facility_name: The Brown Home - A Caring Hands Site

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

raw_content:
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document_type: Plan of Correction


state: NC

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

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:

MHLO010-088

A CARING HEART AFL 2

A. BUILDING:

B. WING

STREET ADDRESS, CITY, STATE, ZIP CODE
1068 VICTORIA LANE NE

NAVASSA, NC 28451

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/30/2019
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
08/22/2019

(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 (x5)
(EACH CORRECTIVE ACTION SHOULD BE COMPLETE

CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

V 000

Vv 118

INITIAL COMMENTS

An annual and follow up survey was completed
on 8/22/19. A deficiency was cited.

This facility is licensed for the following service
category: 10A NCAC 27G .5600F Supervised
Living/Alternative Family Living.

27G .0209 (C) Medication Requirements

10A NCAC 27G .0209 MEDICATION
REQUIREMENTS

(c) Medication administration:

(1) Prescription or non-prescription drugs shall
only be administered to a client on the written
order of a person authorized by law to prescribe
drugs.
(2) Medications shall be self-administered by
clients only when authorized in writing by the
client's physician.

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

(A) client's name;

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

(C) instructions for administering the drug;

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

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

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

STATE FORM

V 000

V 118

6899

1TSZ11

TITLE (X6) DATE

If continuation sheet 1 of 3

PRINTED: 08/30/2019
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
MHL010-088 B. WING 08/22/2019

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

A CARING HEART AFL 2

1068 VICTORIA LANE NE

NAVASSA, NC 28451

This Rule is not met as
Based on record review,

evidenced by:
observation and

interviews, the facility failed to keep MAR's

current for one of one cl
are:

revealed:
- 58 year old female.

Disorder due to Traumat
ntellectual Developmen
Epilepsy and Encephalit

ient (#1). The findings

Review on 08/22/19 of client #1's record

- Date of admission 4/24/19.
- Diagnoses of Major Neurological Cognitive

ic Brain Injury, Moderate
ital Disability, Diabetes,
is.

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118] Continued From page 1 V 118

Review on 8/22/19 of a physician order for client
#1 dated 7/23/19 revealed:

- Trazodone (anti-depressant) 50 milligram (mg)
tablet to be taken 1 time daily at bed time.

Observation on 8/22/19 at 11:45am of Client #1's
medication revealed a blister pack of 50mg of
Trazodone to be administered as 1 tablet at
bedtime.

Review on 8/22/19 of Client #1's July 2019 and
August 2019 MAR's revealed the following
transcribed entries:

July 2019

- Trazodone 100mg 1 tablet at bedtime
documented as administered at 8pm
7/23/19-7/31/19.

August 2019

- Trazodone 100mg documented as administered
Division of Health Service Regulation

STATE FORM

6899 41TSZ11 If continuation sheet 2 of 3

PRINTED: 08/30/2019

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
MHLO010-088 B. WING ____ 08/22/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1068 VICTORIA LANE NE
A CARING HEART AFL 2
NAVASSA, NC 28451
(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118| Continued From page 2 V 118

at 8pm 8/1/19 - 8/21/19.

Interview on 8/22/19 Client #1 stated:
- She took all of her medications everyday and
never missed any.

Interview on 8/22/19 the Licensee stated:
- She administered Client #1's medications
everyday and she never missed any.

Interview on 8/22/19 the Qualified Professional
stated:

- She reviewed Client #1's medications monthly.
- She was not aware the physician ordered a refill
of the Trazodone at 50mg daily.

- She contacted physician and learned the order
for 50mg Trazodone was incorrect and should
have been 100mg.

- She should have caught it when she reviewed
the medications.

- Staff should have recognized the difference in
dosage once client #1's medications were
received.

- She will get the correct prescription filled.

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

Division of Health Service Regulation
STATE FORM 6899 1TSZ11 If continuation sheet 3 of 3

inspection_type: MHLCS Annual and Follow-up

document_type: Statement of Deficiency


summary: Plan of Correction - MHLCS Annual

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A CARING HEART
CASE MANAGEMENT, INC.

December 7, 2018

To Whom It May Concern:

Please accept the two Plan of Correction Forms, which are enclosed, as my response to
the recent Annual Surveys with one also having a Complaint Survey with it. A Caring
Heart Case Management takes these deficiencies very seriously and would like to ensure
you that all deficiencies will be corrected.

If you have any questions, please don’t hesitate to call me at 910-332-3513.

Best Regards,

7 ddiney, WA (ce J LA

Erin Mairs, BA QP
Program Director
A Caring Heart Case Management, Inc.

l Health
DEC 132038

Lic. g Cert, Section

101 West Elizabeth Street ¢ Clinton, NC 28323 © (910) 590-3488
405 East Walnut Street e¢ Goldsboro, NC 27530 @ (919) 587-0189
1528 Evans Street, Suite L-1 e Greenville, NC 27858 @ (252) 290-2397
800 Tiffany Blvd., Suite 100 @ Rocky Mount, NC 27804 @ (252) 216-8221
18 Noble Street © Smithfield, NC 27577 @ (919) 938-9484
2541 South 17" Street @ Wilmington, NC 28401 e (910) 332-3513
1901 Tarboro Street SW, Suite 102 @ Wilson, NC 27893 @ (252)-206-1266

inspection_type: MHLCS Annual


summary: Statement of Deficiency - MHLCS Annual

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:

MHLO010-088

A CARING HEART AFL 2

A. BUILDING:

B. WING

STREET ADDRESS, CITY, STATE, ZIP CODE
1068 VICTORIA LANE NE

NAVASSA, NC 28451

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/11/2018
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

09/05/2018

(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 (x5)
(EACH CORRECTIVE ACTION SHOULD BE COMPLETE

CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

V 000

Vv 118

INITIAL COMMENTS

An annual survey was completed on September
5, 2018. A deficiency was cited.

This facility is licensed for the following category:
10A NCAC 27G .5600F Supervised
Living/Alternative Family Living.

27G .0209 (C) Medication Requirements

10A NCAC 27G .0209 MEDICATION
REQUIREMENTS

(c) Medication administration:

(1) Prescription or non-prescription drugs shall
only be administered to a client on the written
order of a person authorized by law to prescribe
drugs.
(2) Medications shall be self-administered by
clients only when authorized in writing by the
client's physician.

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

(A) client's name;

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

(C) instructions for administering the drug;

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

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

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

STATE FORM

V 000

V 118

6899

KLOG11

TITLE (X6) DATE

If continuation sheet 1 of 3

PRINTED: 09/11/2018
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
MHLO010-088 B. WING ____ 09/05/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1068 VICTORIA LANE NE
A CARING HEART AFL 2
NAVASSA, NC 28451
(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118] Continued From page 1 V 118

This Rule is not met as evidenced by:

Based on observations, interviews, and record
reviews, the facility failed to administer
prescription medications as ordered by the
physician, and maintain an accurate MAR for 1 of
1 client audited (client #1). The findings are:

Review on 9/5/18 of client #1's record revealed:
-29 year old female admitted 10/9/17.
-Diagnoses included Intermittent Explosive
Disorder, Schizoaffective Disorder, and Mild
Intellectual Developmental Disabilities.

-Order dated 2/7/18 for Invega ER (extended
release) 3 mg (milligrams) twice daily (morning
and noon), 6 mg at bedtime. (Schizoaffective
disorder).
-Order dated 6/20/18 for Invega ER 6 mg at night.
Order for Invega ER 3 mg twice daily (morning
and noon) was not reordered, and had been
deleted as a "current order" on the signed
physician orders.

-Order dated 6/12/18 for Quetiapine Fumarate 50
mg, 2 tablets daily for 10 days, Quetiapine
Fumarate 50 mg, 1 tablet for 10 days, Quetiapine
Fumarate 50 mg, 1/2 tablet for 5 days, then stop.
(Schizoaffective disorder).

Observations at 12:05 pm on 9/5/18 of client #1's
medications on hand revealed:

-3 bottles of Invega ER 3 mg on hand. Dispense
date read 8/23/18.

-Instructions for Invega ER 3 mg read to take 1
tablet at breakfast, 1 tablet at lunch, and 2 tablets
at bedtime.

Division of Health Service Regulation
STATE FORM 6899 KLOG11 If continuation sheet 2 of 3

PRINTED: 09/11/2018
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
MHLO010-088 B. WING ____ 09/05/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1068 VICTORIA LANE NE
A CARING HEART AFL 2
NAVASSA, NC 28451
(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118| Continued From page 2 V 118

Review on 9/4/18 and 9/5/18 of client #1's MARs
from 6/1/18 through 9/4/18 revealed:

-Invega ER 3 mg was documented as
administered at 7 am from 6/21/18 - 6/30/18.

-No Invega ER 3 mg documented as
administered at noon from 6/1/18 - 6/20/18.
-Quetiapine Fumarate 50 mg, 2 tablets twice daily
was documented as administered from 6/12/18 -
7/6/18.

nterview on 9/5/18 the staff stated:

-Client #1 received medications in the morning
and at night.

-No medications were sent to be administered at
he day program.

-She administered 2 Invega ER 3 mg tablets in
he morning and at night.

-She did not keep copies of medication orders at
he home. Orders were sent to the Qualified
Professional and filed in the office.

nterview on 9/5/18 the Office Staff stated:

-She prepared the MARs from physician orders.
-It had been difficult to get signed orders for client
#1.
-She did not have a way to show the tapered
dose for Quetiapine Fumarate on the MARs.

Interview on 9/5/18 the Qualified Professional
stated:

-They would have the nurse to help prepare
MARs in the future.

-She would talk with the direct care staff to make
sure medications were given as ordered.

Due to the failure to accurately document
medication administration it could not be
determined if clients received their medications
as ordered by the physician.

Division of Health Service Regulation
STATE FORM 6899 KLOG11 If continuation sheet 3 of 3


facility_name: BlueWest Opportunities-Montford House

summary: Statement of Deficiency - MHLCS Follow-up

raw_content:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G323
NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-MONTFORD HOUSE

PRINTED: 11/07/2025
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION

A. BUILDING
R-C

11/06/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

5 KENMORE STREET

ASHEVILLE, NC 28803

(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 COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
{W 000} | INITIAL COMMENTS {W 000}
Arevisit was conducted on 11/6/2025 for all
previous deficiencies cited on 8/5/2025. All
deficiencies were corrected and no new
non-compliance was found. The facility is in
compliance with all regulations surveyed.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued

program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID:XOBM12

Facility ID: 955478 If continuation sheet Page 1 of 1

inspection_type: MHLCS Follow-up


summary: Plan of Correction - MHLCS Annual and Complaint

raw_content:
DEPARTMENT OF HEALTH AND HUMAN SERVICES ee TORM AR Oe
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES (X4) PROVIDER/SUPPLIER/CLIA
‘AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

{X2) MULTIPLE CONSTRUCTION

COMPLETED

Cc
08/05/2025

A BUILDING

346323 B. WING

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

5 KENMORE STREET
ASHEVILLE, NC 28803

(X4) 10 SUMMARY STATEMENT OF DEFICIENCIES, PROVIDER'S PLAN OF CORRECTION xs)
PREFIX (EACH DEFICIENCY MUST 8E PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION

TAG REGULATORY OR LSC IDENTIFYING INFORMATION} TAG CROSS-REFERENCED TO THE APPROPRIATE Date
DEFICIENCY)

BLUEWEST OPPORTUNITIES-MONTFORD HOUSE

E015 Subsistence Needs for Staff and Patients
CFR(s): 483.475(6)(1)

§403.748(b)(1), $418, 113(b)(6)(iii), §441.184(b)
(1), §460.84(b)(1), §482.15()(1), §483.73(b)(1),
§483.475(b)(1), §485.542(b)(1), §485.625(b)(1)

[(b) Policies and procedures. [Facilities] must
develop and implement emergency preparedness.
policies and procedures, based on the emergency
plan set forth in paragraph {a) of this section, risk
assessment at paragraph (a)(1) of this section,
and the communication plan at Paragraph (c) of
this section. The policies and procedures must
be reviewed and updated every 2 years [annually
for LTC facilities]. At a minimum, the policies and
procedures must address the following:

(1) The provision of subsistence needs for staff

and patients whether they evacuate or shelter in RECE IVED

place, include, but are not limited to the following:

(i) Food, water, medical and pharmaceutical A
supplies mm

(ii) Alternate sources of energy to maintain the OF ISR

following: *MH Licensure Sect

(A) Temperatures to protect patient health and
safety and for the safe and sanitary storage of
provisions,

(B) Emergency lighting.

(C) Fire detection, extinguishing, and alarm
systems.

(D) Sewage and waste disposal.

*[For Inpatient Hospice at §418.113(b)(6X{iii):]
Policies and procedures,

(6) The following are additional requirements for
hospice-operated inpatient care facilities only.
The policies and procedures must address the
following:

(iii) The provision of subsistence needs for

‘ECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused frown corracting providing it is determined that
other safeguards provide sufficient protection to the Patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the dale these documents are made avaitable to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued
Program participation

FORM CMS.2567(02-98) Previous Versions Obsolete Event (D:XOBM11 Facility ID. 955478 if continuation sheet Page 1 of 4

PRINTED: 08/08/2025
FORM APPROVED
COMB NO. 0938-0394
(X3) DATE SURVEY
COMPLETED
Cc
08/05/2025

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

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

(X2) MULTIPLE CONSTRUCTION
A, BUILDING

346323 B. WING

STREET ADDRESS, CITY, STATE, ZIP CODE
5 KENMORE STREET
ASHEVILLE, NC 28803
(x6) 10 SUMMARY STATEMENT OF DEFICIENCIES © PROVIDER'S PLAN OF CORRECTION as
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX {EACH CORRECTIVE ACTION SHOULD BE COMPLETION

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

NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-MONTFORD HOUSE

E015 Continued From page 1 E015
hospice employees and patients, whether they
evacuate or shelter in place, include, but are not
limited to the following:

(A) Food, water, medical, and pharmaceutical

supplies.

(B) Alternate sources of energy to maintain the

following:

(1) Temperatures to protect patient health and

safety and for the safe and Sanitary storage of
provisions.

(2) Emergency lighting.

(3) Fire detection, extinguishing, and alarm

systems,

(C) Sewage and waste disposal,

This STANDARD is not met as evidenced by:

Based on observation, documentation review,

and interviews, the facility failed to implement the

emergency preparedness policy relative to the

provision of subsistence food supply needs for all

clients (#1, #2, #3, #4) and staff as required in the

facility's emergency operations plan (EOP). The

finding is:

Observations during the 8/4/25-8/5/25
recertification survey revealed a closet in the
facility laundry room where the emergency food
supply was stored. Further observations revealed
several food items to be expired ranging from
1115/24-6/15/25,

Interview with staff A on 8/4/25 revealed there is a
designated person who does the shopping for the
emergency food supply. Further interview with
staff A verified that emergency food is usually
rotated every month.

Interview with the qualified intellectual disabilities
professional (QIDP) on 8/5/25 verified that the
emergency food supply should be fully stocked

FORM CMS-2567(02-99) Previous Versions Opsolete Event (0 XOBM11 Facility ID: 955478 if continuation sheet Page 2 of 4

DEPARTMENT OF HEALTH AND HUMAN SERVICES ORME

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

‘STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER;CLIA (X3) DATE SURVEY
‘AND PLAN OF CORRECTION IDENTIFICATION NUMBER: : Soest,

c
08/05/2025

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

346323 i

STREET ADDRESS, CITY, STATE. ZIP CODE
5 KENMORE STREET
ASHEVILLE,NC 28803
(xa) 1D SUMMARY STATEMENT OF DEFICIENCIES 10 PROVIDER'S PLAN OF CORRECTION xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX {EACH CORRECTIVE ACTION SHOULD BE COMPLETION

TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE ‘oars
DEFICIENCY)

NAME OF PROVIDER OR SUPPLIER

SLUEWEST OPPORTUNITIES-MONTFORD HOUSE

E015 Continued From page 2 E015
and rotated regularly to ensure the food does not
expire,

W000 INITIAL COMMENTS W 000

A recertification and complaint survey was
completed on 8/5/25 for intake #NC00232820.
The complaint was substantiated and no
deficiencies were cited. However, deficiencies
were cited for the recertification survey.
W130 PROTECTION OF CLIENTS RIGHTS W 130
CFR(s): 483.420(a)(7)

The facility must ensure the rights of all clients.
Therefore, the facility must ensure privacy during
treatment and care of personal needs.

This STANDARD is not met as evidenced by:
Based on observations, record reviews and
interviews, the facility failed to assure privacy for
1 of 4 audited clients (#2) during personal care.
The finding is:

Observations in the group home on 8/4/25 at 6:17
PM revealed client #2 to walk from his bedroom
to the bathroom fully unclothed while staff B
walked behind him. Further observation at 6:45
PM revealed client #2 to exit the bathroom and
enter his bedroom with no clothes on while staff B
walked behind him. Observations did not reveal
Staff B to prompt client #2 to put on a robe or
cover up while exiting or entering his bedroom
and bathroom.

Review of records for client #2 on 8/5/25 revealed
@ person-centered plan (PCP) dated 7/28/25.
Continued review of the PCP revealed the
following training objectives: participate in an
activity, chores, cut food, fold clothes, brush
teeth, wash his hair, communication, and

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XOBM11 Facility ID: 955478 K continuation sheet Page 3 of 4

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

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

346323
NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-MONTFORD HOUSE

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

W 130 Continued From page 3
behaviors.

Interview with the qualified intellectual disabilities
professional (QIDP) on 8/5/25 confirmed that all
clients should be given Privacy during personal
care. Further interview with the QIDP revealed
Staff should have prompted client #2 to cover up
before exiting and entering his bedroom and
bathroom.

FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: XOBM11

PRINTED: 08/08/2025
FORM APPROVED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ROMBLETED:
Cc
B, WING er 08/05/2025
STREET ADDRESS, CITY, STATE. iP CODE
5 KENMORE STREET
ASHEVILLE, NC 28803
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

Facility ID. 955478 If continuation sheet Page 4 of 4

BlueWest Opportunities — Montford Home
Plan of Correction
Re: Survey Completed August 5, 2025

Please find below our facility’s plan of correction in response to your visit on
August 4&5, 2025. Our plan of correction addresses the E015 and W 130 citations.

£015. SUBSISTENCE NEEDS FOR STAFF AND PATIENTS,

Facilities must develop and implement emergency preparedness policies and
procedures, based on the emergency plan, risk assessment, and the communication
plan. The policies and procedures must be reviewed and updated every 2 years
[annually for LTC facilities]. At a minimum, the policies and procedures must address
the following: (1) The provision of subsistence needs for staff and Patients whether
they evacuate or shelter in place, include, but are not limited to the following: (i)
Food, water, medical and pharmaceutical supplies (ii) Alternate sources of energy to
maintain the following: (A) Temperatures to protect patient health and Safety and for
the safe and sanitary Storage of provisions. (B) Emergency lighting. (C) Fire detection,
extinguishing, and alarm systems. (D) Sewage and waste disposal.

The emergency supply foods which were found to have expired have been replaced. The
inventory has been reassessed, and all food items are within expiry.

The existing inventory sheet posted with the emergency supply will be updated to include
the expiration date for each item.

The emergency supply will be rechecked quarterly by the Dietary Manager to ensure
adequate provisions are maintained according to the policy.

Responsible Person(s): Dietary Manager
Mechanism to ensure compliance: Routine assessment and review.

Frequency of Mechanism: Quarterly

W 130 PROTECTION OF CLIENTS RIGHTS.

The facility must ensure the rights of all clients. Therefore, the facility must ensure
privacy during treatment and care of personal needs.

A training goal will be implemented by the QIDP to address the privacy needs of the client
relative to this survey.

Staff will be re-trained on client rights and the need to ensure privacy during treatment and
care of personal needs.

Responsible Person(s): QIDP

Mechanism to ensure compliance: Face-to-face staft training, implementation of formal
training goal, followed by routine assessment and review.

Frequency of Mechanism: Ongoing monitoring and assessment of client’s performance in
new training goal with monthly review of data. Immediate staff training followed by training
of new employees and review as needed.

inspection_type: MHLCS Annual and Complaint


summary: Statement of Deficiency - MHLCS Annual and Complaint

raw_content:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G323
NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-MONTFORD HOUSE

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

PRINTED: 08/08/2025

FORM APPROVED

OMB NO. 0938-0391

STREET ADDRESS, CITY, STATE, ZIP CODE
5 KENMORE STREET
ASHEVILLE, NC 28803

(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)

(X3) DATE SURVEY

COMPLETED

c
08/05/2025

(8)
COMPLETION
DATE

E015

Subsistence Needs for Staff and Patients

E015

CFR(s): 483.475(b)(1)

§403.748(b)(1), §418.113(b)(6)(iii), §441.184(b)
(1), §460.84(b)(1), §482.15(b)(1), §483.73(b)(1),
§483.475(b)(1), §485.542(b)(1), §485.625(b)(1)

[(b) Policies and procedures. [Facilities] must
develop and implement emergency preparedness
policies and procedures, based on the emergency
plan set forth in paragraph (a) of this section, risk
assessment at paragraph (a)(1) of this section,
and the communication plan at paragraph (c) of
this section. The policies and procedures must
be reviewed and updated every 2 years [annually
for LTC facilities]. At a minimum, the policies and
procedures must address the following:

(1) The provision of subsistence needs for staff
and patients whether they evacuate or shelter in
place, include, but are not limited to the following:
(i) Food, water, medical and pharmaceutical
supplies

(ii) Alternate sources of energy to maintain the
following:

(A) Temperatures to protect patient health and
safety and for the safe and sanitary storage of
provisions.

(B) Emergency lighting.

(C) Fire detection, extinguishing, and alarm
systems.

(D) Sewage and waste disposal.

*[For Inpatient Hospice at §418.113(b)(6)(iii):]
Policies and procedures.

(6) The following are additional requirements for
hospice-operated inpatient care facilities only.
The policies and procedures must address the
following:

(iii) The provision of subsistence needs for

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

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that

TITLE

(X6) DATE

other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days

following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14

days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued

program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:XOBM11

Facility ID: 955478

If continuation sheet Page 1 of 4

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G323
NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-MONTFORD HOUSE

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

PRINTED: 08/08/2025
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

c
08/05/2025

STREET ADDRESS, CITY, STATE, ZIP CODE
5 KENMORE STREET
ASHEVILLE, NC 28803

(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 COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
E 015) Continued From page 1 E015

hospice employees and patients, whether they
evacuate or shelter in place, include, but are not
limited to the following:

(A) Food, water, medical, and pharmaceutical
supplies.

(B) Alternate sources of energy to maintain the
following:

(1) Temperatures to protect patient health and
safety and for the safe and sanitary storage of
provisions.

(2) Emergency lighting.

(3) Fire detection, extinguishing, and alarm
systems.

(C) Sewage and waste disposal.

This STANDARD is not met as evidenced by:
Based on observation, documentation review,
and interviews, the facility failed to implement the
emergency preparedness policy relative to the
provision of subsistence food supply needs for all
clients (#1, #2, #3, #4) and staff as required in the
facility's emergency operations plan (EOP). The
finding is:

Observations during the 8/4/25-8/5/25
recertification survey revealed a closet in the
facility laundry room where the emergency food
supply was stored. Further observations revealed
several food items to be expired ranging from
1/15/24-6/15/25.

Interview with staff A on 8/4/25 revealed there is a
designated person who does the shopping for the
emergency food supply. Further interview with
staff A verified that emergency food is usually
rotated every month.

Interview with the qualified intellectual disabilities
professional (QIDP) on 8/5/25 verified that the

emergency food supply should be fully stocked

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:XOBM11

Facility ID: 955478 If continuation sheet Page 2 of 4

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G323
NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-MONTFORD HOUSE

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

PRINTED: 08/08/2025
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

c
08/05/2025

STREET ADDRESS, CITY, STATE, ZIP CODE
5 KENMORE STREET
ASHEVILLE, NC 28803

CFR(s): 483.420(a)(7)

The facility must ensure the rights of all clients.
Therefore, the facility must ensure privacy during
treatment and care of personal needs.

This STANDARD is not met as evidenced by:
Based on observations, record reviews and
interviews, the facility failed to assure privacy for
1 of 4 audited clients (#2) during personal care.
The finding is:

Observations in the group home on 8/4/25 at 6:17
PM revealed client #2 to walk from his bedroom
to the bathroom fully unclothed while staff B
walked behind him. Further observation at 6:45
PM revealed client #2 to exit the bathroom and
enter his bedroom with no clothes on while staff B
walked behind him. Observations did not reveal
staff B to prompt client #2 to put on a robe or
cover up while exiting or entering his bedroom
and bathroom.

Review of records for client #2 on 8/5/25 revealed
a person-centered plan (PCP) dated 7/28/25.
Continued review of the PCP revealed the
following training objectives: participate in an
activity, chores, cut food, fold clothes, brush
teeth, wash his hair, communication, and

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:XOBM11

(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 COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
E015) Continued From page 2 E015
and rotated regularly to ensure the food does not
expire.
W 000 | INITIAL COMMENTS W 000
Arecertification and complaint survey was
completed on 8/5/25 for intake #NC00232820.
The complaint was substantiated and no
deficiencies were cited. However, deficiencies
were cited for the recertification survey.
W 130 | PROTECTION OF CLIENTS RIGHTS W 130

Facility ID: 955478 If continuation sheet Page 3 of 4

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G323
NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-MONTFORD HOUSE

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

PRINTED: 08/08/2025

FORM APPROVED

OMB NO. 0938-0391

STREET ADDRESS, CITY, STATE, ZIP CODE
5 KENMORE STREET
ASHEVILLE, NC 28803

(X3) DATE SURVEY

COMPLETED

c
08/05/2025

(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 COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 130 | Continued From page 3 W 130

behaviors.

Interview with the qualified intellectual disabilities
professional (QIDP) on 8/5/25 confirmed that all
clients should be given privacy during personal
care. Further interview with the QIDP revealed
staff should have prompted client #2 to cover up
before exiting and entering his bedroom and
bathroom.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:XOBM11

Facility ID: 955478

If continuation sheet Page 4 of 4


summary: Statement of Deficiency - MHLCS Annual

raw_content:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
(X1) PROVIDER/SUPPLIER/CLIA

STATEMENT OF DEFICIENCIES

PRINTED: 07/31/2024
FORM APPROVED
OMB NO. 0938-0391

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
34G323 B. WING 07/31/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
BLUEWEST OPPORTUNITIES-MONTFORD HOUSE 5 KENMORE STREET
. ASHEVILLE, NC 28803
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 000. INITIAL COMMENTS W 000
This facility is in compliance with the
CONDITIONS OF PARTICIPATION for
Intermediate Care Facilities for Individuals with
Intellectual Disabilities found at 42 CFR 483.400
THROUGH 483.460 AND 42 CFR 483.480
(General/Health Requirements).
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued

program participation.

FORM CMS-2567 (02-99) Previous Versions Obsolete Event ID: W7QP11

Facility ID: 955478 If continuation sheet Page 1 of 1


summary: Statement of Deficiency - MHLCS Complaint

inspection_type: MHLCS Complaint


summary: Statement of Deficiency - MHLCS Annual

raw_content:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
(X1) PROVIDER/SUPPLIER/CLIA

STATEMENT OF DEFICIENCIES

PRINTED: 08/02/2023
FORM APPROVED
OMB NO. 0938-0391

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
34G323 B. WING 08/02/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
BLUEWEST OPPORTUNITIES-MONTFORD HOUSE 5 KENMORE STREET
. ASHEVILLE, NC 28803
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 000. INITIAL COMMENTS W 000
This facility is in compliance with the
CONDITIONS OF PARTICIPATION for
Intermediate Care Facilities for Individuals with
Intellectual Disabilities found at 42 CFR 483.400
THROUGH 483.460 AND 42 CFR 483.480
(General/Health Requirements).
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that

other safeguards provide sufficient protection to the patients. (See instructions.

.) Except for nursing homes, the findings stated above are disclosable 90 days

following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued

program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WKHR11

Facility ID: 955478 If continuation sheet Page 1 of 1


raw_content:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

PRINTED: 11/14/2022
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

34G323

NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-MONTFORD HOUSE

A. BUILDING
R

11/09/2022
STREET ADDRESS, CITY, STATE, ZIP CODE

5 KENMORE STREET
ASHEVILLE, NC 28803

(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 COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 000 | INITIAL COMMENTS W 000
Arevisit was conducted on 11/9/22 for all
previous deficiencies cited on 8/10/22. All
deficiencies were corrected and no new
non-compliance was found. The facility is in
compliance with all regulations surveyed.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued

program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: 4LML12

Facility ID: 955478

If continuation sheet Page 1 of 1


summary: Plan of Correction - MHLCS Annual

raw_content:
RINTED:
DEPARTMENT OF HEALTH AND HUMAN SERVICES " FORM Felis

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES. (X41) PROVIDER/SUPPLIER/CLIA |(X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

34G323 B. WING 08/10/2022

STREET ADDRESS, CITY, STATE. ZIP CODE
5 KENMORE STREET
ASHEVILLE, NC 28803
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL | PREFIX | (EACH CORRECTIVE ACTION SHOULD BE COMPLETION

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

NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-MONTFORD HOUSE

W 263 PROGRAM MONITORING & CHANGE
CFR(s): 483.440(f)(3)(ii)

The committee should insure that these programs
are conducted only with the written informed
consent of the client, parents (if the client is a
minor) or legal guardian.

This STANDARD is not met as evidenced by:
The specially constituted committee, designated
as the human rights committee (HRC) failed to
assure written consent was obtained from 4 of 5
client guardians (#1, #2, #4 and #5) regarding the
use of intrusive bathroom door alarms in the
home as evidenced by observations, interview
and record verification. The finding is:

Observations in the group home during the
8/9-10/22 survey revealed each of the bathroom
doors in the group home to be alarmed and
sound any time any client or staff would enter or
exit the bathrooms. The sound of the most |
frequented bathroom was noted to be louder and
more intense than the other alarms in the home.
Further observations revealed some of the clients

to complain about the noise including client #1 |
saying “That's noisy!" and client #3 noting that "! | RECEIVED
hate that thing! It gets on your nerves at night." | A

| UG 29 2022

Interview with the qualified intellectual disabilities .
professional (QIDP), substantiated by review of DHSR-MH Licensure Sect
client #3's person centered plan (PCP) dated
6/16/22, revealed the clients use of door alarms
as part of his behavior programming came with
him when he moved into the group home from a |
sister facility. Further review of the PCP revealed
the client's behavior support plan (BSP) dated |

7/14/20 addresses several target behaviors and '
also includes the use of bathroom alarms to alert |

staff of the client's whereabouts, |

fOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE. TITLE (X6) DATE
Vor DP s[eefoz.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued

program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:4LML11 Facliity ID: 955478 If continuation sheet Page 1 of 4

PRINTED: 08/18/:
DEPARTMENT OF HEALTH AND HUMAN SERVICES CORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
A. BUILDING COMPLETED

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

346323 B. WING

08/10/2022

STREET ADDRESS, CITY, STATE, ZIP CODE
5 KENMORE STREET
ASHEVILLE, NC 28803

NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-MONTFORD HOUSE

(x4) 1D 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 COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

Continued From page 1
Review of client #1, #2, #4 and #5's PCPs dated
1/19/22, 1/6/22, 9/9/21 and 6/19/22, respectively
revealed no consents were obtained from the
clients' guardians to assure informed consent
was provided for the loud intrusive bathroom door
alarms being used in the home for the monitoring |
of one client. |
W 287 MGMT OF INAPPROPRIATE CLIENT W 287}
BEHAVIOR
CFR(s): 483.450(b)(3) |

Techniques to manage inappropriate client
behavior must never be used for the convenience |
of staff.
This STANDARD is not met as evidenced by: | |
The facility failed to assure techniques to
manage inappropriate client behavior were not
used for the convenience of staff for 1 of 5
sampled clients (#3) as evidenced by
observations, interviews and record verification.
The finding is:

Observations in the group home during the
8/9-10/22 survey revealed each of the bathroom
doors in the group home to be alarmed and
sound any time any client or staff would enter or
exit the bathrooms. The sound of the most
frequented bathroom was noted to be louder and
more intense than the other alarms in the home.
Further observations revealed some of the clients
to complain about the noise including client #1
saying "That's noisy!" and client #3 noting that "!
hate that thing! It gets on your nerves at night."

Interview with the qualified intellectual disabilities |
professional (QIDP), substantiated by review of
client #3's person centered plan (PCP) dated

6/16/22, revealed the client's use of door alarms

If continuation sheet Page 2 of 4

FORM CMS-2567 (02-99) Previous Versions Obsolete Event 1D: 4LML11 Facility ID: 955478

PRINTED: 08/18/2022
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES. OMB NO, 0938-0391

(X1) PROVIDER/SUPPLIERI/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
IDENTIFICATION NUMBER: A. BUILDING COMPLETED

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

346323 B, WING 08/10/2022

STREET ADDRESS, CITY, STATE, ZIP CODE
5 KENMORE STREET
ASHEVILLE, NC 28803
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES | PROVIDER'S PLAN OF CORRECTION x5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION

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

NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-MONTFORD HOUSE

W 287 Continued From page 2
as part of his behavior programming came with
him when he moved into the group home from a
sister facility. Further review of the PCP revealed |
the client's behavior support plan (BSP) dated
7/14/20 which addresses the target behaviors of
inappropriate sexual stimulation, lying,
inappropriate verbal statements, invading privacy,
stealing, non-compliance, inappropriate
physicalV/sexual contact, verbal aggression,
property destruction, physical aggression, AWOL,
SIB, Tantrums and PICA. Further review of the
BSP, substantiated by further interview with the
QIDP, revealed the BSP with these target
behaviors also came with the client when he
moved into the facility and the client's behaviors |
in this group home have been greatly reduced |
from his previous group home. |

Continued interview with the QIDP revealed the
alarms are to notify staff of the whereabouts of
client #3 even though these alarms affect
everyone in the home. Subsequent interviews |
with the QIDP revealed no issues have been
noted with client #3 and using the bathroom
inappropriately. It is further noted that the alarms
were implemented when the client moved in and
have remained in place without staff determining
the continued need for the intrusive alarms.

W 288 MGMT OF INAPPROPRIATE CLIENT W 288

BEHAVIOR

CFR(s): 483.450(b)(3)

Techniques to manage inappropriate client
behavior must never be used as a substitute for | |
an active treatment program.

This STANDARD is not met as evidenced by:
The facility failed to assure techniques to
manage inappropriate client behavior were not

955478 If continuation sheet Page 3 of 4

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:4LML11 Facility ID:

PRINTED: 08/18/2022
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO, 0938-0394

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

346323 B. WING
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

5 KENMORE STREET

ASHEVILLE, NC 28803

(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES | PROVIDER'S PLAN OF CORRECTION x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL | {EACH CORRECTIVE ACTION SHOULD BE. COMPLETION

TAG REGULATORY OR LSC IDENTIFYING INFORMATION) | CROSS-REFERENCED TO THE APPROPRIATE OATE
| DEFICIENCY)

08/10/2022

BLUEWEST OPPORTUNITIES-MONTFORD HOUSE

W 288 Continued From page 3
used as a substitute for an active treatment | |
program for 4 of 5 clients in the group home (#2,
#3, #4 and #5) as evidenced by observations,
interviews and record verification. The finding is:

Afternoon observations in the group home on |
8/9/22 at 4:05 PM revealed staff getting a
container of snack items from the office and
offering it to the clients for snack. Further
observations of a note on the office door noted
that "4 PM and 8 PM snacks are locked in the
office. They no longer go in the pantry."
Interview with the facility qualified intellectual
disabilities professional (QIDP) revealed this
procedure had been going on for several months
and was due to clients stealing food from the
snack box when it was in the pantry. Further
interview revealed wrappers of various types had
been found in the clients’ rooms and it was a
concern that some of the clients might injure
themselves trying to climb on the shelves in the |
pantry to get to the snacks. |

Continued interview with the QIDP, substantiated
by review of clients #2, #3, #4 and #5's person
centered plans (PCPs) dated 1/6/22, 6/16/22, | |
9/9/21 and 6/19/22 respectively, revealed none of |
the clients have objective training to teach them
how to access food appropriately. Further review
of their PCPs revealed while some of the clients
may have a need to lose or maintain their current
weight, none of the clients have food restrictions
due to texture or consistency issues. The facility
failed to teach and train the clients to access their
food appropriately instead of simply removing
their food and locking it in the office.

FORM CMS-2567 (02-99) Previous Versions Obsolete Event ID:4LML11 Facility 1D: 955478 If continuation sheet Page 4 of 4

BlueWest Opportunities —- Montford Home
Plan of Correction
Re: Survey Completed August 9-10, 2022

Please find below our facility's plan of correction in response to your visit on August 9-10, 2022.
Our plan of correction addresses the W263, W287, and W288 citations.

W 263 PROGRAM MONITORING & CHANGE. The committee should ensure that these programs
are conducted only with the written informed consent of the client, parents (if the client is a
minor) or legal guardian.

QIDP will acquire consent from guardians and Human Rights Committee for all clients in the home for
existing alarms on bathroom doors.

Responsible Person(s): QIDP

Mechanism to ensure compliance: Proper consents acquired.

Frequency of Mechanism: If the need continues, consents will be renewed in accordance with
regulations.

W 287 MGMT OF INAPPROPRIATE CLIENT BEHAVIOR. Techniques to manage inappropriate client
behavior must never be used for the convenience of staff.

QIDP and Licensed Clinical Psychologist will meet with the team to re-evaluate the need of bathroom
alarms in client #3’s Behavior Support Plan. Additionally, staff training will occur to ensure a clear
understanding of the supervision needs of client #3.

Responsible Person(s): QIDP, Licensed Clinical Psychologist

Mechanism to ensure compliance: Regular assessment and review; staff training.

Frequency of Mechanism: At least monthly.

W 288 MGMT OF INAPPROPRIATE CLIENT BEHAVIOR. Techniques to manage inappropriate client
behavior must never be used as a substitute for an active treatment program.

Snacks will be stored in the kitchen pantry and accessible to the clients. Each client with an identified
need in healthy choice-making will have formal programs to address this need. Additionally, there will

be visual reminders posted in the kitchen/pantry area for teaching purposes.

Responsible Person(s): QIDP
Mechanism to ensure compliance: Regular Assessment and review.

Frequency of Mechanism: At least monthly.


summary: Statement of Deficiency - MHLCS Annual

raw_content:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G323
NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-MONTFORD HOUSE

(x4) ID
PREFIX
TAG

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

(X2) MULTIPLE CONSTRUCTION

A. BUILDING

ID
PREFIX
TAG

PRINTED: 08/18/2022

FORM APPROVED

OMB NO. 0938-0391

STREET ADDRESS, CITY, STATE, ZIP CODE
5 KENMORE STREET
ASHEVILLE, NC 28803

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

(X3) DATE SURVEY

COMPLETED

08/10/2022

(8)

COMPLETION
DATE

W 263

PROGRAM MONITORING & CHANGE

CFR(s): 483.440(f)(3)(ii)

The committee should insure that these programs
are conducted only with the written informed
consent of the client, parents (if the client is a
minor) or legal guardian.

This STANDARD is not met as evidenced by:
The specially constituted committee, designated
as the human rights committee (HRC) failed to
assure written consent was obtained from 4 of 5
client guardians (#1, #2, #4 and #5) regarding the
use of intrusive bathroom door alarms in the
home as evidenced by observations, interview
and record verification. The finding is:

Observations in the group home during the
8/9-10/22 survey revealed each of the bathroom
doors in the group home to be alarmed and
sound any time any client or staff would enter or
exit the bathrooms. The sound of the most
frequented bathroom was noted to be louder and
more intense than the other alarms in the home.
Further observations revealed some of the clients
to complain about the noise including client #1
saying "That's noisy!" and client #3 noting that "!
hate that thing! It gets on your nerves at night."

Interview with the qualified intellectual disabilities
professional (QIDP), substantiated by review of
client #3's person centered plan (PCP) dated
6/16/22, revealed the clients use of door alarms
as part of his behavior programming came with
him when he moved into the group home from a
sister facility. Further review of the PCP revealed
the client's behavior support plan (BSP) dated
7/14/20 addresses several target behaviors and
also includes the use of bathroom alarms to alert
staff of the client's whereabouts.

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

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that

W 263

TITLE

(X6) DATE

other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days

following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14

days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued

program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID:4LML11

Facility ID: 955478

If continuation sheet Page 1 of 4

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G323
NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-MONTFORD HOUSE

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

(x4) ID
PREFIX
TAG

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

5 KENMORE STREET
ASHEVILLE, NC 28803

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

PREFIX
TAG

STREET ADDRESS, CITY, STATE, ZIP CODE

DEFICIENCY)

PRINTED: 08/18/2022
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

08/10/2022

(8)
COMPLETION
DATE

W 263 | Continued From page 1

Review of client #1, #2, #4 and #5's PCPs dated
1/19/22, 1/6/22, 9/9/21 and 6/19/22, respectively
revealed no consents were obtained from the
clients' guardians to assure informed consent
was provided for the loud intrusive bathroom door
alarms being used in the home for the monitoring
of one client.

MGMT OF INAPPROPRIATE CLIENT
BEHAVIOR

CFR(s): 483.450(b)(3)

W 287

Techniques to manage inappropriate client
behavior must never be used for the convenience
of staff.

This STANDARD is not met as evidenced by:
The facility failed to assure techniques to
manage inappropriate client behavior were not
used for the convenience of staff for 1 of 5
sampled clients (#3) as evidenced by
observations, interviews and record verification.
The finding is:

Observations in the group home during the
8/9-10/22 survey revealed each of the bathroom
doors in the group home to be alarmed and
sound any time any client or staff would enter or
exit the bathrooms. The sound of the most
frequented bathroom was noted to be louder and
more intense than the other alarms in the home.
Further observations revealed some of the clients
to complain about the noise including client #1
saying "That's noisy!" and client #3 noting that "!
hate that thing! It gets on your nerves at night."

Interview with the qualified intellectual disabilities
professional (QIDP), substantiated by review of
client #3's person centered plan (PCP) dated
6/16/22, revealed the client's use of door alarms

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:4LML11

W 263

W 287

Facility ID: 955478

If continuation sheet Page 2 of 4

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G323
NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-MONTFORD HOUSE

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

(x4) ID
PREFIX
TAG

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

5 KENMORE STREET
ASHEVILLE, NC 28803

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

PREFIX
TAG

STREET ADDRESS, CITY, STATE, ZIP CODE

DEFICIENCY)

PRINTED: 08/18/2022
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

08/10/2022

(8)
COMPLETION
DATE

W 287 | Continued From page 2

as part of his behavior programming came with
him when he moved into the group home from a
sister facility. Further review of the PCP revealed
the client's behavior support plan (BSP) dated
7/14/20 which addresses the target behaviors of
inappropriate sexual stimulation, lying,
inappropriate verbal statements, invading privacy,
stealing, non-compliance, inappropriate
physical/sexual contact, verbal aggression,
property destruction, physical aggression, AWOL,
SIB, Tantrums and PICA. Further review of the
BSP, substantiated by further interview with the
QIDP, revealed the BSP with these target
behaviors also came with the client when he
moved into the facility and the client's behaviors
in this group home have been greatly reduced
from his previous group home.

Continued interview with the QIDP revealed the
alarms are to notify staff of the whereabouts of
client #3 even though these alarms affect
everyone in the home. Subsequent interviews
with the QIDP revealed no issues have been
noted with client #3 and using the bathroom
inappropriately. It is further noted that the alarms
were implemented when the client moved in and
have remained in place without staff determining
the continued need for the intrusive alarms.
MGMT OF INAPPROPRIATE CLIENT
BEHAVIOR

CFR(s): 483.450(b)(3)

W 288

Techniques to manage inappropriate client
behavior must never be used as a substitute for
an active treatment program.

This STANDARD is not met as evidenced by:
The facility failed to assure techniques to
manage inappropriate client behavior were not

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:4LML11

W 287

W 288

Facility ID: 955478

If continuation sheet Page 3 of 4

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G323
NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-MONTFORD HOUSE

(X2) MULTIPLE CONSTRUCTION

A. BUILDING

STREET ADDRESS, CITY, STATE, ZIP CODE

5 KENMORE STREET
ASHEVILLE, NC 28803

PRINTED: 08/18/2022
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

08/10/2022

used as a substitute for an active treatment
program for 4 of 5 clients in the group home (#2,
#3, #4 and #5) as evidenced by observations,
interviews and record verification. The finding is:

Afternoon observations in the group home on
8/9/22 at 4:05 PM revealed staff getting a
container of snack items from the office and
offering it to the clients for snack. Further
observations of a note on the office door noted
that "4 PM and 8 PM snacks are locked in the
office. They no longer go in the pantry."
Interview with the facility qualified intellectual
disabilities professional (QIDP) revealed this
procedure had been going on for several months
and was due to clients stealing food from the
snack box when it was in the pantry. Further
interview revealed wrappers of various types had
been found in the clients' rooms and it was a
concern that some of the clients might injure
themselves trying to climb on the shelves in the
pantry to get to the snacks.

Continued interview with the QIDP, substantiated
by review of clients #2, #3, #4 and #5's person
centered plans (PCPs) dated 1/6/22, 6/16/22,
9/9/21 and 6/19/22 respectively, revealed none of
the clients have objective training to teach them
how to access food appropriately. Further review
of their PCPs revealed while some of the clients
may have a need to lose or maintain their current
weight, none of the clients have food restrictions
due to texture or consistency issues. The facility
failed to teach and train the clients to access their
food appropriately instead of simply removing
their food and locking it in the office.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:4LML11

Facility ID: 955478

(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 COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 288 | Continued From page 3 W 288

If continuation sheet Page 4 of 4


raw_content:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES.

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

34G323
NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-MONTFORD HOUSE

PRINTED: 03/16/2022
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY

(X2) MULTIPLE CONSTRUCTION

A. BUILDING COMPLETED
Cc
BWING 03/09/2022

STREET ADDRESS, CITY, STATE, ZIP CODE
5 KENMORE STREET
ASHEVILLE, NC 28803

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 000. INITIAL COMMENTS W 000
Acomplaint survey was conducted on 3/9/22.
Deficiencies were not cited as a result of the
complaint survey for Intake #NC00186395.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued

program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:IF5L11

Facility ID: 955478 If continuation sheet Page 1 of 1


raw_content:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA

PRINTED: 02/22/2022
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY

(X2) MULTIPLE CONSTRUCTION

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
Cc
346323 B. WING 02/17/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
BLUEWEST OPPORTUNITIES-MONTFORD HOUSE 5 KENMORE STREET
. ASHEVILLE, NC 28803
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 000. INITIAL COMMENTS W 000
Acomplaint survey was conducted on 2/17/22.
Deficiencies were not cited as a result of the
complaint survey for Intake #NC00184704.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued

program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:5SKY11

Facility ID: 955478 If continuation sheet Page 1 of 1


raw_content:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G323
NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-MONTFORD HOUSE

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

STREET ADDRESS, CITY, STATE, ZIP CODE
5 KENMORE STREET
ASHEVILLE, NC 28803

PRINTED: 10/28/2021
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

R
10/26/2021

(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 COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 000 | INITIAL COMMENTS W 000
Arevisit was conducted on 10/26/2021 for all
previous deficiencies cited on 6/23/2021 and
recited 8/26/21. All deficiencies have been
corrected and no new noncompliance was found.
The facility is in compliance with all regulations
surveyed.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued

program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID:TZGI13.

Facility ID: 955478

If continuation sheet Page 1 of 1


raw_content:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES.

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

34G323

NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-MONTFORD HOUSE

PRINTED: 08/26/2021
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING
R

B. WING 08/26/2021

STREET ADDRESS, CITY, STATE, ZIP CODE
5 KENMORE STREET
ASHEVILLE, NC 28803

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

(x8)
COMPLETION
DATE

{W 189} STAFF TRAINING PROGRAM
CFR(s): 483.430(e)(1)

The facility must provide each employee with
initial and continuing training that enables the
employee to perform his or her duties effectively,
efficiently, and competently.

This STANDARD is not met as evidenced by:
Based on observation, record review and
interviews, the facility failed to ensure staff were
sufficiently trained relative to personal possession
access for 1 of 3 sampled clients (client #3). The
finding is:

Observation in the group home on 6/23/21 at 8:10
AM revealed client #3 to ask staff A for his
hairbrush after his shower. Continued observation
revealed client #3 to wait for an available staff to
retrieve his hairbrush from the medication room
as the medication closet was occupied with staff
B and another client for medication
administration. Subsequent observation revealed
staff A to knock on the door of the medication
room and request the hairbrush from staff B for
the client.

Review of records for client #3 indicated an
individual support plan (ISP) dated 7/6/20.
Continued review of client #3's ISP revealed
training objectives relative to: safe eating,
brushing teeth, handwashing, and to return
belongings to his room when prompted. A review
of client #3's behavior support plan (BSP) dated
9/11/20 revealed target behaviors of inappropriate
sexual stimulation, lying, stealing, invading
privacy, noncompliance, verbal/physical
aggression, AWOL, property destruction,
self-injurious behavior, PICA, inappropriate

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

{W 189}

TITLE (X6) DATE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued

program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:TZGI12

Facility ID: 955478 If continuation sheet Page 1 of 2

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
(X1) PROVIDER/SUPPLIER/CLIA

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

34G323
NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-MONTFORD HOUSE

PRINTED: 08/26/2021
FORM APPROVED
OMB NO. 0938-0391

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

A. BUILDING COMPLETED
R
BWING 08/26/2021

STREET ADDRESS, CITY, STATE, ZIP CODE
5 KENMORE STREET
ASHEVILLE, NC 28803

touching, and tantrums. Subsequent review of
client #3's BSP revealed with no interventions
relative to restricting access to personal
possessions.

Interview with the clinical director on 6/23/21
verified client #3 had no restrictions relative to
access to personal possessions. Continued
interview with the clinical director verified client
#3's hairbrush should not be kept locked in the
medication room of the group home. Interview
with the facility qualified intellectual disabilities
professional (QIDP) additionally verified staff
should not be implementing any restricted access
to client #3's hairbrush or any other personal
property.

A follow-up visit was conducted on 8/26/21.
Review of internal records on 8/26/21 relative to
the facility's Plan of Correction (POC) revealed no
evidence of in-service trainings related to client
rights. Continued review of the internal records
revealed no evidence of clinical monitoring, as
also indicated in the POC, relative to client rights
and current restrictions.

Interview with the program administrator on
8/26/21 revealed evidence of in-service trainings
and clinical monitoring relative to the POC were
not available for review during the follow-up
survey. Continued interview with the program
administrator revealed the qualified intellectual
disabilities professional (QIDP) had evidence of
in-service training and clinical monitoring,
however, the QIDP was not available for the
follow-up survey.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:TZGI12

(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 COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
{W 189} Continued From page 1 {W 189}

Facility ID: 955478 If continuation sheet Page 2 of 2


summary: Plan of Correction - MHLCS Follow-up

raw_content:
PRINTED: 08/26/2021
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES 41) PROVIDER/SUPPLIERICLIA (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED

R
08/26/2021

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

346323 B. WING

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

5 KENMORE STREET
ASHEVILLE, NC 28803
SUMMARY STATEMENT OF DEFICIENCIES iD PROVIDER'S PLAN OF CORRECTION (Xx)
PREFIX {EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION

REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TOTHEAPPROPRIATE | —OATE
DEFICIENCY)

BLUEWEST OPPORTUNITIES-MONTFORD HOUSE

{W 189} STAFF TRAINING PROGRAM —

{W 189} \ |
CFR(s): 483.430(e)(1) Gee ar real aed

The facility must provide each employee with |
initial and continuing training that enables the
employee to perform his or her duties effectively,
efficiently, and competently.

This STANDARD is not met as evidenced by:
Based on observation, record review and
interviews, the facility failed to ensure staff were
sufficiently trained relative to personal possession
access for 1 of 3 sampled clients (client #3). The
finding is:

Observation in the group home on 6/23/21 at 8:10"
AM revealed client #3 to ask staff A for his
hairbrush after his shower. Continued observation
revealed client #3 to wait for an available staff to
retrieve his hairbrush from the medication room
as the medication closet was occupied with staff
B and another client for medication
_ administration. Subsequent observation revealed
staff A to knock on the door of the medication i
| room and request the hairbrush from staff B for
the client.

Review of records for client #3 indicated an
| individual support plan (ISP) dated 7/6/20. |
Continued review of client #3's ISP revealed
training objectives relative to: safe eating, |
brushing teeth, handwashing, and to return
belongings to his room when prompted. A review
of client #3's behavior support plan (BSP) dated
9/11/20 revealed target behaviors of inappropriate
sexual stimulation, lying, stealing, invading
privacy, noncompliance, verbal/physical
aggression, AWOL, property destruction,
self-injurious behavior, PICA, inappropriate

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVES SIGNATURE THLE (X6) DATE

OS \\ -\-
Any deficiency statement ending with an asjefisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protectiéato the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is Provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued
program participation,

FORM CMS-2567 (02-98) Previous Versions Obsolete Event IO: TZGi12 Facility 1D: 955478

If continuation sheet Page 1 of 2

PRINTED: 1
DEPARTMENT OF HEALTH AND HUMAN SERVICES PORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A, BUILDING COMPLETED

R

346323 Evens 08/26/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

5 KENMORE STREET
ASHEVILLE, NC 28803

BLUEWEST OPPORTUNITIES-MONTFORD HOUSE

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES 10 PROVIDER'S PLAN OF CORRECTION x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY) |
{W 189} Continued From page 1 | {W189}
touching, and tantrums. Subsequent review of a " atte € oe
client #3's BSP revealed with no interventions * ~
relative to restricting access to personal
possessions.

Interview with the clinical director on 6/23/21
verified client #3 had no restrictions relative to
access to personal possessions. Continued
interview with the clinical director verified cliant
#3's hairbrush should not be kept locked in the
medication room of the group home. Interview
with the facility qualified intellectual disabilities
professional (QIDP) additionally verified staff
should not be implementing any restricted access
to client #3's hairbrush or any other personal
property.

A follow-up visit was conducted on 8/26/21.
Review of internal records on 8/26/21 relative to

| the facility's Plan of Correction (POC) revealed no
evidence of in-service trainings related to client
rights. Continued review of the internal records
revealed no evidence of clinical monitoring, as
also indicated in the POC, relative to client rights
and current restrictions.

Interview with the program administrator on
8/26/21 revealed evidence of in-service trainings
and clinical monitoring relative to the POC were
not available for review during the follow-up
survey. Continued interview with the program
administrator revealed the qualified intellectual

_ disabilities professional (QIDP) had evidence of

_ in-service training and clinical monitoring,
however, the QIDP was not available for the
follow-up survey.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: TZGt12 Facility 1D: 955478 If continuation sheet Page 2 of 2

DHSR - Mental Heaith

afi SEP 1 § 2021
BlueWest
OPO OANTUNITIES Lic. & Cert. Section
September 8, 2021

Mental Heaith Licensure and Certification Section
NC Division of Health Service Regulation

2718 Mail Service Center

Raleigh, NC 27699-2718

Re: Follow-up Survey Completed 8/26/21
BlueWest Opportunities— Montford House, 5 Kenmore St. Asheville, NC 28803
Plan of Correction MHL-011-105 FID: 080671

W 189 Staff Training Program. The facility must provide each employee with initial and continuing
training that enables the employee to perform his or her duties effectively, efficiently, and competently.

The staff will be trained by QIDP on the client’s right to access personal possessions. QIDP will also
review and train staff on all restrictions currently in place for the individuals they support.

Staff training will be provided to all current direct support staff by September 26, 2021. Regular
assessments and any follow-up thereby identified will be conducted by members of the clinical and
management teams.

Responsible Person(s): QIOP
Mechanism to ensure compliance: Regular Assessment

Frequency of Mechanism: At least monthly

Nhl Mou 4l3/2/

Melanie Moore, QIDP Date

DHSR - Mental Health

BlueWest
: Lic. & Cert. Section

September 8, 2021

Mental Health Licensure and Certification Section
NC Division of Health Service Regulation

2718 Mail Service Center

Raleigh, NC 27699-2718

Re: Follow-up Survey Completed 8/26/21
BlueWest Opportunities- Montford House, 5 Kenmore St. Asheville, NC 28803
Plan of Correction MHL-011-105 FID: 080671

W 189 Staff Training Program. The facility must provide each employee with initial and continuing
training that enables the employee to perform his or her duties effectively, efficiently, and competently.

The staff will be trained by QIDP on the client’s right to access personal possessions. QIDP will also
review and train staff on all restrictions currently in place for the individuals they support.

Staff training will be provided to all current direct support staff by September 26, 2021. Regular
assessments and any follow-up thereby identified will be conducted by members of the clinical and
management teams.

Responsible Person(s): QIDP
Mechanism to ensure campliance: Regular Assessment

Frequency of Mechanism: At least monthly

When! Moon 413/2/

Melanie Moore, QIDP Date


summary: Plan of Correction - MHLCS Annual

raw_content:
PRINTED: 07/02/2021
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES (<1) PROVIDER/SUPPLIERICLIA (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING =

346323 BEING 06/23/2021
STREET ADDRESS, CITY, STATE, ZIP CODE
5 KENMORE STREET

ASHEVILLE, NC 28803

NAME OF PROVIDER OR SUPPLIER

BLUEWEST OPPORTUNITIES-MONTFORD HOUSE

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

DEFICIENCY)

see attached

STAFF TRAINING PROGRAM
CFR(s): 483.430(6)(1)

The facility must provide each employee with
initial and continuing training that enables the
employee to perform his or her duties effectively,
efficiently, and competently.

This STANDARD is not met as evidenced by:
Based on observation, record review and
interviews, the facility failed to ensure staff were
sufficiently trained relative to Personal possession
access for 1 of 3 sampled clients (client #3). The
finding is:

Observation in the group home on 6/23/21 at 8:10
AM revealed client #3 to ask staff A for his
hairbrush after his shower. Continued observation
revealed client #3 to wait for an available staff to
retrieve his hairbrush from the medication room
as the medication closet was occupied with staff
B and another client for medication
administration. Subsequent observation revealed
Staff A to knock on the door of the medication
room and request the hairbrush from staff B for
the client.

DHSR - Mental Health
Review of records for client #3 indicated an

individual support plan (ISP) dated 7/6/20.

Continued review of client #3's ISP revealed JUL 26 2021
training objectives relative to: safe eating,
brushing teeth, handwashing, and to return ij i
belongings to his room when Prompted. A review Lic. & Cert. Section
of client #3's behavior support plan (BSP) dated
9/11/20 revealed target behaviors of inappropriate
sexual stimulation, lying, stealing, invading
Privacy, noncompliance, verbal/physical
aggression, AWOL, property destruction,
self-injurious behavior, PICA, inappropriate

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

LLU.

Any deficiency statement ending with an asterisk (*) denotes a deficienoy which the ineiiution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of carrection is provided. For Nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued
Program participation.

FORM CMS-2567(02-98) Previous Versions Obsolete Event ID: T2G111 Facility ID: 955478 If continuation sheet Page 1 of 4

Plan of Correction

Montford Group Home
Annual Recertification Survey
June 22 -June 23, 2021

W 189 Staff Training Program. The facility must provide each employee with initial and continuing
training that enables the employee to perform his or her duties effectively, efficiently, and competently.

The staff will be trained by QIDP regarding the client’s right to access personal Possessions. QIDP will
also review and train staff on all restrictions Currently in place for the individuals they support, as stated
in each individual support plan with proper consent.

Initial training will be Provided to all current direct support staff by August 1, 2021, followed by training
for new staff as part of new employee training. After initial training, there will be one or more
observations in the home each week conducted by either the QIDP, site director, or manager to ensure
clients have proper access to personal possessions.

W 436 Space and Equipment. The facility must furnish, maintain in good repair, and teach clients to use
and make informed choices about the use of dentures, eyeglasses, hearing, and other communication
devices identified by the interdisciplinary team as needed by the client.

The agency will ensure client (#2) always has one set of eyeglasses available to him by obtaining a
second set for backup due to this client’s history of breakage. These will be ordered by August 13, 2021.

Client (#2) will be supported with a formal training goal related to proper eyeglasses care. This program
will be implemented by the QIDP by August 1, 2021.

Program, and ongoing for new staff as part of their initial training. Progress on client #2’s training
Program will be monitored by the QIDP or designee monthly, and modified as needed, and noted in the
client record.