raw_content:
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

MHL001-149

1710 SYK'

JUST IN TIME YOUTH SERVICES

B. WING

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 09/21/2018
FORM APPROVED

09/07/2018

STREET ADDRESS, CITY, STATE, ZIP CODE
ES STREET

BURLINGTON, NC 27215

(X3) DATE SURVEY
COMPLETED

Allegations, & Protection

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

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

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

c. Misappropriation of the property of a
healthcare facility.

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

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

Facilities must have evidence that all alleged

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
Acomplaint survey was completed on September
7, 2018. The complaint was unsubstantiated
(Intake #NC00142337). A deficiency was cited.
This facility is licensed for the following service
category:
10A NCAC 27G .1700 Residential Treatment
Staff Secure For Children or Adolescents Level
Il.
V 132) G.S. 131E-256(G) HCPR-Notification, V 132

TITLE

68CM11

(X6) DATE

If continuation sheet 1 of 3

PRINTED: 09/21/2018

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
MHL001-149 B. WING ____ 09/07/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 132] Continued From page 1 V 132

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

This Rule is not met as evidenced by:

Based on interview and record review, the facility
ailed to assure that all allegations of harm or
abuse against healthcare personnel was reported
io the Health Care Personnel Registry (HCPR).
The findings are:

Review on 9/6/18 of Client #1's record revealed
he following information;

-- Admitted to the facility on 6/15/18.

-- Age 11 years old.

-- Diagnoses include Attention Deficit
Hyperactivity Disorder, Oppositional Defiant
Disorder - Moderate to Severe, Post Traumatic
Stress Disorder, Unspecified Depressive Disorder
and Unspecified Bipolar Disorder.

Psychological Testing on 3/9/17 produced a Full
Scale IQ of 87.

Interview on 9/6/18 with the facility Director
revealed that a Child Protective Services worker
had come to the facility to investigate an
allegation that Client #1 made that a named staff
Division of Health Service Regulation

STATE FORM 6899 68CM11 If continuation sheet 2 of 3

PRINTED: 09/21/2018

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
MHL001-149 B. WING ____ 09/07/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1710 SYKES STREET
JUST IN TIME YOUTH SERVICES
BURLINGTON, NC 27215
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 132] Continued From page 2 V 132

had hurt dim during a therapeutic intervention that
had happened (date unknown).

Review on 9/6/18 of the North Carolina Incident

Response Improvement System (IRIS) revealed
no incident report had been completed regarding
the above event.

Interview on 9/7/18 with the facility Director
revealed that she was unaware that any
allegation of harm/abuse/neglect or exploitation
made by a client receiving services should be
reported to the HCPR, and that no one had done
this for this event.

Division of Health Service Regulation
STATE FORM 6899 68CM11 If continuation sheet 3 of 3


state: NC

facility_name: Just In Time Youth Services

summary: Plan of Correction - MHLCS Complaint

raw_content:
Division of Health Service Regulation

PRINTED: 09/21/201

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

MHLOO01-149)

FORM APPROVED
(X2) MULTIPLE + CONSTRUCTION (X3) DATE SURVEY
A BUI COMPLETED
LDING:
09/07/2018

NAME OF PROVIDER OR SUPPLIER

JUST IN TIME Y~UTH SERVICES

STREET ADDRESS, CITY, STATE, ZIP CODE
1710 SYKES STREET

BURLINGTON, NC 27215

[RECEIVED

By DHSR - Mental Health Lic. & Cert. Section at 10:02 am, Oct 03, 2018

Notification, Allegations, & Protection

GS. §131E-256 HEALTH CARE
PERSONNEL REGISTRY

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

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

c. Misappropriation of the property of

a healthcare facility.

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

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

Facilities must have evidence that all alleged

ervices in formed facility that they
ere responsible for completing an
INC IRIS and notifying the NC
[Healthcare Personnel Registry of
he allegations/compliant within 72
hours of learning of situation.
Facility at this time complied with
completing the online NC IRIS and
notifying the NC Healthcare
Personnel Registry. Facility also
uring in-house staff meeting
informed all staff members of these
procedures when learning of
llegation/complaint against
healthcare personnel.

(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)
he facility was unaware that they
V 000) INITIAL COMMENTS V 000 ’
needed to notify/report to NC IRIS or
A complaint survey was completed on September INC Healthcare Registry when they
7, 201 8. The complaint was unsubstantiated earned of allegations abuse against
(Intake #NC00142337). A deficiency was cited. healthcare personnel on
This facility is licensed for the following 11712018, which is when the facility
service category: as informed of compliant through
10A NCAC 27G .1700 Residential Treatment (Guildford County DSS initiation of
Staff Secure For Children or Adolescents investigation. Johanna Edwards,
Level Ill. RN (Nurse Consultant) for NC
Department of Health and Human
V 132) G.S. 131E-256(G) HCPR- V 132

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

TITLE

(x6) DATE

STATE FORM

6899

68CM11

If continuation sheet 1 of 3

PRINTED: 09/21/201
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 BUI COMPLETED
LDING:

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

1710 SYKES STREET
JUST IN TIME Y~UTH SERVICES

BURLINGTON, NC 27215
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE

TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

V 132 | Continued From page 1 V 132

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

This Rule is not met as evidenced by:

Based on interview and record review, the facility
failed to assure that all allegations of harm or
abuse against healthcare personnel was reported
to the Health Care Personnel Registry (HCPR).
The findings are:

Review on 9/6/1 8 of Client #1's record revealed
the following information;

-- Admitted to the facility on 6/15/1 8.

-- Age 11 years old.

-- Diagnoses include Attention Deficit
Hyperactivity Disorder, Oppositional Defiant
Disorder - Moderate to Severe, Post Traumatic
Stress Disorder, Unspecified Depressive
Disorder and Unspecified Bipolar Disorder.

-- Psychological Testing on 3/9/17 produced a
Full Scale IQ of 87.

Interview on 9/6/1 8 with the facility Director
revealed that a Child Protective Services worker
had come to the facility to investigate an
allegation that Client #1 made that a named staff

Division of Health Service Regulation
STATE FORM 6899 68CM11 If continuation sheet 2 of 3

PRINTED: 09/21/201
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 BUI COMPLETED
LDING:
MHLOO1-149) 09/07/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET
BURLINGTON, NC 27215

JUST IN TIME Y~UTH SERVICES

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

DEFICIENCY)
V 132 | Continued From page 2 Vv 132

had hurt dim during a therapeutic intervention
that had happened (date unknown).

Review on 9/6/1 8 of the North Carolina Incident
Response Improvement System (IRIS) revealed
no incident report had been completed regarding
the above event.

Interview on 9/7/1 8 with the facility Director
revealed that she was unaware that any
allegation of harm/abuse/neglect or exploitation
made by a client receiving services should be
reported to the HCPR, and that no one had done
this for this event.

Division of Health Service Regulation
STATE FORM 6899 68CM11 If continuation sheet 3 of 3

- | NORTH CAROLINA
4 SAFETY ASSESSMENT
£,, Page 1 of 8

County Name: ail

Social Worker Name:
Children:

Date Report Received:

Part A. FACTORS INFLUENCING CHIL.) VULNERABILITY
These are conditions resulting in child’s inability to pjotect self. Mark all that apply to any child.

Child is age 0-5. © Child has diminished mental capacity.
Child has diagnosed or suspected medical © Child has diminished physical capacity.
or mental condition, including medically fragile. DI None apply

CO Child has limited or no readily accessible support network.

The vulnerability of each child needs to be conside/‘ed throughout the assessment. Younger children and children with diminished mental or
physical capacity or repeated victimization should be ;onsidered more vulnerable. Complete this assessment based on the most vulnerable child.

Part B. CURRENT INDICATORS OF SAFI/TY

The following list is comprised of safety indicators, diifined as behaviors or conditions that describe a child being in imminent danger of serious
harm. Assess the above household for each of the saf ty indicators. Mark “yes” for any and all safety indicators present in the family’s current
situation and mark “no” for any and all of the safety ii|dicators absent from the family’s current situation based on the information at the time.
Mark all that apply.

1. Yes No Caretaker caused and/or alliiwed serious physical harm to the child or made a plausible threat to cause serious
physical harm in the current assessment as indicated by:

Serious injury or abuse to the child other than accidental.

Caretaker fears he/she jvill maltreat the child.

Threat to cause harm ot retaliate against the child.

Substantial or unreason ble use of physical force.

Drug-exposed infant/child

Caretaker committed act that placed child at risk of significant/serious pain that could result in
impairment or loss of b))dily function.

O Caretaker intended to hurt child and does not show remorse.

DO Death of a child.

\
oo00000

Comments:

2. Yes (No Child sexual abuse is suspet ted to have been committed by:

© Parent;
Other caretaker; OR

O Unknown person AND the parent or other caretaker cannot be ruled out, AND circumstances suggest
that the child’s safety may be of immediate concern.

Comments:

i DSS-5231 Revised 01/17 Initials
Child Welfare Services )

GC 1305 Initials

NORTH CAROLINA
_ SAFETY ASSESSMENT
Page 2 of 8

3.) | Yes No/ Caretaker is aware of the po, J ential harm AND unwilling, OR unable to protect the child from serious harm or
threatened harm by others. ‘This may include physical abuse, emotional abuse, sexual abuse, or neglect.
(Domestic violence behavio’s should be captured under Indicator 10.)

© Caretaker fails to protect child from serious harm or threatened harm by other family members, other

household members, o1 other having regular access to the child.

© An individual(s) with i chronic, or severe violent behavior resides in the home or caretaker allows

Com

access to the child.

iments:

|
4, Yes No ) Caretaker’s explanation or llick of explanation for the injury to the child is questionable or inconsistent with
the type of injury, and the njiture of the injury suggests that the child’s safety may be of immediate concern.

|

O Medical exam shows in ury is the result of abuse; caretaker offers no explanation, denies, or attributes to
an accident. |

O Caretaker’s explanation for the observed injury is inconsistent with the type of injury.

O Caretaker’s description of the cause of the injury minimizes the extent of harm to the child.

O Caretaker’s and/or co lateral contacts’ explanation for the injury has significant discrepancies or

Com

contradictions.

iments:

5)
)

Ss Yes’ No Caretaker fails to provide supervision to protect child from potentially serious harm.

© Caretaker present but ¢ tild wanders outdoors alone, plays with dangerous objects, or on window ledges,

ete.

O Caretaker leaves child i lone (period of time varies with age and developmental status).
© Caretaker makes inade<juate/inappropriate child care arrangements or plans very poorly for child’s care.

O Caretaker’s whereabouts are unknown

aD 7 mal } lf ,

Comments: } Va t “
1. Wills J Kk ,°

6. Yes No Caretaker does not meet the child’s immediate needs for food or clothing. For sh We be l re h
v ay

© _No food provided or av hilable to the child, or child is starved/deprived of food/drink for long periods. ¢
© Child appears malnourished.

b50 dak radon ae bake 3 OA J¥inw Cuvol Ai? itn® fk ate

vo A

“ro

ey /il «nch on

© Child is without minim illy warm clothing in cold months.

Comments:

DSS-5231 Revised 01/17
Child Welfare Services

iF
wnials 7 C ey ho ff

Initials

t Yes re)

9. Yes {No,

4

10. Yes | No

NORTH CAROLINA

| SAFETY ASSESSMENT
Page 3 of 8

Caretaker does not meet thd

(suicidal/homicidal). |

|

child’s immediate needs for medical or critical mental health care

© Caretaker does not seel treatment for child’s immediate medical condition(s) or does not follow
prescribed treatments. |

Child has exceptional needs that parents cannot/will not meet.

Child is suicidal and parents will not take protective action.

Child is homicidal and parents will not take protective action.

Child shows effects of naltreatment (i.e. emotional symptoms, lack of behavior control, or physical
symptoms).

ooog

Comments:

Physical living conditions a’e hazardous and immediately threatening to the health and/or safety of the child.

Leaking gas from a sto}/e or heating unit.

Dangerous substances (jr objects stored in unlocked lower shelves or cabinets, under sink, or in the
open.

Lack of water, heat, pli mbing, or electricity and provisions are inappropriate (i.e. using stove as heat
source).

Open/broken/ missing }vindows.

Exposed electrical wires.

Excessive garbage or riitted or spoiled food that threatens health.

Serious illness/significi nt injury due to current living conditions (i.e. lead poisoning, rat bites, etc.)
Evidence of human or [pial waste throughout the living quarters.

Guns and other weapors are not stored in a locked or inaccessible area.
Dangerous drugs are ohne manufactured on premises with child present.

OH000000 0 ao

Comments:

Caretaker’s current substan‘ ¢ abuse seriously impacts his/her ability to supervise, protect, or care for the
child.

© The caretaker is currenily high on drugs or alcohol.

‘There is a current, ong¢ ing pattern of substance abuse that leads directly to neglect and/or abuse of the
child.

Comments:

Domestic violence exists in [he household and poses an imminent danger of serious physical harm and/or
emotional harm to the child

© Child was in immediate danger of serious physical harm by being in close proximity to an incident(s) of
assaultive behavior/domes| ic violence between adults in the household. This includes the child(ren) being
in visual or hearing proximity of domestic violence events in the home.

Comments:

Ly 44, ”

oe DSS-5231 Revised 01/17 initials Cy} 27
Child Welfare Services

Initials

“Wh teas, pile

12% Yes.) No

NORTH CAROLINA
SAFETY ASSESSMENT

Page 4 of 8
Caretaker persistently deser bes the child in predominantly negative terms or acts toward the child in negative
ways, AND these actions make the child a danger to self or others, suicidal, act out aggressively, or severely
withdrawn.

Caretaker repeatedly d¢ scribes the child in a demeaning or degrading manger (i.e. as evil, possessed,
stupid, ugly, etc.)

Caretaker repeatedly cy rses and/or puts child down.

Caretaker repeatedly scapegoats a particular child in the family.

Caretaker blames child for a particular incident, or distorts child’s behavior as a reason to abuse.
Caretaker repeatedly e3 pects unrealistic behavior(s) for the child’s age/developmental stage.
Caretaker views child és responsible for the caretaker’s or family’s problems.

OoH000 a

Comments:

Caretaker’s physical ability, emotional stability, developmental status, or cognitive deficiency seriously
impairs his/her current abilijy to supervise, protect, or care for the child.

Caretaker has a physicé| condition that seriously impairs his/her ability to parent the child.
Emotional instability, | out, or distorted perception is seriously impeding ability to parent.

Depression or feelings >f hopelessness/helplessness immobilize the caretaker, who then fails to maintain
child/home. |

Caretaker is overwhelnjed by child’s dysfunctional emotional, physical, or mental characteristics.
Caretaker’s cognitive d clays result in lack of knowledge about basic parenting skills.

OO oo0

Comments:

13, Yes No Family currently refuses acc ess to or hides the child and/or seeks to hinder an assessment.
1 Family currently refuse § access to the child and cannot or will not provide the child’s location.
1 Family removed the ch Id from a hospital against medical advice.
O Family has previously ‘led in response to a CPS assessment.
OD Family has a history of keeping the child away from peers, school, or other outsiders for extended
periods to avoid CPS assessment.
0 Family is otherwise atti mpting to block or avoid CPS assessment.
Comments:
DSS-5231 Revised 01/17 Initials 5 ES
Child Welfare Services eS

Initials

oO000000

NORTH CAROLINA
SAFETY ASSESSMENT

Page 5 of 8

14. Yes /No) Current circumstances, combined with information that the caretaker has or may have previously maltreated

a child in his/her care, sugg(ist that the child’s safety may be of immediate concern based on the severity of
the previous maltreatment or the caretaker’s response to the previous incident.

Prior death of a child.

Prior serious harm to aty child.

Termination of parental rights.

Prior removal of any ckild.

Prior CPS substantiatian or services needed finding.

Prior threat of serious arm to child.

Caretaker failed to beni(fit from previous professional help.

Comments:___

oOo
Oo

Oo

15. Yes No ) Child is fearful of caretaker other family members, or people living in or having access to the home.

Child cries, cowers, cri ages, trembles, or exhibits or verbalizes fear in relation to certain individuals.
Child exhibits anxiety, nightmares, or insomnia related to a situation associated with a person in the
home.

Child fears unreasonab e retribution/retaliation from caretaker, others in the home, or others having
access to the child.

Comments:

16... Yes No. Other (specify):

Initials

Initials

THE ALLEGATIONS ALO!E DO NOT CONSTITUTE THE NEED FOR A SAFETY

INTER /ENTION/SAFETY AGREEMENT.

If any Indicators of Immediate Safety are marked “Yes”, skip the bottom of this page and continue on the next page.

If all Indicato +s of Immediate Safety 1 through 16 are “No”,

| check this box [) Safe and complet the part below (the remaining pages do not need to be completed).

Child’s Parent or Legal Guardian: Late Signed: | Child’s Parent or Legal Guardian: Date Signed:
Child’s Parent or Legal Guardian: Late Signed: | CPS Social Worker: Date Signed:
Other Party: Late Signed: | CPS Supervisor: Date Signed:

CPS Social Worker’s Name: Phone Number:

Email Address:

CPS Supervisor’s Name:

| Phone Number: Email Address:

DSS-5231 Revised 01/17
Child Welfare Services

aa DSS-5231 Revised 01/17 Initials.

NORTH CAROLINA
SAFETY ASSESSMENT

Page 6 of 8
PAR/[ C: SAFETY INTERVENTIONS
Directions: For each factor identified in Sectior B, consider the resources available in the family and the community that might
help to keep the child(ren) safe. Check each response necessary to protect the child(ren) and explain below.

Family Sati interventions (Safe with a plin)
1. Monitoring and/or use of dire¢t services by county child welfare agency.

©) 2. Use family, neighbors, or oth¢r individuals in the community in the development and implementation of a

/ safety agreement.
3. Use community agencies or s¢rvices.

O 4. The alleged perpetrator will leive or has left the home--either voluntarily or in response to legal action.
O 5. A protective caretaker will mave or has moved to a safe environment with the child(ren) and there are no
restrictions on protective caretiker’s access to the child(ren)
© 6. Identification of a Temporary |safety Provider by the parent with the social worker monitoring
O A Temporary Safety Provider will move into the family home.
© The child(ren) will reside in the home of a Temporary Safety Provider.
Explain why responses 1-5 wete insufficient.

Child Welfare Safety Intervention (Unsafe) _
© 1. Removal of any child in the hesehold; interventions 1-6 do not adequately ensure the child(ren)’s safety.
Explain why a Family Safety Intervention (1-6) could not be used to protect the child.

PART D: SAFETY DECISION

Directions: Identify the safety decision by chec ting the appropriate line below. Check one line only. This decision should be
based on the assessment of all safety indicators, child vulnerability, and any other information known about this case.

A. — Safe: There are no children | kely to be in immediate danger of serious harm. (Indicators of Immediate Safety
all marked No, Marked Safe on Page 5).

B. Safe with a plan: al One or tnore safety indicators are present; Safety Agreement required.
Fan ily Safety Interventions 1, 2, and/or 3 will address safety indicators
1 The alleged perpetrator left the home.
0 A protective caretaker moved to a safe environment with the child(ren).
1 Us¢ of a Temporary Safety Provider.

C. Unsafe: 1 Oni or more children were removed in response to legal action.

Are all safety indicators in Part B marked No (no
indicators apply to the household)?

Safe with a Plan, Complete

Do Family Safety Interventions #1, 2, 3,4 and/or 5 addi 2ss Safety Agreement (page 7).

the safety indicators identified in Part B?

Safe with a Plan. Complete
Safety Agreement (page 7). Also
complete an Initial Safety
Provider Assessment,

Will a Temporary Safety Provider, # 6 address
the safety indicators identified in Part B?

Do any children require removal from the caretakers
(Child Welfare Safety Intervention #1)?

Child Welfare Services
Initials

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aq ysnut pue Ajrurey oy) YUM poyeosd oq ysnu uEyd oY “oINyNF o[Qeoasor0y 10 oyeIPoUTUT oY} UT P]TYO ke 0} Jory) YpTOAdS k st a19y) UOYM ATUO pasn SI JUoUUDOISe AjaJes y :asodang

LNGWATADV ALAAVS +O LAV.

850 L Beg LNGFNAAAOV ALAAVS TVLINGYVd AUVAOdNAL
) ) )

TEMPORARY PARENTAL SAFETY AGREEMENT
Page 8 of 8

STANDING AND AGREEMENT

PARENT OR CARETAKER INITIALS

1. I (the parent or caretaker) agree {hat I participated in the development of and reviewed
this safety agreement. I agree t¢ work with the providers and services as described above.

2. My participation in this agreemént is not an admission of child abuse or neglect on my
part and cannot be used as an admission of child abuse or neglect.

3. Tunderstand that I have the righ’ to revoke and/or have the Temporary Parental Safety
Agreement reviewed at any time. (See bottom of page.) I also understand that ifa
Safety Agreement cannot be agred upon or if the actions in the Safety Agreement are not
followed, the county child welfate agency may have the authority to request that the court
make a determination on how th? child(ren)’s safety will be assured.

4. I (the parent or caretaker) confirjn that this agreement does not conflict with any existing
court order, or if I am affected by a court order, all parties affected by the court order
agree to this safety agreement or, a temporary basis.

) 5. I (the parent or caretaker) understand that CPS may refer for further services, may restrict Sd
access to my child(ren), or may jisk the court to order that I complete services or place the
child in foster care.

6. Ifa Temporary Safety Provider js utilized, I understand that CPS will share any )
information with the Temporary Safety Provider for the safety and welfare of my child
while the child lives in that hom) or the Temporary Safety Provider resides in the family
home.

7. This safety agreement will cea‘ to be in effect when I am notified by my social
worker or CPS is no longer prividing services to my family during the assessment J
phase. If needed, this agreement will be reviewed by this date: appeotr Onn ee

TEMPORARY SAFETY PROVIDER

1. If the parent is unable to provide a safe environment for the child and the court names the
county child welfare agency as t Je child’s legal custodian, I will be given consideration as

" a placement for the child if I agrije and continued placement is determined to be safe.

2. If 1 (the person providing care as Temporary Safety Provider) am unable to carry out this
plan successfully, or if the child In my care is considered to be in an unsafe situation, the
child will be moved to a different placement and further CPS involvement may be

i wae court interv ntion.

Child’s Parent or Legal Guardian: Date Signed: Child’s Parent or Legal Guardian: Date Signed:
\ {aw ao : fim
Child’s Parent or Legal Guardian: Date Signed: | CPS Social Worker Ly Date Sigted: ty
’ ) }
. 4 Date Signed: 7[CPS Supervisor: # t Date Signed:
Temporaty Safety Pfowider: Date Signed: | Temporary Safety Provider: Date Signed:

Who Can I ¢
qu
GPS Social Worker's Name:

ct? ~— (Who can I con ment, or if | have

s about thi

t iffcircumstances change, if | have questions about CPS involy

s of this agreement?)
y (| Binail, Address;

| {EmaibAddress: 2 {éo

ent? Who do I contact to revoke any or all p:

_ Phon¢ Numb:

LA ]
CPS Supervisof's Name: be Phone, Number:

byl dWhi

REVOCATION: I revoke my consent ti) the Temporary Parental Safety Agreement.

Signed: Date:

DSS-5231 Revised 01/17
Child Welfare Services

NC DEPARTMENT OF ROY COOPER - Governor

=P H EA LT H A ND MANDY COHEN, MD, MPH Secretary
HUMAN SERVICES
Division of Health Service Regulation MARK PAYNE - Director

September 18, 2018

Mr. Lewis Pinnix, Director
Just In Time Youth Services
1710 Sykes Street
Burlington, NC 27244

Dear Mr. Pinnix:

Thank you for the report to the Health Care Personnel Registry Section regarding the following incident: |
allegedly abused a resident (D.L.) on or about August 17, 2018. .

The Department is responsible for screening allegations to determine if the reported allegation requires an investigation by the
State for listing on the Health Care Personnel Registry. In screening the reported allegations, the Department strives to ensure
the safety of residents and to assure that the rights of the accused are protected. After carefully reviewing the reported
allegation, the Department has determined that an investigation will not be conducted in this case.

I would appreciate you contacting me if you disagree with our assessment of the case or have reason to believe a full
investigation should be initiated. If you have any questions or we may be of assistance, please contact us. Please reference
the control NA number shown below with any future correspondence.

Sincerely,

oO Leten,
|

Joi B. Deberry

HCPI Investigator

Health Care Personnel Investigations

PO Box 13761

Durham, NC 27709

Phone: 919-714-2009 Fax: 919-405-3827

NA-09-0181-18

NC DEPARTMENT OF HEALTH AND HUMAN SERVICES*DIVISION OF HEALTH SERVICE REGULATION
COMPLAINT INTAKE AND HEALTH CARE PERSONNEL INVESTIGATIONS

LOCATION: 1205 Umstead Drive, Lineberger Building, Raleigh, NC 27603
MAILING ADDRESS: 2719 Mail Service Center, Raleigh, NC 27699-2719
www.ncdhhs.gov/dhsr/ * TEL: 919-855-3968 » FAX: 919-733-3207

AN EQUAL OPPORTUNITY / AFFIRMATIVE ACTION EMPLOYER

inspection_type: MHLCS Complaint

document_type: Plan of Correction


facility_name: Life Cycles Residenital Facility Level III

summary: Statement of Deficiency - MHLCS Annual

raw_content:
PRINTED: 12/15/2025

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
MHL001-200 B. WING 12/11/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

5450 PATILLO CHURCH RD

LIFE CYCLES RESIDENTIAL LEVEL III BURLINGTON, NC 27217

(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 December
11, 2025. No deficiencies were cited.

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

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

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

STATE FORM 6899 8XM211 If continuation sheet 1 of 1

inspection_type: MHLCS Annual

document_type: Statement of Deficiency


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:

MHLO001-200

LIFE CYCLES RESIDENTIAL LEVEL III

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 12/16/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
5450 PATILLO CHURCH RD
BURLINGTON, NC 27217

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

12/10/2024

An annual survey was completed on December
10, 2024. 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

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


summary: Statement of Deficiency - MHLCS Complaint

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 03/30/2023
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
MHLO001-200 03/24/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
5450 PATILLO CHURCH RD
LIFE CYCLES RESIDENTIAL LEVEL III
BURLINGTON, NC 27217
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000) INITIAL COMMENTS Vv 000

Acomplaint survey was completed on March 24,
2023. The complaint was unsubstantiated (intake
#NC00198150). No deficiencies were cited.

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

Residential Treatment Staff Secure for Children
or Adolescents.

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

STATE FORM

6899

ZUDH11

TITLE (X6) DATE

If continuation sheet 1 of 1


facility_name: Life Cycles Residential Facility

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:

MHLO001-218

LIFE CYCLES RESIDENTIAL FACILITY

H JIM MINOR ROAD

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 11/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2448 SOUTI
MEBANE, NC 27302

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

11/14/2025

An annual survey was completed on November
14, 2025. No deficiencies were cited.

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

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

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

STATE FORM

6808 06/911

(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


raw_content:
PRINTED: 02/03/2025

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL001-218 B. WING 01/30/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

2448 SOUTH JIM MINOR ROAD

LIFE CYCLES RESIDENTIAL FACILITY MEBANE, NC 27302

(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 January
30, 2025. The complaints were unsubstantiated
(intake #NC00225244, #NC00225284,
#NC00225500). No deficiencies were cited.

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

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

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

STATE FORM 6899 UCUO11 If continuation sheet 1 of 1


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

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

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

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

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

DEFICIENCY)
V 000} INITIAL COMMENTS V 000

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

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

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

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

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

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

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

c. Misappropriation of the property of a
healthcare facility.

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

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

STATE FORM 6899 KOBR11 If continuation sheet 1 of 11

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL001-149 B. WING

NAME OF PROVIDER OR SUPPLIER
1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/08/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
09/05/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

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

(X4) ID
PREFIX
TAG

ID
PREFIX
TAG

CROSS-REFERENCED TO THE APPROPRIATE

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

(x5)
COMPLETE
DATE

DEFICIENCY)

V 132] Continued From page 1 V 132

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

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

This Rule is not met as evidenced by:

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

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

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

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

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

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

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

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

Division of Health Service Regulation

STATE FORM

6899 KOBR11

If continuation sheet 2 of 11

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

MHL001-149

NAME OF PROVIDER OR SUPPLIER

JUST IN TIME YOUTH SERVICES

PRINTED: 09/08/2025

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

STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET
BURLINGTON, NC 27215

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

(X4) ID
PREFIX
TAG

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

ID
PREFIX
TAG

(x5)
COMPLETE
DATE

V 132] Continued From page 2

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

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

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

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

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

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

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

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

V 366} 27G .0603 Incident Response Requirements

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

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

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

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

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

Division of Health Service Regulation
STATE FORM

V 132

V 366

6899

KOBR11 If continuation sheet 3 of 11

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

MHL001-149

PRINTED: 09/08/2025

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

STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET
BURLINGTON, NC 27215

JUST IN TIME YOUTH SERVICES

specified timeframes not to exceed 45 days;

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

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

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

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

immediately securing the client record

by:

(A) obtaining the client record;

(B) making a photocopy;

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

(2) convening a meeting of an internal

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

Division of Health Service Regulation
STATE FORM

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 366} Continued From page 3 V 366

6899 KOBR11 If continuation sheet 4 of 11

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL001-149 B. WING

NAME OF PROVIDER OR SUPPLIER
1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/08/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
09/05/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

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

(B) gather other information needed;

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

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

(3) immediately notifying the following:

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

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

(C) the provider agency with responsibility

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

(D) the Department;

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

(F) any other authorities required by law.

Division of Health Service Regulation

STATE FORM 6899

KOBR11

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

DEFICIENCY)
V 366} Continued From page 4 V 366

If continuation sheet 5 of 11

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL001-149 B. WING

NAME OF PROVIDER OR SUPPLIER

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/08/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
09/05/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

This Rule is not met as evidenced by:

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

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

-Admission date of 5/24/24.

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

-He was 12 years old.

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

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

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

Division of Health Service Regulation

STATE FORM 6899

KOBR11

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

DEFICIENCY)
V 366] Continued From page 5 V 366

If continuation sheet 6 of 11

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL001-149 B. WING

NAME OF PROVIDER OR SUPPLIER
1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/08/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
09/05/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

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

(X4) ID
PREFIX
TAG

ID
PREFIX
TAG

CROSS-REFERENCED TO THE APPROPRIATE

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

(x5)
COMPLETE
DATE

DEFICIENCY)

V 366 | Continued From page 6 V 366

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

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

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

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

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

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

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

(1) reporting provider contact and
identification information;

(2) client identification information;

(3) type of incident;

(4) description of incident;

(5) status of the effort to determine the

Division of Health Service Regulation

STATE FORM 6899

KOBR11

If continuation sheet 7 of 11

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL001-149 B. WING

NAME OF PROVIDER OR SUPPLIER
1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/08/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
09/05/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

cause of the incident; and

(6) other individuals or authorities notified
or responding.

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

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

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

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

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

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

Division of Health Service Regulation

STATE FORM 6899

KOBR11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 367 | Continued From page 7 V 367

If continuation sheet 8 of 11

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL001-149 B. WING

NAME OF PROVIDER OR SUPPLIER
1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/08/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
09/05/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

include summary information as follows:

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

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

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

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

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

This Rule is not met as evidenced by:

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

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

-Admission date of 5/24/24.

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

Division of Health Service Regulation

STATE FORM

6899 KOBR11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 367 | Continued From page 8 V 367

If continuation sheet 9 of 11

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL001-149 B. WING

NAME OF PROVIDER OR SUPPLIER

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/08/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
09/05/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

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

(X4) ID
PREFIX
TAG

ID
PREFIX
TAG

CROSS-REFERENCED TO THE APPROPRIATE

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

(x5)
COMPLETE
DATE

DEFICIENCY)

V 367 | Continued From page 9 V 367

-He was 12 years old.

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

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

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

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

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

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

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

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

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

EXTERIOR REQUIREMENTS

(c) Each facility and its grounds shall be

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

odor.

This Rule is not met as evidenced by:

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

Division of Health Service Regulation

STATE FORM 6899

KOBR11

If continuation sheet 10 of 11

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL001-149 B. WING

NAME OF PROVIDER OR SUPPLIER
1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/08/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
09/05/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

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

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

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

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

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

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

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

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

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

Division of Health Service Regulation

STATE FORM 6899

KOBR11

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

If continuation sheet 11 of 11

inspection_type: MHLCS Annual, Complaint, and Follow-up


raw_content:
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHLO001-149

A. BUILDING:

1710 SYKES STREET
BURLINGTON, NC 27215

JUST IN TIME YOUTH SERVICES

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 04/15/2025

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

Cc
04/09/2025

(x4) ID
PREFIX
TAG

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

ID
PREFIX
TAG

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

DEFICIENCY)

(xs)
COMPLETE
DATE

V 000!

V 132|

INITIAL COMMENTS

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

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

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

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

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

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

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

c. Misappropriation of the property of a
healthcare facility.

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

e. Fraud against a health care facility or against

Division of Health Service Regulation

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

STATE FORM

V 000

V 132

6899

28V711

TITLE

(X6) DATE

If continuation sheet 1 of 6

Division of Health Service Regulation

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

MHLO001-149

NAME OF PROVIDER OR SUPPLIER

A. BUILDING:

1710 SYKES STREET
BURLINGTON, NC 27215

JUST IN TIME YOUTH SERVICES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 04/15/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

Cc
04/09/2025

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 132] Continued From page 1 V 132

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

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

This Rule is not met as evidenced by:

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

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

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

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

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

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

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

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

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

Division of Health Service Regulation
STATE FORM

6809

28V711

If continuation sheet 2 of 6

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHLO001-149

A. BUILDING:

1710 SYKES STREET
BURLINGTON, NC 27215

JUST IN TIME YOUTH SERVICES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 04/15/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

Cc
04/09/2025

(x4) ID
PREFIX
TAG

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

ID
PREFIX
TAG

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

(xs)
COMPLETE
DATE

V 132

V 367|

Continued From page 2

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

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

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

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

27G .0604 Incident Reporting Requirements

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

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

(1) reporting provider contact and
identification information;

(2) client identification information;

(3) type of incident;

(4) description of incident;

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

(6) other individuals or authorities notified

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

Division of Health Service Regulation
STATE FORM

V 132

V 367

6809

28V711

If continuation sheet 3 of 6

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHLO001-149

A. BUILDING:

1710 SYKES STREET
BURLINGTON, NC 27215

JUST IN TIME YOUTH SERVICES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 04/15/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

Cc
04/09/2025

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

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

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

(1) hospital records including confidential
information;

(2) reports by other authorities; and

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

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

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

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

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

Division of Health Service Regulation
STATE FORM

6809

28V711

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 367 | Continued From page 3 V 367

If continuation sheet 4 of 6

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHLO001-149

A. BUILDING:

1710 SYKES STREET
BURLINGTON, NC 27215

JUST IN TIME YOUTH SERVICES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 04/15/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

Cc
04/09/2025

the definition of a level II or level III incident;

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

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

(6) a statement indicating that there have

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

This Rule is not met as evidenced by:

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

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

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

Welfare Custody.

-He was 13 years old.

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

Division of Health Service Regulation
STATE FORM

6809

28V711

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 367 | Continued From page 4 V 367

If continuation sheet 5 of 6

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHLO001-149

A. BUILDING:

1710 SYKES STREET
BURLINGTON, NC 27215

JUST IN TIME YOUTH SERVICES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 04/15/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

Cc
04/09/2025

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

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

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

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

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

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

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

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

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

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

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

Division of Health Service Regulation
STATE FORM

6809

28V711

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 367 | Continued From page 5 V 367

If continuation sheet 6 of 6


raw_content:
PRINTED: 03/17/2025

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

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

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

DEFICIENCY)
V 000} INITIAL COMMENTS V 000

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

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

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

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

STATE FORM 6899 NHH311 If continuation sheet 1 of 1


summary: Statement of Deficiency - MHLCS Annual and Complaint

raw_content:
Division of Health Service Regulation

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

MHLO001-149

NAME OF PROVIDER OR SUPPLIER

A. BUILDING:

1710 SYKES STREET
BURLINGTON, NC 27215

JUST IN TIME YOUTH SERVICES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/26/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

09/20/2024

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

ID
PREFIX
TAG

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

(xs)
COMPLETE
DATE

V 000} INITIAL COMMENTS

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

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

Residential Treatment Staff Secure for Children
or Adolescents

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

The survey sample consisted of audits of 3
current clients.

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

10A NCAC 27G .0303 LOCATION AND
EXTERIOR REQUIREMENTS

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

This Rule is not met as evidenced by:

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

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

-The bathroom near the front door sink was
clogged.

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

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

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

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

STATE FORM

V 000

V 736

6899

X4ZL11

TITLE

(X6) DATE

If continuation sheet 1 of 2

Division of Health Service Regulation

PRINTED: 09/26/2024
FORM APPROVED

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

-The handle to the stove was broken.

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

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

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

Division of Health Service Regulation
STATE FORM

6809

X4ZL11

If continuation sheet 2 of 2

inspection_type: MHLCS Annual and Complaint


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

raw_content:
Division of Health Service Regulation

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

PRINTED: 06/24/2024

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

MHLO001-149

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

1710 SYKES STREET
BURLINGTON, NC 27215

JUST IN TIME YOUTH SERVICES

FORM APPROVED

) DATE SURVEY
COMPLETED

R-C
06/19/2024

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

DEFICIENCY)
V 000) INITIAL COMMENTS Vv 000

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

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

Residential Treatment Staff Secure for Children
or Adolescents

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

The survey sample consisted of audits of 3
current clients.

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

STATE FORM

6899

TITLE

(X6) DATE

If continuation sheet 1 of 1

inspection_type: MHLCS Complaint and Follow-up