's personnel record
revealed:

-Hire date of 1/7/16.

-She was hired as a Paraprofessional.
-Evidence Based Protective Interventions (EBPI)
nterventions - Base Plus training in alternatives
(0 restrictive interventions had expired on
8/29/25.

-No current training in alternatives to restrictive
interventions.

Review on 9/25/25 of the Licensed Professional's
personnel record revealed:

-Hire date of 1/3/15.

-She was hired as a Licensed Professional.
-EBPI Interventions - Base Plus training in
alternatives to restrictive interventions had
expired on 8/29/25.

-No current training in alternatives to restrictive
interventions.

Interview on 9/25/25 with Staff #4 revealed:
-She acknowledged missing the latest EBPI
training due to health issues.

-Acknowledged not having a current training on
Alternatives to Restrictive Interventions.

Interview on 9/25/25 with the Program Director
revealed:

-Staff #4 missed last week's training.

Division of Health Service Regulation

STATE FORM

6899 £63811

If continuation sheet 10 of 16

Division of Health Service Regulation

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

MHL001-155 B. WING

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

NEW POSSIBILITIES HOME FOR CHILDREN, L BURLINGTON, NC 27215

PRINTED: 09/29/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

09/25/2025

(X4) ID
PREFIX
TAG

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

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

COMPLETE
DATE

DEFICIENCY)

V 536 | Continued From page 10 V 536

-Son recently passed away a few months ago and
she has had had some health issues.

-Couldn't make it to the last training.

-She was not aware that the Licensed
Professional's EBPI training had expired.

-She acknowledged that staff #4 and the
Licensed professional's training on alternatives to
restrictive interventions.

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

ITO

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

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

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

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

(d) The training shall be competency-based,
include measurable learning objectives,
measurable testing (written and by observation of

Division of Health Service Regulation

STATE FORM 6899 £63811

If continuation sheet 11 of 16

PRINTED: 09/29/2025

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL001-155 B. WING 09/25/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
813 TRAIL ONE
NEW POSSIBILITIES HOME FOR CHILDREN, L
BURLINGTON, NC 27215
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 537 | Continued From page 11 V 537

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.
(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);

Division of Health Service Regulation

STATE FORM 6899

£63811

If continuation sheet 12 of 16

PRINTED: 09/29/2025

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL001-155 B. WING 09/25/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
813 TRAIL ONE
NEW POSSIBILITIES HOME FOR CHILDREN, L
BURLINGTON, NC 27215
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 537 | Continued From page 12 V 537
(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) understanding the adult learner;

(B) methods for teaching content of the
course;

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

(7) Trainers shall be retrained at least

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

Division of Health Service Regulation
STATE FORM 6899 £63811 If continuation sheet 13 of 16

PRINTED: 09/29/2025

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL001-155 B. WING 09/25/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
813 TRAIL ONE
NEW POSSIBILITIES HOME FOR CHILDREN, L
BURLINGTON, NC 27215
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 537 | Continued From page 13 V 537
Rule.
(8) Trainers shall be currently trained in
CPR.
(9) Trainers shall have coached experience

in teaching the use of restrictive interventions at
least two times with a positive review by the
coach.
(10) Trainers shall teach a program on the
use of restrictive interventions at least once
annually.
(11) Trainers shall complete a refresher
instructor training at least every two years.

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

(1) Documentation shall include:

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

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

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

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

(2) Coaches shall teach at least three
times, the course which is being coached.
(3) Coaches shall demonstrate
competence by completion of coaching or
train-the-trainer instruction.

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

This Rule is not met as evidenced by:
Based on record reviews and interview, the
Division of Health Service Regulation

STATE FORM

6899 £63811

If continuation sheet 14 of 16

PRINTED: 09/29/2025
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL001-155 B. WING 09/25/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
813 TRAIL ONE
NEW POSSIBILITIES HOME FOR CHILDREN, L
BURLINGTON, NC 27215
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 537 | Continued From page 14 V 537

facility failed to ensure two of three staff (Staff #4
and the Licensed Professional) received annual
training updates in seclusion, physical restraint
and isolation time-out. The findings are:

Review on 9/25/25 of Staff #4's personnel record
revealed:

-Hire date of 1/7/16.

-She was hired as a Paraprofessional.
-Evidence Based Protective Interventions (EBPI)
Interventions - Base Plus training in seclusion,
physical restraint and isolation expired effective
8/29/25.
-No current training in seclusion, physical
restraint and isolation time-out.

Review on 9/25/25 of the Licensed Professional's
personnel record revealed:

-Hire date of 1/3/15.

-She was hired as a Licensed Professional.
-EBPI Interventions - Base Plus training in
seclusion, physical restraint and isolation expired
effective 8/29/25.

-No current training in seclusion, physical
restraint and isolation time-out.

Interview on 9/25/25 with Staff #4 revealed:
-She acknowledged missing the latest EBPI
training due to health issues.
-Acknowledged not having a current training
update on seclusion, physical restraint and
isolation time-out.

Interview on 9/25/25 with the Program Director
revealed:

-Staff #4 missed last week's training.

-Son recently passed away a few months ago and
she has had had some health issues.

-Couldn't make it to the last training.

-She was not aware that the Licensed

Division of Health Service Regulation

STATE FORM 6899 £63811 If continuation sheet 15 of 16

PRINTED: 09/29/2025
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL001-155 B. WING 09/25/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
813 TRAIL ONE
NEW POSSIBILITIES HOME FOR CHILDREN, L
BURLINGTON, NC 27215
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 537 | Continued From page 15 V 537

Professional's EBPI training had expired.
-Facility had not done a restraint in along time.
-Facility was able to perform restraints if needed
as it was part of their policy.

-She acknowledged that staff #4 and the
Licensed professional's training on seclusion,
restraint and isolation time out had expired last
month.

Division of Health Service Regulation
STATE FORM 6899 £63811 If continuation sheet 16 of 16

document_type: Statement of Deficiency


state: NC

facility_name: New Possibilities Home For Children  LLC

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

raw_content:
PRINTED: 09/10/2024

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL001-155 B. WING 09/05/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
813 TRAIL ONE
NEW POSSIBILITIES HOME FOR CHILDREN, L BURLINGTON, NC 27215
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000) INITIAL COMMENTS V 000
An annual, complaint and follow up survey was
completed on September 5, 2024. The complaint
was unsubstantiated (intake #NC00221388). No
deficiencies were cited.
This facility is licensed for the following service
category: 10A NCAC 27G .1700 Residential
Treatment Staff Secure for Children or
Adolescents.
This facility is licensed for 4 and has a current
census of 3. The survey sample consisted of
audits of 3 current clients.
Division of Health Service Regulation
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

STATE FORM 6899 Z86D11 If continuation sheet 1 of 1

inspection_type: MHLCS Annual, Complaint, and Follow-up


summary: Statement of Deficiency - MHLCS Annual and Complaint

raw_content:
PRINTED: 11/16/2023
FORM APPROVED
Division of Health Service Regulation

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

MHL001-155 B. WING _____ 11/06/2023

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
813 TRAIL ONE
BURLINGTON, NC 27215

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

DEFICIENCY)

NEW POSSIBILITIES HOME FOR CHILDREN, L

V 000} INITIAL COMMENTS Vv 000

An annual and complaint survey was completed
on 11/6/23. The complaints were unsubstantiated
(intake #NC00209034 and #NC00209207).
Deficiencies were cited.

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

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

V 105} 27G .0201 (A) (1-7) Governing Body Policies V 105

10A NCAC 27G .0201 GOVERNING BODY
POLICIES

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

(1) delegation of management authority for the
operation of the facility and services;

(2) criteria for admission;

(3) criteria for discharge;

(4) admission assessments, including:

(A) who will perform the assessment; and

(B) time frames for completing assessment.

(5) client record management, including:

(A) persons authorized to document;

(B) transporting records;

(C) safeguard of records against loss, tampering,
defacement or use by unauthorized persons;
(D) assurance of record accessibility to
authorized users at all times; and

(E) assurance of confidentiality of records.

(6) screenings, which shall include:

(A) an assessment of the individual's presenting
problem or need;

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

STATE FORM 6899 16K811 If continuation sheet 1 of 14

PRINTED: 11/16/2023

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL001-155 B. WING 11/06/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
813 TRAIL ONE
NEW POSSIBILITIES HOME FOR CHILDREN, L
BURLINGTON, NC 27215
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 105] Continued From page 1 V 105

(B) an assessment of whether or not the facility
can provide services to address the individual's
needs; and

(C) the disposition, including referrals and
recommendations;

(7) quality assurance and quality improvement
activities, including:

(A) composition and activities of a quality
assurance and quality improvement committee;
(B) written quality assurance and quality
improvement plan;

(C) methods for monitoring and evaluating the
quality and appropriateness of client care,
including delineation of client outcomes and
utilization of services;

(D) professional or clinical supervision, including
a requirement that staff who are not qualified
professionals and provide direct client services
shall be supervised by a qualified professional in
that area of service;

(E) strategies for improving client care;

(F) review of staff qualifications and a
determination made to grant
treatment/habilitation privileges:

(G) review of all fatalities of active clients who
were being served in area-operated or contracted
residential programs at the time of death;

(H) adoption of standards that assure operational
and programmatic performance meeting
applicable standards of practice. For this
purpose, "applicable standards of practice"
means a level of competence established with
reference to the prevailing and accepted
methods, and the degree of knowledge, skill and
care exercised by other practitioners in the field;

Division of Health Service Regulation

STATE FORM 6899

16K811

If continuation sheet 2 of 14

PRINTED: 11/16/2023

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL001-155 B. WING 11/06/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
813 TRAIL ONE
NEW POSSIBILITIES HOME FOR CHILDREN, L
BURLINGTON, NC 27215
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 105} Continued From page 2 V 105

This Rule is not met as evidenced by:

Based on record review and interviews, the
facility failed to develop and implement adoption
of standards that ensured operational and
programmatic performance meeting applicable
standards of practice for the use of Urine Drug
Screen (UDS) Testing including the CLIA (Clinical
Laboratory Improvement Amendments) waiver.
The findings are:

Review on 10/24/23 of former client #4's (FC #4)
record revealed:

-Admission date of 2/28/23.

-Diagnoses of Disruptive Mood Dysregulation
Disorder, Conduct Disorder, Post Traumatic
Stress Disorder, Attention Deficit Hyperactivity
Disorder and History of Substance Abuse.
-She was 15 years old.

-She was discharged on 10/10/23.

-Clinical Assessment dated 1/23/23-FC #4 was
removed from her home at the age of 7 due to
drug use. "[FC #4] admitted she was displaced

from her foster care
smoking, snorting pi
following rules."

-Person Centered P

home because she was
Is, running away and not

lan dated 1/30/23:

5/18/23-Goal Review Section-It was documented
FC #4 had two positive urine test for Marijuana
since her placement (No specific dates of positive
urine test).

Review on 10/24/23 of a Staff Communication
note dated 6/15/23 revealed:

-"[FC #4] was given a drug test."

Division of Health Service Regulation

STATE FORM

6899 16K811

If continuation sheet 3 of 14

PRINTED: 11/16/2023
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL001-155 B. WING 11/06/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
813 TRAIL ONE
NEW POSSIBILITIES HOME FOR CHILDREN, L
BURLINGTON, NC 27215
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 105} Continued From page 3 V 105

Interview on 10/25/23 with the Program
Coordinator revealed:

-Staff did UDS for FC #4 at the facility.

-Staff did a UDS for FC #4 twice.

-She confirmed the facility failed to have a CLIA
waiver in order to complete urine drug screens.

Interviews on 10/24/23 and 10/25/23 with the
Director/Qualified Professional/Associate
Professional revealed:

-FC #4 had substance abuse issues.

-FC #4 was doing drugs at school.

-Staff did urine drug screen on FC #4 at the
facility.

-She thought staff did 2-3 urine drug screen on
FC #4 at the facility.

-Staff were not consistently documenting urine
drug screens for client #4.

-"Staff had been doing urine drug screens on
clients on and off over the last few years."

-The facility had no CLIA waiver, "I never even
heard of a CLIA waiver."

-"No one ever told me | needed a CLIA waiver to
do a urine drug screen."

-She confirmed the facility failed to have a CLIA
waiver in order to complete urine drug screens.

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

10A NCAC 27G .0209 MEDICATION
REQUIREMENTS

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

(2) Medications shall be self-administered by
clients only when authorized in writing by the

Division of Health Service Regulation
STATE FORM 6899 16K811 If continuation sheet 4 of 14

PRINTED: 11/16/2023

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL001-155 B. WING 11/06/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
813 TRAIL ONE
NEW POSSIBILITIES HOME FOR CHILDREN, L
BURLINGTON, NC 27215
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118| Continued From page 4 V 118

client's physician.

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

(A) client's name;

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

(C) instructions for administering the drug;

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

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

This Rule is not met as evidenced by:

Based on record reviews and interview, the
facility failed to keep the MAR current affecting
two of three audited clients (#1 and #2). The
findings are:

Review on 10/24/23 of client #1's record
revealed:

-An admission date of 6/12/23

-Diagnoses of Disruptive Mood Dysregulation
Disorder, Post Traumatic Stress Disorder (PTSD)
and Parent-Child Relational Problem.

Division of Health Service Regulation

STATE FORM

6899 16K811

If continuation sheet 5 of 14

PRINTED: 11/16/2023

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL001-155 B. WING 11/06/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
813 TRAIL ONE
NEW POSSIBILITIES HOME FOR CHILDREN, L
BURLINGTON, NC 27215
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118| Continued From page 5 V 118

-She was 14 years old.

Review on 10/25/23 of client #1's physician's
orders dated 8/8/23 revealed:

-Vitamin D3 50 (microgram) mcg (Vitamin
Deficiency), take one tablet by mouth every
morning.

-Quetiapine 100 (milligram) mg (Bipolar
Disorder), take one and % tablet (150 mg) by
mouth every morning.

-Quetiapine 100 mg , take two tablets (200 mg)
by mouth at bedtime.

-Melatonin tablet 3 mg (Sleep), take 3 tablets (9
mg) by mouth every night at bedtime.

-Prazosin HCL 2 mg (Urinary Retention) , take 2
capsules (4 mg) by mouth once daily before bed.
-Sertraline 5 mg (Depression), take one tablet by
mouth every evening.

Review on 10/25/23 of MARs dated from August
2023 through October 25, 2023 for client #1
revealed:

-September 2023-No staff initials to document
administration of the following medication:
Melatonin 3 mg on 9/11, 9/27 and 9/30
Quetiapine 200 mg on 9/15, 9/27 and 9/30
Prazosin HCL 2 mg on 9/1, 9/2, 9/7 and 9/27
Vitamin D3 on 9/30

Sertraline 5 mg on 9/30

-August 2023- No staff initials to document
administration of the following medication:

Melatonin 3 mg on 8/28

Quetiapine 200 mg on 8/13, 8/14 and 8/21

Prazosin HCL 2 mg on 8/11 and 8/21

Review on 10/24/23 of client #2's record
revealed:

-An admission date of 8/3/22.

Division of Health Service Regulation

STATE FORM

6899 16K811

If continuation sheet 6 of 14

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL001-155 B. WING

NAME OF PROVIDER OR SUPPLIER
813 TRAIL ONE

NEW POSSIBILITIES HOME FOR CHILDREN, L BURLINGTON, NC 27215

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 11/16/2023
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

11/06/2023

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

(X4) ID
PREFIX
TAG

CROSS-REFERENCED TO THE APPROPRIATE

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

(x5)
COMPLETE
DATE

DEFICIENCY)

V 118| Continued From page 6 V 118

-Diagnoses of Attention Deficit Hyperactivity
Disorder (ADHD), PTSD and Cannabis Use
Disorder.

-She was 17 years old.

Review on 10/25/23 of client #2's physician's
orders revealed:

Order dated 9/27/23:

Hydroxyzine HCL 25 mg (Anxiety), take one tablet
by mouth every night at bedtime.

Concerta 36 mg (ADHD), take one tablet by
mouth every morning.

Order dated 7/26/23:

Flovent HFA 110 mcg (Breathing issues), inhale 2
puffs by mouth twice daily.

Melatonin 5 mg, take one tablet by mouth every
night at bedtime.

Prazosin HCL 5 mg, take one capsule by mouth
every night at bedtime.

Aripiprazole 5 mg (Bipolar Disorder), take one
tablet by mouth at bedtime.

Minerin cream 454 grams (gm) (Eczema), apply
one gram topically twice daily.

Vitamin D3 2000 units, take one capsule by
mouth once daily.

Nasal allergy spray 55 mcg (Allergy symptoms),
place 2 sprays into each nostril once daily.
Docusate Sodium 100 mg (Constipation), take
one capsule by mouth once daily.

Fluticasone spray 50 mcg (Sneezing, itchy or
runny nose), place two sprays into each nostril
once daily.

Review on 10/25/23 of MARs dated from August
2023 through October 25, 2023 for client #2
revealed:

-September 2023- No staff initials to document
Division of Health Service Regulation

STATE FORM 6899

16K811

If continuation sheet 7 of 14

PRINTED: 11/16/2023

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL001-155 B. WING 11/06/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
813 TRAIL ONE
NEW POSSIBILITIES HOME FOR CHILDREN, L
BURLINGTON, NC 27215
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118| Continued From page 7 V 118

administration of the following medication:
Flovent HFA 110 mcg on 9/1, 9/22, 9/24, 9/25 and
9/30 am doses.

Flovent HFA 110 mcg on 9/14, 9/15, 9/16, 9/18,
9/19, 9/24, 9/25, 9/27 and 9/29 pm doses.
Hydroxyzine HCL 25 mg on 9/18, 9/20 and 9/27.
Melatonin 5 mg on 9/18, 9/20 and 9/27.
Prazosin HCL 5 mg on 9/18, 9/20 and 9/27.
Aripiprazole 5 mg on 9/18, 9/20 and 9/27.
Minerin cream 454 gm on 9/8, 9/20, 9/22, 9/23
and 9/27.

Nasal Allergy spray 55 mcg on 9/1, 9/2, 9/3.
Concerta 36 mg on 9/1, 9/2 and 9/3.
Fluticasone spray 50 mcg on 9/1, 9/2, 9/3 and
9/4.

-August 2023- No staff initials to document
administration of the following medication:
Flovent HFA 110 mcg on 8/23, 8/24, 8/25, 8/26
and 8/27 am doses.

Flovent HFA 110 mcg on 8/2, 8/4, 8/7, 8/11, 8/16,
8/17, 8/25, 8/26, 8/28 and 8/31 pm doses.
Hydroxyzine HCL 25 mg on 8/2, 8/4, 8/11, 8/23,
8/25, 8/28 and 8/31.

Melatonin 5 mg on 8/2, 8/4, 8/11, 8/23, 8/25, 8/26,
8/28 and 8/31.

Prazosin HCL 5 mg on 8/4, 8/5, 8/11, 8/25, 8/26,
8/28 and 8/31.

Aripiprazole 5 mg on 8/2, 8/4, 8/11, 8/23, 8/25,
8/26, 8/28 and 8/31.

Minerin cream 454 gm on 8/4, 8/11,8/25, 8/26,
8/28 and 8/31.

Concerta 36 mg on 8/23, 8/24, 8/25, 8/26 and
8/27.

Fluticasone spray 50 mcg on 8/24, 8/25 and 8/26.
Docusate Sodium 100 mg on 8/23, 8/24, 8/25,
8/26 and 8/27.

Vitamin D3 2000 units on 8/23, 8/24, 8/25, 8/26,
8/27.

Division of Health Service Regulation

STATE FORM 6899

16K811

If continuation sheet 8 of 14

PRINTED: 11/16/2023

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL001-155 B. WING 11/06/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
813 TRAIL ONE
NEW POSSIBILITIES HOME FOR CHILDREN, L
BURLINGTON, NC 27215
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118| Continued From page 8 V 118

Interview on 10/25/23 with Director/Qualified
Professional/Associate Professional revealed:
-Staff administered both morning and evening
medications to the clients.

-Clients were getting their medications daily,
however "people not signing off."

-If clients are out of the facility, "they (staff) should
have written a code" on the MAR.

-"It is a medication error on staff."

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

clients received their medications as ordered by
the physician.

V 295} 27G .1703 Residential Tx. Child/Adol - Req. forA | V 295
P

10A NCAC 27G .1703 REQUIREMENTS FOR
ASSOCIATE PROFESSIONALS

(a) In addition to the qualified professional
specified in Rule .1702 of this Section, each
facility shall have at least one full-time direct care
staff who meets or exceeds the requirements of
an associate professional as set forth in 10A
NCAC 27G .0104(1).
(b) The governing body responsible for each
facility shall develop and implement written
policies that specify the responsibilities of its
associate professional(s). Ata minimum these
policies shall address the following:

(1) management of the day to day
day-to-day operations of the facility;

(2) supervision of paraprofessionals
regarding responsibilities related to the
implementation of each child or adolescent's
treatment plan; and

(3) participation in service planning

Division of Health Service Regulation
STATE FORM

6899 16K811

If continuation sheet 9 of 14

Division of Health Service Regulation

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

MHL001-155 B. WING
NAME OF PROVIDER OR SUPPLIER

813 TRAIL ONE

NEW POSSIBILITIES HOME FOR CHILDREN, L BURLINGTON, NC 27215

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 11/16/2023
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

11/06/2023

(X4) ID
PREFIX
TAG

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

ID
PREFIX
TAG

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

(x5)
COMPLETE
DATE

V 295] Continued From page 9 V 295

meetings.

This Rule is not met as evidenced by:

Based on record review and interviews, the
facility failed to employ an Associate Professional
(AP) who provided services to the group home on
a full-time basis. The findings are:

Review on 10/25/23 of the Personnel Record for
the Director/Qualified Professional (QP)/AP
revealed:

-There was no specific date of hire.

-She had job descriptions for the AP and QP
positions.

Review on 10/25/23 of the facility's license
revealed:
-The facility was licensed for four clients.

nterview on 10/24/23 with staff #1 revealed:
-The owner of the facility served as the AP and
QP for the facility.

nterviews on 10/24/23 and 10/25/23 with the
Director/QP/AP revealed:

-She opened her facility in 2008.

-She was the QP for the facility.

-She worked between 10-16 hours per week at
his facility.

-She was also serving as the AP for the facility.
-She didn't know she could not work in both of
hose positions at the facility.

-She had been serving as the AP and QP "on and
off" for several years.

Division of Health Service Regulation

STATE FORM 6899

16K811

If continuation sheet 10 of 14

PRINTED: 11/16/2023

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL001-155 B. WING 11/06/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
813 TRAIL ONE
NEW POSSIBILITIES HOME FOR CHILDREN, L
BURLINGTON, NC 27215
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 296 | Continued From page 10 V 296
V 296] 27G .1704 Residential Tx. Child/Adol - Min. V 296

Staffing

410A NCAC 27G .1704 MINIMUM STAFFING
REQUIREMENTS

(a) A qualified professional shall be available by
telephone or page. A direct care staff shall be
able to reach the facility within 30 minutes at all
times.

(b) The minimum number of direct care staff
required when children or adolescents are
present and awake is as follows:

(1) wo direct care staff shall be present for
one, two, three or four children or adolescents;
(2) hree direct care staff shall be present

for five, six, seven or eight children or
adolescents; and

(3) ‘our direct care staff shall be present for
nine, ten, eleven or twelve children or
adolescents.

(c) The minimum number of direct care staff
during child or adolescent sleep hours is as
follows:
(1) wo direct care staff shall be present
and one shall be awake for one through four
children or adolescents;

(2) wo direct care staff shall be present
and both shall be awake for five through eight
children or adolescents; and

(3) hree direct care staff shall be present
of which two shall be awake and the third may be
asleep for nine, ten, eleven or twelve children or
adolescents.

(d) In addition to the minimum number of direct
care staff set forth in Paragraphs (a)-(c) of this
Rule, more direct care staff shall be required in
the facility based on the child or adolescent's
individual needs as specified in the treatment
plan.

Division of Health Service Regulation
STATE FORM 6899 16K811 If continuation sheet 11 of 14

PRINTED: 11/16/2023

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL001-155 B. WING 11/06/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
813 TRAIL ONE
NEW POSSIBILITIES HOME FOR CHILDREN, L
BURLINGTON, NC 27215
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 296 | Continued From page 11 V 296

(e) Each facility shall be responsible for ensuring
supervision of children or adolescents when they
are away from the facility in accordance with the
child or adolescent's individual strengths and
needs as specified in the treatment plan.

This Rule is not met as evidenced by:

Based on record reviews, and interviews, the
acility failed to ensure at least two direct care
staff were present for up to four adolescents. The
indings are:

Review on 10/24/23 of client #1's record
revealed:

-An admission date of 6/12/23

-Diagnoses of Disruptive Mood Dysregulation
Disorder (DMDD), Post Traumatic Stress
Disorder (PTSD) and Parent-Child Relational
Problem.

-She was 14 years old.

Review on 10/24/23 of client #2's record
revealed:

-An admission date of 8/3/22.

-Diagnoses of Attention Deficit Hyperactivity
Disorder (ADHD), PTSD and Cannabis Use
Disorder.

-She was 17 years old.

Review on 10/31/23 of client #3's record
revealed:

-An admission date of 4/11/23

Division of Health Service Regulation

STATE FORM

6899 16K811

If continuation sheet 12 of 14

PRINTED: 11/16/2023
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL001-155 B. WING 11/06/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
813 TRAIL ONE
NEW POSSIBILITIES HOME FOR CHILDREN, L
BURLINGTON, NC 27215
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 296 | Continued From page 12 V 296

-Diagnoses of PTSD and DMDD.
-She was 14 years old.

Interview on 10/25/23 with Client #1 revealed:
- There were two staff for 1st and 2nd shift.
-There was one staff at the facility during
overnight shifts.

Interview on 10/25/23 with Client #2 revealed:
- "Typically" two staff worked on first and second
shift.

- There was only one staff at night.

Interview on 10/25/23 with Client #3 revealed:
-For the last 2-3 months there was only one staff
working during 3rd shift Monday through Friday.

Interview on 10/24/23 with staff #1 revealed:
-She worked 3rd shift 2-3 days a week and as
needed.

-She worked alone during 3rd shift with the
clients.

-She had been working alone at the facility during
3rd shift for about a month.

Interview on 10/25/23 with the Program
Coordinator revealed:

-She came in at 7 am during the week and
assisted the 3rd shift staff with transporting the
clients to school.

-Staff worked alone during third shift Monday
through Friday.

-She wasn't sure how long 3rd shift staff had
been working alone at the facility.

Interview on 10/24/23 and 10/25/23 with the
Director/Qualified Professional/Associate
Professional revealed:

-Two staff worked each shift.

-The Facility had 3 shifts: 7am-3pm, 3pm-11pm,
Division of Health Service Regulation

STATE FORM 6899 16K811 If continuation sheet 13 of 14

PRINTED: 11/16/2023

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL001-155 B. WING 11/06/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
813 TRAIL ONE
NEW POSSIBILITIES HOME FOR CHILDREN, L
BURLINGTON, NC 27215
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 296 | Continued From page 13 V 296

and 11pm-7am.

-During 3rd shift "a lot of times two staff, most of
the time one staff."

-"Sometimes | am able to stay, sometimes | am
not, staffing is a issue."

Division of Health Service Regulation
STATE FORM 6899 16K811 If continuation sheet 14 of 14

inspection_type: MHLCS Annual and Complaint


summary: Statement of Deficiency - MHLCS Annual

raw_content:
Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL001-155

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

813 TRAIL ONE

NEW POSSIBILITIES HOME FOR CHILDREN, LLC
BURLINGTON, NC 27215

PRINTED: 11/06/2022

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

R
10/24/2022

An annual survey was completed on October 24,
2022. No deficiencies were cited.

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

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

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

STATE FORM

6899

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000) INITIAL COMMENTS Vv 000

TITLE

(X6) DATE

If continuation sheet 1 of 1

inspection_type: MHLCS Annual


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

raw_content:
Division of Health Service Regulation

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

MHL001-155

NEW POSSIBILITIES HOME FOR CHILDREN, LLC

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 10/07/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
813 TRAIL ONE
BURLINGTON, NC 27215

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

09/27/2021

An annual and follow-up survey was completed
on September 27, 2021. No deficiencies were
cited.

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

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

STATE FORM

6899

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000) INITIAL COMMENTS Vv 000

TITLE

(X6) DATE

If continuation sheet 1 of 1

inspection_type: MHLCS Annual and Follow-up


summary: Statement of Deficiency - MHLCS Annual

raw_content:
Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

NEW POSSIBILITIES HOME FOR CHILDREN, L

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
MHLO001-155

B. WING

813 TRAIL ONE

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 06/21/2019
FORM APPROVED

06/18/2019

STREET ADDRESS, CITY, STATE, ZIP CODE

BURLINGTON, NC 27215

(X3) DATE SURVEY
COMPLETED

10A NCAC 27G .0207 EMERGENCY PLANS
AND SUPPLIES

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

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

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

This Rule is not met as evidenced by:

Based on record reviews and interviews, the
facility failed to conduct fire drills under conditions
that simulate emergencies at least quarterly and
repeated for each shift. The findings are:

Record review on 6/18/19 of the facility's fire drill
log revealed the following:

-6/13/19- 10:00 a.m., 1st shift.

-2/20/19- 3:45 p.m., 2nd shift.

-1/16/19- 6:30 a.m.; 3rd shift.

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

STATE FORM

6899

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000) INITIAL COMMENTS V 000
An annual survey was completed on June 18,
2019. Deficiencies were cited.
This facility is licensed for the following service
category: 10A NCAC 27G .1700 Residential
Treatment Level III.
V 114) 27G .0207 Emergency Plans and Supplies Vv 114

TITLE

(X6) DATE

JURY11 If continuation sheet 1 of 3

PRINTED: 06/21/2019
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL001-155 B. WING ____ 06/18/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
813 TRAIL ONE
NEW POSSIBILITIES HOME FOR CHILDREN, L
BURLINGTON, NC 27215
(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 114] Continued From page 1 Vv 114

-12/18/18- 6:00 a.m., 3rd shift.

-11/15/18- 5:00 p.m., 2nd shift.

-10/7/18- 4:25 p.m., 2nd shift.

-9/27/18- 6:00 a.m., 3rd shift.

-8/19/18- 3:45 p.m., 2nd shift.

-For the third quarter of 2018, there were no fire
drills for 1st shift.

-For the fourth quarter of 2018, there were no fire
drills for 1st shift.

-For the first quarter of 2019, there were no fire
drills for 1st shift.

Interviews on 6/18/19 with clients #2 and #3
revealed:
-Fire drills had been conducted at the center.

Interview on 6/18/19 with client #3 revealed:
-She had only been at the residence for about a
week.

-She had not experienced any fire drills yet.

Interview on 6/18/19 with the Program
Coordinator revealed:

-Facility operated under three shifts.

-First shift ran from 7:00 a.m. to 3:00 p.m.
-Second shift ran from 3:00 p.m. to 11:00 p.m.
-Third shift ran from 11:00 p.m. to 7:00 a.m.
-She was unaware that there had been no fire
drills conducted on the 1st shift.

-She confirmed staff failed to conduct drills under
conditions that simulate fire and disaster
emergencies under each shift on each quarter.

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

10A NCAC 27G .0303 LOCATION AND
EXTERIOR REQUIREMENTS

(c) Each facility and its grounds shall be
maintained in a safe, clean, attractive and orderly

Division of Health Service Regulation
STATE FORM 6899 JURY11 If continuation sheet 2 of 3

PRINTED: 06/21/2019
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL001-155 B. WING ____ 06/18/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
813 TRAIL ONE
NEW POSSIBILITIES HOME FOR CHILDREN, L
BURLINGTON, NC 27215
(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 736 | Continued From page 2 V 736

manner and shall be kept free from offensive
odor.

This Rule is not met as evidenced by:

Based on observation and interview, the facility
failed to ensure facility grounds were maintained
in a clean, safe and attractive manner. The
findings are:

Observation on 6/18/19 at about 12:20 p.m. of the
bedroom located on the left of the hallway
revealed:

-Paint was peeled/chipped off on wall near door.
-Walls had writings and scratches made on
several places.

Observation on 6/18/19 at about 12:25 p.m. of the
bedroom located on the right hand of the hallway
revealed:

-Wallpaper with picture of twin towers was peeling
off on the bottom right side.

-Large hole behind the door made by door nob.

Interview on 6/18/19 with the Program Director
revealed:

-She was aware rooms needed to be repainted.
-Facility had just started painting the bedrooms
and had only completed one.

-Hole on the wall was made by one of the
residents as she slammed the door open.
-Agency was responsible for maintaining and
replacing items as they brake down as well as
painting inside the home.

-She confirmed the facility failed to ensure facility
grounds were maintained in a safe, clean,
attractive and orderly manner.

Division of Health Service Regulation
STATE FORM 6899 JURY11 If continuation sheet 3 of 3


summary: Statement of Deficiency - MHLCS Complaint

raw_content:
Division of Health Service Regulation

PRINTED: 11/21/2018
FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL001-155 B. WING 11/15/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
813 TRAIL ONE
NEW POSSIBILITIES HOME FOR CHILDREN, L
BURLINGTON, NC 27215
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000) INITIAL COMMENTS V 000
Acomplaint survey was completed on November
15, 2018. The complaint was unsubstantiated
(Intake #NC00145297). No deficiencies were
cited.
This facility is licensed for the following service
category: 10A NCAC 27G .1700 Residential
Treatment Staff Secure for Children or
Adolescents.
Division of Health Service Regulation
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
STATE FORM 6899 X3TU11 If continuation sheet 1 of 1

inspection_type: MHLCS Complaint


summary: Statement of Deficiency - MHLCS Annual

raw_content:
Division of Health Service Regulation

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

MHLO001-155

NEW POSSIBILITIES HOME FOR CHILDREN, LLC

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 04/19/2018

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
813 TRAIL ONE
BURLINGTON, NC 27215

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

04/17/2018

An annual survey was completed on April 17,
2018. There were no deficiencies cited.

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

Residential Treatment Staff Secure for Children
or Adolescents.

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

STATE FORM

6899

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000) INITIAL COMMENTS Vv 000

TITLE

(X6) DATE

If continuation sheet 1 of 1