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

raw_content:
Division of Health Service Requlation

MTs

PRINTED: 10/1

4/2019

FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA I

(X2) MULTIPLE CONSTRUCTION

(X3) DATE SURVEY,

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A: BUILDING: COMPLETED
| R
MHL002-028 BINS 09/26/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
. 243 LILEDOUN ROAD
LUCA'S HOPE Ill TAYLORSVILLE, NC 28681
(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000 INITIAL COMMENTS V 000
An annual, followup and complaint survey was
completed on September 26, 2019. The
complaint was substantiatedd (#NC00154873).
Deficiencies were cited.
This facility is licensed for the following service
catetgory: 10A NCAC 27G .1300 Residential
Treatment for Children or Adolescents.
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
drug.

(5) Client requests for medication changes or
checks shall be recorded and kept with the MAR
Division of Health Service Regulation

DHSR-Mental Health

Lic. & Cert. Section

LABORATORY DIRECTOR'S OR PROV[DER/SUPPLIER REPRESENTATYE'S SIGNATURE TITLE (x6) DATE
f a v
Valnar 2 = Dieecton. LO-19 19

6808 If continuation sheet 1 of 25

STATE FORM M53714

PRINTED: 10/14/2019
FORM APPROVED

Division of Health Service Requlation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED
A ILDING:
\ R
MHL002-028 [8 WING —_________—§ 09/26/2019
_29leoFebT9 |
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
243 LILEDOUN ROAD
LUCA'S HOPE lil i
TAYLORSVILLE, NC 28684
(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (%5)
PREFIX (EACH DEFICIENCY MUST 3E PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
SS  Os DVO ll
V 118 Continued From page 1 V 118
tile followed up by appointment or consultation
with a physician.

This Rule is not met as evidenced by:

Based on record review and interviews the faciliiy
failed to ensure medications were administered
as ordered for 1 of 3 audited clients (#2), failed to
ensure MARs were current and that medications
were only self-administered on the order of a
physician for 3 of 3 audited clients (#1, #2, #3)
The findings are:

Client #1:

Record review on 9/3/19 for Client #1 revealed:
-Admitted on 10/23/17 with diagnoses of Mild
Intellectual Disability, Disruptive Mood
Dysregulation Disorder, Conduct Disorder,
Attention Deficit Hyperactivity Disorder, and
Learning Disorder.

-Physician's orders dated 5/18/19 for Depakote
500mg, one in the evening and Trazodone 50mg
one at bedtime.

-No physician's order to self-administer
medications.

Review on 9/3/19 of the MARs for 6/2019-9/2019
revealed:

-Administration of Depakote and Trazodone was
not documented from 7/26/19-7/31/19.

Interview on 9/3/18 with Client #1 revealed:

-He received his medications daily. He Knew that

he took Trazodone and Depakote at night and

indicated that he had never missed his nighttime

medications.

Division of Health Service Regulation

STATE FORM ane M5371 ‘f continuation sheet 2 of 25

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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
L MHL002-028 Be WING 5 09/26/2019
NAME OF PROVIDER OR SUPPLIER. STREET ADDRESS, CITY, STATE, ZIP CODE
243 LILEDOUN ROAD
LUCA'S HOPE Ill ~
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
Vv 118 Continued From page 2 V 118

-He stated that a staff member always
administered his medications.

Client #2:

Record review on 9/3/19 for Client #2 revealed:
-Admitted on 11/12/18 with diagnoses of Autism,
Attention Deficit Hyperactivity Disorder, and Bi
Polar Disorder.

-Physician's order dated 5/8/19 for Lithium
Carbonate 300mg, two in the morning and one at
bedtime.

-Physician's order dated 5/8/19 for Propranolol
10mg, one daily.

-Physician's order dated 5/8/19 was for Latuda
60mg, one with dinner. The order was changed
on 7/10/19 to 20mg at breakfast and 40mg with
dinner.

-No physician's order to self-administer
medications.

Review on 9/3/19 of the MARs for 6/2019-9/2019
revealed:

-The PM dose of Lithium Carbonate was not
documented as administered on 8/3/19.

-The August and September MARs indicated the
Propranolol dose was 20mg not 10mg. The
dosed had been decreased on 5/8/19 but the
August and September MARs were still showing
the old dose.

-The PM dose for Latuda was being administered
at 8:00PM not with dinner.

Interview on 9/3/18 with Client #2 revealed:

-He received his medications daily. He took his
Latuda at bedtime

-He stated that a staff member always
administered his medications.

-He had never missed taking any of his
medications.

Division of Health Service Regulation
STATE FORM bs M53711 li continuation sheet 3 of 25

Division of Health Service Regulation

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

|

(X2) MULTIPLE CONSTRUCTION
A. BUILDING: __

| 8. WING
MHL002-028 |

PRINTED: 10/14/2019
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
09/26/2019

NAME OF PROVIDER OR SUPPLIER

LUCA'S HOPE III

STREET ADDRESS, CITY, STATE, ZIP CODE

243 LILEDOUN ROAD
TAYLORSVILLE, NC 28681

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL
TAG REGULATORY OR LSC IDENTIFYING INFORMATION)

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

=

Client #3:

Record review on 9/3/19 for Client #3 revealed:
-Admitted on 10/24/18 with diagnoses of Attention
Deficit Hyperactivity Disorder, Other Specified Bi
Polar Disorder, Intermittent Explosive Disorder,
and Oppositional Defiance Disorder.
-Physician's order dated 5/8/19 for Depakote
500mg, one twice daily.

-Physician's order dated 5/8/19 for Trazodone
50mg, one at bedtime. The order changed on
8/14/19 t0 50mg at bedtime as needed.

-No physician's order to self-administer
medications.

Review on 9/3/19 of the MARs for 6/2019-9/2019
revealed:

-The August MAR did not indicate the change to
PRN (as needed).

-The PM administration of Depakote was not
documented on 6/17/19.

Interview on 9/3/18 with Client #3 revealed:

-He received his medications daily. He had never
missed any medications.

-He stated that a staff member always
administered his medications. He had never
given himself his mediations.

Interview on 9/4/18 with the Director revealed:
-She was responsible for the oversight of
medication administration.

-She wrote the MARs but at times some of the
other staff helped with that.

-She was usually the person responsible for
updates to MARs.

-Client #2 had always taken the Latuda at
8:00PM. Their dinner was usually at 6:00PM.
-She had not realized that the several days in July

V 118 Continued From page 3 V41u8

Division of Health Service Regulation
STATE FORM e980

M83711 If continuation sheet 4 of 25

Division of Health Service Requlation

PRINTED: 10/14/2019
FORM APPROVED

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

MHL002-028 | B. WING

NAME OF PROVIDER OR SUPPLIER

(X2) MULTIPLE CONSTRUCTION
| A. BUILDING:

STREET ADDRESS, CITY, STATE, ZIP CODE
243 LILEDOUN ROAD

(X3) DATE SURVEY
COMPLETED

R
09/26/2019

LUCA'S HOPE:IIL TAYLORSVILLE, NC 28681
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118 Continued From page 4 V1i8 (Lucas Rope WAY ensure tis wal
the Depakote and Trazodone had not been Ne Longer happen Noy maicing Chang es
documented for Client #1. She confirmed thai Minat Involve Ae Directoe nsw
Client #1 had not missed any medications. the meas aie Checked a a Werkl
~She kept her MARs on the computer and at the basis, SHAPE WAL monrdok Bach one
beginning of each month she would print new lugon ENA in the mat wren the
ones, She indicated that she had failed to “t meds, EF SHAPE See missin tials
change the Propranolol dosage on subsequent we Meds. c IImmedi {
MARs for Client #2. tne toatl Moly the Supeav: int I
im 5
-She stated that she tried to educate her clients Clients will no lonyer be atlowedrc pyp
about their medications. She wanted them to Yagia DOM medi cation, Ui, & (\ only a
“know their meds." . ai 4 =e, Dideclor wll
-She would have them sit down one at a time and done bu authorized Stet F A
she would pull out their medications. She then Cn Sure G\\ med Changes ade
would have them read the label and pop out the UPdatedl ON We Mat$-
medication into a cup, show it to her and then
take their medication in front of her. She
supervised this process. She would then put her
initials on the MAR.
-She felt this was a time of education for each
client. This was a process that only she did with
the clients.
-She did not consider this self-administration and
therefore did not have orders from their
physicians.
This deficiency constitutes a re-cited deficiency
and must be corrected within 30 days.
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:

Division of Health Service Regulation

STATE FORM

6a93

If continuation sheet 5 of 25

M53711

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FORM APPROVED

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING. COMPLETED
R
MHL002-028 EWING 09/26/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
243 LILEDOUN ROAD
LUCA'S HOPE Ill :
TAYLORSVILLE, NC 28681
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES. 1D PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
a
V 132 Continued From page 5 V 132

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
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 interview the facility
failed to report an allegation of abuse by a staff
member to the Health Care Personnel Registry.
The findings are:
Division of Health Service Regulation
STATE FORM 6399 M53711 'f continuation sheet 6 of 25

Division of Health Service Requlation

PRINTED: 10/14/2019

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

MHLO002-028

FORM APPROVED
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
A, BUILDING: COMPLETED
R
B. WING

09/26/2019

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

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 || 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

Division of Health Service Regulation
STATE FORM

‘ 243 LILEDOUN ROAD
LUCA'S HOPE! TAYLORSVILLE, NC 28681
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES iD PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 132 Continued From page 6 V132, Lucas Bde Will ensuce Wiis
fe oF Incideny Wi\l Mok happen
See V367 for additional information. agin by Re Porti wv ek xE ang
Record review on 9/4/19 revealed no Reports OW albegakons ave made
poet dt ofa report made to the Health Pegacding Neg wet 40 the
are Personnel Registry. .
Death CALE Registty, The TDicecto:
eee on 9/4/19 and 9/20/19 with the Director | Wilt be Ane one Le AS. bie For
revealed: <
-A report was made to the Department of Social ENS ivnly WS Process rs fel
Services (DSS) that FC #4 was being abused,
specifically choked by a staff member. DSS
came on site to investigate the allegation. DSS
found no evidence of abuse.
-After she learned of the allegation, she
conducted her own investigation. She
interviewed all the clients, met with staff,
contacted the guardian.
-FC #4 clearly stated the allegation was not true.
-Neither she nor DSS found any evidence of |
abuse.
-She indicated that she never had to do a report
to the Health Care Registry before.
-She was not aware of that procedure.
V 367 27G .0604 Incident Reporting Requirements | V367

e8ee MS3711 if continuation sheet 7 of 25

Division of Health Service Regulation

PRINTED: 10/14/2019
FORM APPROVED

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
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 Ill 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 Ill

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION. (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER A BUILDING COMPLETED
. BUI
R
L MHL002-028 B. WING) =. 09/26/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
243 LILEDOUN ROAD
LUCA'S HOPE Ill
c OPE TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES D PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
L DEFICIENCY)
V 367 Continued From page 7 V 367

Division of Health Service Regulation
STATE FORM e300 M53711

ff continuation sheet 8 of 25

PRINTED: 10/14/2019

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: ACBUBING! COMPLETED
R
MHL002-028 B. WING _______£ 09/26/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
243 LILEDOUN ROAD
LUCA'S HOPE Ill
TAYLORSVILLE, NC 28681
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (x6)
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

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 || or level Ill incident;

(2) restrictive interventions that do not meet
the definition of a level Il 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 I! and level |!!
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 Level II and III incidents were
reported to the Local Management Entity (LME)
within 72 hours of becoming aware of the incident
effecting 1 of 1 client (#Former Client #4), The
findings are:

Division of Health Service Regulation
STATE FORM 899 M53711 lf continuation sheet 9 of 25

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FORM APPROVED

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED
R
MHL002-028 B. WING 09/26/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 367 Continued From page 9 V 367

Review on 9/3/19 of incident reports submitted |
into IRIS (Incident Reporting Improvement | |
System) revealed no report for the incident on

6/23/19 |

Review of incident reports on 9/4/19 revealed:
-On 6/23/19 "Staff engaged with client (FC #4) to
get him to come in and eat dinner ...Client started
cursing staff and walked up to staff (Staff #1) as
he raised his arm like he was going to hit me. |
stopped his hand from hitting me and held on to it
and client feel down to the group yelling and
rolling around on the ground. Client would not get
up and | was afraid that he was going to hurt
himself because he has his hands around his
neck trying to choke himself ...1 tried to keep him
still because of the sticks, rocks and tree limbs
that were on the ground. My hand was tangled in
his shirt after he started trying to get out of it and
it was hurting my hand. Another peer (Client #2)
came out afterwards and he felt that | was getting
hurt and he tried to help me because he could
see my hand while client was out of control.
Client kicked his peer very hard while screaming
and yelling and this caused the other peer to try
to protect himself by hitting his peer. Client finally
got up and said that he was going to leave and
would not come into the house. Client walked
around the edge of the yard as if he was going to
leave the premises and remained close to the
road until the Director came back to talk to him

Interviews on 9/4/19 and 9/20/19 with the Director
revealed:

-A report was made to the Department of Social
Services (DSS) that FC #4 was being abused,
specifically choked by a staff member. DSS
came on site to investigate the allegation.

-She found no evidence of abuse by her staff
Division of Health Service Regulation

STATE FORM cess M53711 If continuation sheet 10 of 25

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FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED
R
MHL002-028 MG 09/26/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
‘i 243 LILEDOUN ROAD
LUCA'S HOPE Ill
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

v3e7Lucaty Rope ws\\ ensure oat
Q\\ Tncidenks are Reported + sulom

V 367 Continued From page 10

member and DSS unsubstantiated the allegation. ro
FC #4 clearly stated the allegation was not true. theo & Wwe This SU Stem ih
-She failed to write up the IRIS report and submit Se chou wil\ be RES Pons. bic Four

it for this incident.
it for this inciden’ hon honk, GAL a

V 536 27E .0107 Client Rights - Training on Alt to Rest. | V536 Ty Cidents OLe submite wodhin :
im Aa hour Mme Frame

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

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

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

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

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

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

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

Division of Health Service Regulation
STATE FORM cass M537411 If continuation sheet 11 of 25

PRINTED: 10/14/2019

FORM APPROVED
Division of Health Service Requlation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA | (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: | 4. BUILDING: COMPLETED

R
MHL002-028 5 OMING _______—_— 09/26/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
243 LILEDOUN ROAD
‘A'S HOPE Ill
LUCA'S H TAYLORSVILLE, NC 28681
(X4) 1D SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
hic
V 536 Continued From page 11 V 536 |
Paragraph (g) of this Rule. i

(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

(8) 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:

Division of Health Service Regulation
STATE FORM sage M53714 If continuation sheet 12 of 25

PRINTED: 10/14/2019
FORM APPROVED

Division of Health Service Requlation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA ] (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER. A. BUILDING COMPLETED
DING
R
MHL002-028 a 09/26/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES. 1D PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
LL
V 536 Continued From page 12 V 536

(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
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.

Division of Health Service Regulation
STATE FORM ease M53714 if continuation sheet 13 of 25

PRINTED: 10/14/2019
FORM APPROVED

Division of Health Service Requlation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA ] (x2) MULTIPLE CONSTRUCTION
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: |

| A BUILDING

(X3) DATE SURVEY
COMPLETED

R
MHL002-028 B.WING oo = 09/26/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
4 243 LILEDOUN ROAD
LUCAS HOPE Il TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 536 Continued From page 13 V 636
(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.

This Rule is not met as evidenced by:

Based on record review and interviews the facility
failed to ensure that 1 of 5 audited staff (#2)
received initial training in alternatives to restrictive |
interventions and failed to ensure that 4 of 5
audited staff (#1, #3, #4, and the Qualified
Professional) received the refresher training
annually. The findings are:

Review on 9/4/19 of the personnel record for Staff |
#1 revealed:

-Hired on 2/23/17.

-NCI (North Carolina Interventions) training that
included alternatives to restrictive interventions on
1/30/18. No refresher training documented.

Division of Health Service Regulation
STATE FORM 6399 M53711 if continuation sheet 14 of 25

Division of Health Service Requiation

PRINTED: 10/14/2019
FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION, (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING. COMPLETED
|
R
MHL002-028 | 8. wins 09/26/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
243 LILEDOUN ROAD
LUCA'S HOPE Ill
TAYLORSVILLE, NC 28681
(X4) 1D SUMMARY STATEMENT OF DEFICIENCIES iD PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE. COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 536

V 536 Continued From page 14

Review on 9/4/19 of the personnel record for
Staff #2 revealed:

-Hired on 7/15/19.

-No NCI training documented. No training in
alternatives to restrictive interventions.

Review on 9/4/19 of the personnel record for Siaff
#3 revealed:

-Hired on 9/25/16.

-NCI training that included alternatives to
restrictive interventions on 8/13/17. No refresher
training documented since that time. |

Review on 9/23/19 of the personnel record for
Staff #4 revealed:

-Hired on 7/25/18.

-NCI training that included alternatives to
restrictive interventions on 7/18/18. No refresher
training documented since that time.

Review on 9/4/19 of the personnel record for the
Qualified Professional revealed:

-Hired on 10/1/14.

-NCI training that included alternatives to
restrictive interventions on 8/13/17. No refresher
training documented since that time.

Interviews on 9/4/19 and 9/20/19 with the Director | |
revealed:

-NCI training had ended and the training she had
once used was no longer available.

-Three weeks ago, her prior trainer had informed

her of a new training.

-She had tried to find a replacement for NCI but
didn't realized how long it had been.

-She indicated there was a lapse in training for ali
staff.

-She contacted her trainer about possible training
during the survey. She had staff trained in the

use of restrictive interventions and de-escalation
Division of Health Service Reguiation

STATE FORM ance

M53711 If continuation sheet 15 of 25

Division of Health Service Regulation

PRINTED: 10/14/2019
FORM APPROVED

STATEMENT OF DEFICIENCIES. (X1) PROVIDER/SUPPLIER/CLIA

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL002-028 8. WING

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY,

EUCA'S'HOPE Ill TAYLORSVILLE, NC

[

(X2) MULTIPLE CONSTRUCTION

243 LILEDOUN ROAD

(X3) DATE SURVEY
COMPLETED

R
09/26/2019

STATE, ZIP CODE

28681

SUMMARY STATEMENT OF DEFICIENCIES. D

PROVIDER'S PLAN OF CORRECTION 0%)

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

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

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

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

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

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

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

(f) Content of the training that the service

(X4) ID
pe (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 15 V 536 Lucas Pope OWN ensure Vncet
on 9/12/19. OW SUE bepuided Atatniny wit]
vagy De Kee Caden and atl Start

wit be Given Ganual Retresha tlus
Mee chor wit moneor Ye Bates Yeo
Aden eyPines ONG frerbaly ba sis [+o

Prevent and \oPS< rn MMainia 5 Foo ptaFt

Division of Health Service Regulation
STATE FORM

6800

M537 11 if continuation sheet 16 of 25

PRINTED: 10/14/2019

FORM APPROVED
Division of Health Service Requlation
STATEMENT OF DEFICIENCIES. (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED
R
MHL002-028 BIN te ts 09/26/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28684
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES D PROVIDER'S PLAN OF CORRECTION 5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

5 ]
V 537 Continued From page 16 V537— |

provider plans to employ must be approved by
the Division of MH/DD/SAS pursuant to
Paragraph (q) 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);

(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:

() Trainers shall demonstrate competence

Division of Health Service Regulation
STATE FORM S369 M53741 If continuation sheet 17 of 25

PRINTED: 10/14/2019

FORM APPROVED
Division of Health Service Requlation
STATEMENT OF DEFICIENCIES (X41), PROVIDER/SUPPLIERI/CLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER K-RUILDING COMPLETED
1 R
MHL002-028 | NG os ee 09/26/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
243 LILEDOUN ROAD
ul "S HOPE III
UCA'S TAYLORSVILLE, NC 28684
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES iD PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 537 Continued From page 17 V 537

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

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.

Division of Health Service Regulation
STATE FORM Base M53717 if continuation sheet 18 of 25

Division of Health Service Regulation

PRINTED: 10/14/2019
FORM APPROVED

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

MHLO002-028

NAME OF PROVIDER OR SUPPLIER

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

| B. WING

(X3) DATE SURVEY
COMPLETED

R
09/26/2019

STREET ADDRESS, CITY, STATE, ZiP CODE
243 LILEDOUN ROAD

V 537 Continued From page 18

(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.
(I) 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 review and interviews the facility
failed to ensure that 1 of 5 audited staff (#2)
received initial training in seclusion, physical
restraint and isolation time-out and failed to
ensure that 4 of 5 audited staff (#1, #3, #4, and
the Qualified Professional) received the refresher
training annually affecting 2 of 4 audited clients
(#2, Former Client #4). The findings are:

Review on 9/4/19 of the record for Former Client

LUCA'S HOPE Ill
UcAs'HO TAYLORSVILLE, NC 28684
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES iD PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 537

Lucas Wope as alieady bbrousbk
Wig Rule rn ComPviance by
Berrray AM SURE TLained I the
Direchor tol\ tnsuce Yet movi
Forward Sake will Lecweve Rettespex
Classes AN GA Ganual basis an ofde
40 Femain EY Compliance worth
Minis lute, te S4aeF Fetonds willbe
Montloged tA a

Division of Health Service Regulation
STATE FORM

ease

M3711 'f continuation sheet 19 of 25

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROV!
AND PLAN OF CORRECTION

MHL002-028

IDER/SUPPLIER/CLIA (X2) MULT|PLE CONSTRUCTION
IDENTIFICATION NUMBER: A. BUILDING:

PRINTED: 10/14/2019
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
09/26/2019

E WING

STREET AD!

NAME OF PROVIDER OR SUPPLIER,

DRESS, CITY, STATE, ZIP CODE

243 LILEDOUN ROAD

V 537 Continued From page 19

#4 (FC #4) revealed:

-Admitted on 5/6/19 with diagnoses of Attention
Deficit Hyperactivity Disorder and Disruptive
Mood Dysregulation.

-Discharged on 8/27/19

-Age 14.

-Comprehensive Clinical Assessment indicated
FC #4 struggled with emotional regulation,
making appropriate behavioral choices, and
instigated arguments. Behaviors included yelling,
cursing, threatening physical violence, instigated
negative peer interactions, and verbal
aggression. It was also noted that FC #4 could
de-escalate with support.

-Safety assessment indicated that FC #4 had a
history of property destruction and fighting with
others.

Review on 9/4/19 of the record for Client #2
revealed:

-Admitted on 11/12/18 with diagnoses of Autism,
Attention Deficit Hyperactivity Disorder, and Bi
Polar Disorder.

-Age 17.

-History of property destruction, non-compliance
with rules, and physical aggression towards
others.

Review on 9/4/19 of the personnel record for Staff
#1 revealed:

-Hired on 2/23/17.

-NCI (North Carolina Interventions) training on
1/30/18. No refresher training documented.

Review on 9/4/19 of the personnel record for
Staff #2 revealed:

-Hired on 7/15/19.

-No NC! training documented.

Review on 9/4/19 of the personnel record for Staff

LUCA'S HOPE Ill
TAYLORSVILLE, NC 28681
(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (x8)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 537

Division of Health Service Regulation
STATE FORM

6899 !f continuation sheet 20 of 25

M53714

PRINTED: 10/14/2019

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
R
MHL002-028 BOWING oe ee 09/26/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
243 LILEDOUN ROAD
LUCA‘S HOPE Ill
TAYLORSVILLE, NC 28684
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES iD PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST 8 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 20 V 537
#3 revealed:

-Hired on 9/25/16. |
-NCI training on 8/13/17. No refresher training
documented since that time.

Review on 9/23/19 of the personnel record for
Staff #4 revealed:

-Hired on 7/25/18.

-NCI training on 7/18/18. No refresher training
documented since that time.

Review on 9/4/19 of the personne! record for the
Qualified Professional revealed:

Hired on 10/1/14.

-NCI training on 8/13/17. No refresher training
documented since that time.

Review of incident reports on 9/4/19 revealed:

-On 6/23/19 "Staff engaged with client (FC #4) to

get him to come in and eat dinner ...Client started

cursing staff and walked up to staff (Staff #1) as

he raised his arm like he was going to hit me. | |
stopped his hand from hitting me and held on to it
and client feel down to the group yelling and
rolling around on the ground. Client would not get
up and | was afraid that he was going to hurt
himself because he has his hands around his
neck trying to choke himself ...| tried to keep him
still because of the sticks, rocks and tree limbs
that were on the ground. My hand was tangled in
his shirt after he started trying to get out of it and
it was hurting my hand. Another peer (Client #2)
came out afterwards and he felt that | was getting
hurt and he tried to help me because he could
see my hand while client was out of control

Client kicked his peer very hard while screaming
and yelling and this caused the other peer to try |
to protect himself by hitting his peer. Client finally

got up and said that he was going to leave and |
would not come into the house. Client walked |
Division of Health Service Regulation

STATE FORM 6es9 M53711 If continuation sheet 21 of 25

PRINTED: 10/14/2019
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: ASBUILDIN COMPLETED
ING
|
R
MHL002-028 Bi WING 09/26/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
243 LILEDOUN ROAD
LUCA'S HOPE III 4
CAS: TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES D PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
—
V 537 Continued From page 21 V 537

around the edge of the yard as if he was going to
leave the premises and remained close to the
road until the Director came back to talk to him

Interview on 9/4/19 with Staff #1 revealed:

-At one time she worked in the facility but now
she worked in the office assisting the Director.
On the date of the incident she was filling in with
Staff #4.

-On 6/23/19 she was outside with FC #4 directing
him to come inside for dinner. He began to curse
and yell and as she walked toward him he
approached her with his hand raised like he was
going to hit her. She indicated that she blocked
him first then reached around and grabbed the
back of his shirt with one hand. He dropped to
the ground rolling around, kicking and screaming. |
She stated he was trying to choke himself and
she was trying to grab his other hand to get it
away from his neck. She was still holding on to
his shirt and her hand was getting tangled in his
shirt. She was able to get his hand to release
from around his neck. FC #4 was still on the
ground laying on his side and she continued to
have a grip on his shirt and was attempting to
hold one of his arms next to his side.

-She indicated she "was trying to restrain" FC #4.
-While FC #4 was still on the ground Client #2
engaged and was trying to grab the feet of FC #4
FC #4 kicked Client #2 multiple times and then
Client #2 started hitting FC #4. Staff #4
intervened and got Client #2 calmed down.

-FC #4 rolled onto his back and stood up. Her
hand was still tangled in his shirt, but she got her
hand free when FC #4 started running to the
edge of the yard. He was walking on the edge of
the yard when the Director arrived.

-FC #4 had red marks on his neck and scrapes
on his skin from being in the pine needles.

Division of Health Service Regulation
STATE FORM e200 M53711 lf continuation sheet 22 of 25

Division of Health Service Requlation

STATEMENT OF DEFICIENCIES

(X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION

PRINTED: 10/14/2019
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

V 537 Continued From page 22
-She had not received any NCI training in 2019

Interview on 9/18/19 with Staff #4 revealed:
-Client #2 had informed her that Staff #1 needed
help outside with FC #4.

-She indicated that Staff #1 was trying to get FC
#4 to calm down. Staff #1 was holding onto his
shirt and FC #4 had thrown himself to the ground
He was thrashing around on the ground, and her
hand was tangled in his shirt. FC #4 was trying to
choke himself and Staff #1 was telling him
repeatedly to calm down.

-When Client #2 began to hit FC #4 she “grabbed
him" and put him in a “little hug". She was trying
to keep his arms down and turn him away. Client
#2 responded and turned away.

-She indicated that they had been trained in
restrictive interventions last week.

Interviews on 9/4/19 and 9/20/19 with the Director
revealed:

-On 6/23/19 she was contacted by staff and when
she arrived the altercation was over. FC #4 was
sitting on the edge of the yard.

-Staff #1 was trying to get him inside the house
and FC #4 was mad because it was not his turn
to pick out the movie to watch. He approached
Staff #1 with his fist drawn. Staff #1 thought he
was going to hit her. Staff #1 indicated that she
had blocked his hand and grabbed his shirt.
When FC #4 fell to the ground she was trying to
get her hand loose from being twisted up in his
shirt. When Client #2 engaged in the incident he
hit FC #4 after being kicked. Staff #4 was able to
get Client #2 under control.

-Neither client was injured during the incident.
-FC #4 had a history of hitting female staff. She
observed red marks on his neck which he
indicated were caused when he was trying to get
out of his shirt during the incident. He told her he

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:
i R
MHL002-028 | 8. WING 09/26/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
243 LILEDOUN ROAD
LUCA'S HOPE Ill
TAYLORSVILLE, NC 28684
(X4) 1D SUMMARY STATEMENT OF DEFICIENCIES iD PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

Division of Health Service Regulation
STATE FORM ass

M537 11

If continuation sheet 23 of 25

PRINTED: 10/14/2019
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 BULEING COMPLETED
R
MHL002-028 ELWING, 09/26/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 286381
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES D PROVIDER'S PLAN OF CORRECTION (5)
PREFIX (EACH DEFICIENCY MUST 8€ 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 23 V 537

didn't mean to hurt Staff #1's hand.

-NCI training had ended and the training she had
once used was no longer available.

-Three weeks ago, her prior trainer had informed
her of a new training.

-She had tried to find a replacement for NCI but
didn't realized how long it had been.

-She indicated there was a lapse in training for all
staff.

-She contacted her trainer about possible training
during the survey. She had staff trained in the
use of restrictive interventions and de-escalation
on 9/12/19.

Review on 9/24/19 of the Plan of Protection
completed and signed by the Director on 9/24/19
revealed:
-"Luca's Hope will ensure that all required
trainings are kept up to date and valid without
lapse in the dates of certification, while adhering
to the new safety plan. Luca's Hope has
corrected the above violation by getting staff the
required training EBP! (Evidence Based
Protective Interventions) training on 9/12/19.
Luca's Hope will perform quarterly training
reviews to ensure that dates and validity of
training are kept current."
-"Luca's Hope will start a new practice that |
involves reviewing skills that staff have learned
and how they should be implemented in the event
that a client becomes angry, has an outburst and
becomes threatening and physically aggressive.
The home will conduct this review on a monthly
basis during the mandatory staff meeting.
Included in this review the clinician will review the
following steps with staff that work directly with
clients.
1. How to identify/assess the Safety/Risk Level

a. What behaviors is the client using?
Aggression, threats, property damage, emotional
Division of Health Service Regulation
STATE FORM 8888; M53711 if continuation sheet 24 of 25

PRINTED: 10/14/2019
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
R
MHL002-028 BINS 09/26/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES Dp 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 24 V 537

outburst

b. How much control/influence do you have
with client? No control, some control, usually
have no control
2. Most effective immediate safety action is to:
a. Separate from client when he starts to
escalate in anger; b. Do not engage with client if
they don't won't to talk or join the group, not |
receptive; c. Calmly go to another area, leaving
client space to calm down while continuing to
monitor client to ensure their safety.”

FC #4 had a history of physical aggression
towards peers and staff. Without proper
de-escalation he would engage in physical fights
with others. Client #2 also had a history of
physical aggression. On 6/26/19, FC #4 became
physically aggressive with Staff #1. She failed to
implement a proper restraint and was unable to
de-escalate FC #4. He tried to harm himself
during the event and subsequently was
aggressive toward Client #2 when he got
involved. When Staff #4 intervened, she
restrained Client #2 with an improper physical
hold. Due to not having current training in
restrrictive interventions, neither Staff #1 nor Staff
#4 knew the proper responses to use with two
clients whose behaviors escalated out of conirol.
Failure to train staff in the use of restrictive
interventions who work with clients who exhibit
aggressive behaviors is detrimental to the health
safety, and welfare of clients and constitutes a
Type B rule violation. If the violation is not
corrected within 45 days, an administrative
penalty of $200.00 per day will be imposed for
each day the facility is out of compliance beyond
the 45th day.

Division of Health Service Regulation
STATE FORM e205 M53711 If continuation sheet 25 of 25

ROY COOPER * Governor
MANDY COHEN, MD, MPH - Secretary
MARK PAYNE = Director, Division of Health Service Regulation

DHSR-Mental Health

October 15, 2019

. ; nay & | 2019
Valarie Stanback, Director
Luca’s Hope, LLC ‘ .
PO Box 442 Lic. & Cert. Section
Sherrills Ford, NC 28673

Re: — Annual, Follow up and Complaint Survey completed September 26, 2019
Luca's Hope Ill, 243 Liledoun Road, Taylorsville, NC 28681
MHL # 002-028

E-mail Address: valariestanback@yahoo.com

(Intake #NC00154873)
Dear Ms. Stanback:

Thank you for the cooperation and courtesy extended during the annual, follow up and
complaint survey completed September 26, 2019. The complaint was substantiated.

Enclosed you will find all deficiencies cited listed on the Statement of Deficiencies Form. The
purpose of the Statement of Deficiencies is to provide you with specific details of the practice
that does not comply with state regulations. You must develop one Plan of Correction that
addresses each deficiency listed on the State Form, and return it to our office within ten days of
receipt of this letter. Below you will find details of the type of deficiencies found, the time frames
for compliance plus what to include in the Plan of Correction.

Type of Deficiencies Found

e Type B rule violation is cited for 10A NCAC 27E .0108 Training in Seclusion, Physical
Restraint and Isolation Time Out (V537).

e Are-cited standard level deficiency.

e All other tags cited are standard level deficiencies.

Time Frames for Compliance

e Type B violation(s) must be corrected within 45 days from the exit date of the survey,
which is November 10, 2019. Pursuant to North Carolina General Statute § 122C-24.1,
failure to correct the enclosed deficiency by the 45" day from the date of the survey may
result in the assessment of an administrative penalty of $200.00 (Two Hundred) against
Luca’s Hope, LLC for each day the deficiency remains out of compliance.

e Re-cited standard level deficiencies must be corrected within 30 days from the exit of
the survey, which is October 26, 2019.

¢ Standard level deficiencies must be corrected within 60 days from the exit of the
survey, which is November 25, 2019.

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

LOCATION: 1800 Umstead Drive, Williams Building, Raleigh, NC 27603
MAILING ADDRESS: 2718 Mail Service Center, Raleigh, NC 27699-2718
www.nedhhs.govidhsr + TEL: 919-855-3795 + FAX: 919-715-8078

AN EQUAL OPPORTUNITY / AFFIRMATIVE ACTION EMPLOYER

October 15, 2019
Valarie Stanback
Luca’s Hope LLC

What to include in the Plan of Correction

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

Make a copy of the Statement of Deficiencies with the Plan of Correction to retain for your
records. Please do not include confidential information in your plan of correction and
please remember never to send confidential information (protected health information)
via email.

Send the original completed form to our office at the following address within 10 days of receipt
of this letter.

Mental Health Licensure and Certification Section
NC Division of Health Service Regulation
2718 Mail Service Center
Raleigh, NC 27699-2718

A follow up visit will be conducted to verify all violations have been corrected. If we can be of
further assistance, please call Sonia Eldridge at 828-665-9911.

Sincerely,

Keom Rea

Kem Roberts
Facility Compliance Consultant |
Mental Health Licensure & Certification Section

Cc: QM@partnersbhm.or
dhhs@vayahealth.com
Pam Pridgen, Administrative Assistant

document_type: Plan of Correction