raw_content:
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING:

MHL060968 B. WING

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE CHARLOTTE, NC 28211

PRINTED: 09/10/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
04/30/2025

DEFICIENCY)

(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

V 000} INITIAL COMMENTS Vv 000

Acomplaint survey was completed on April 30,
2025. The complaints were substantiated (intake
#NC00228706 and #NC002287 13). Deficiencies
were cited.

This facility is licensed for the following service
category: 10A NCAC 27G .1400 Day Treatment
or Children and adolescents with Emotional or
Behavioral Disturbances.

This facility has a current census of 30 . The
survey sample consisted of audits of 1 current
client.

This Statement of Deficiencies was amended on
9/9/25 as a result of the informal meeting on
7/22/25. Rule 10ANCAC 27D .0304 Protection
rom Harm, Abuse, Neglect or exploitation was
amended from a Type A1 to a Type B in Rule 10A
NCAC 27G .0203 Competencies of Qualified
Professionals and Associate Professionals.

V 109} 27G .0203 Privileging/Training Professionals Vv 109

10A NCAC 27G .0203 COMPETENCIES OF
QUALIFIED PROFESSIONALS AND
ASSOCIATE PROFESSIONALS

(a) There shall be no privileging requirements for
qualified professionals or associate professionals.
(b) Qualified professionals and associate
professionals shall demonstrate knowledge, skills
and abilities required by the population served.
(c) At such time as a competency-based
employment system is established by rulemaking,
then qualified professionals and associate
professionals shall demonstrate competence.

(d) Competence shall be demonstrated by
exhibiting core skills including:

(1) technical knowledge;

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

(X6) DATE

STATE FORM 6899 KUZI11

If continuation sheet 1 of 11

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL060968 B. WING

NAME OF PROVIDER OR SUPPLIER
6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE CHARLOTTE, NC 28211

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/10/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
04/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

cultural awareness;

analytical skills;

decision-making;

interpersonal skills;

communication skills; and

Clinical skills.

(e) Qualified professionals as specified in 10A
NCAC 27G .0104 (18)(a) are deemed to have
met the requirements of the competency-based
employment system in the State Plan for
MH/DD/SAS.

(f) The governing body for each facility shall
develop and implement policies and procedures
for the initiation of an individualized supervision
plan upon hiring each associate professional.
(g) The associate professional shall be
supervised by a qualified professional with the
population served for the period of time as
specified in Rule .0104 of this Subchapter.

This Rule is not met as evidenced by:

Based on record reviews and interviews, 1 of 1
Qualified Professional (QP) failed to demonstrate
he knowledge, skills, and abilities to meet the
needs of clients. The findings are:

Review on 4/16/25 of Client #1's record revealed:
- 9 years old

-Diagnoses of Oppositional Defiant Disorder and
Posttraumatic Stress Disorder

Review on 4/21/25 of the QP's personnel record
revealed:

-Date of hire 2/28/22

Division of Health Service Regulation

STATE FORM

6899 KUZI11

(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 109} Continued From page 1 Vv 109

If continuation sheet 2 of 11

PRINTED: 09/10/2025
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA. (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
c
MHL060968 B. WING _____ 04/30/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE CHARLOTTE, NC 28211

(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 109} Continued From page 2 Vv 109
-Job Title QP.

-Abuse training on 9/18/24.

Review on 4/21/25 at 12:00pm of the Facility's
Video Footage dated 3/14/25 revealed:

-Client #1 was seen sitting in his chair.

-The QP got up from her seat, walked over to
Client #1, pulled him to the floor and then walked
back to her seat.

-Client #1 got up off the floor and sat in his chair.

Review on 4/16/25 of the North Carolina Incident
Response Improvement System (IRIS) revealed:
-On 3/19/25 while reviewing video footage in
reference to another incident, the Program
Supervisor saw the QP walk over to Client #1 and
pushed him out of his chair on 3/14/25.

-Client #1 fell to the floor.

-The QP walked back over to her seat and Client
#1 got up and sat in his chair.

Review on 4/21/25 of the facility's document titled
"Internal Review Findings of Fact Summary-
3.31.24: Incident 3.19.25 revealed:
-"Allegation: While reviewing video for another
Internal Investigation, program manager
(Program Supervisor) saw staff (QP) pull client
(Client #1) off a desk and throw the to the floor.
-The video shows the staff member (QP)
approaching the youth (Client #1) after an
exchange of words and then the youth is on the
floor. The video is dark.

The youth (Client #1) is repeatedly saying
dummy. The staff member (QP) can be heard
saying 'Don't start with me today, I'm the wrong
one.' After the physical exchanged the youth
challenged the staff verbally to which she stated,
‘| just did something about it."

-The cause of the incident is seen as staff
member (QP) exacting revenge on the youth
Division of Health Service Regulation

STATE FORM 6899 KUZI11 If continuation sheet 3 of 11

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL060968 B. WING

NAME OF PROVIDER OR SUPPLIER
6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE CHARLOTTE, NC 28211

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/10/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
04/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

(Client #1) for challenging her. Staff was
reactionary.

-Recommendations: It is recommended that the
staff member (QP) be on a 60-day Performance
mprovement Plan during which time she
completed TCI (therapeutic crisis intervention)
refresher training with a concentration on Handle
with Care concepts that assist with being
proactive and utilizing verbal de-escalation
techniques as well as positive engagement
strategies."

nterview on 4/21/25 with the Program Supervisor
revealed:

-On 3/19/25 he was reviewing video footage in
reference to another incident when he came upon
ootage of the QP pushing Client #1 out of his
chair on 3/14/25.

-Completed the NC IRIS report and reported the
incident to Human Resources (HR) on 3/20/25.
-HR did the internal investigation (3/27/25-
3/31/25).

-Did not question the QP.

-Did not know the outcome of the internal
investigation.

-Client #1 did not sustain any injuries.

Attempted interview on 4/25/25 with Client #1
revealed:

-His legal guardian would not consent to an
interview because Client #1 "does not speak
good english and he has trouble following
conversations."

Interview on 4/28/25 with Staff #2 revealed:

-Did not remember a lot of the details of the
incident between the QP and Client #1 on
3/14/25.

-Remembered Client #1 was disrupting the other
clients and "talking back, calling staff names like
Division of Health Service Regulation

STATE FORM

6899 KUZI11

(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 109} Continued From page 3 Vv 109

If continuation sheet 4 of 11

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL060968 B. WING

NAME OF PROVIDER OR SUPPLIER
6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE CHARLOTTE, NC 28211

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/10/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
04/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

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

(X4) ID
PREFIX
TAG

ID
PREFIX
TAG

CROSS-REFERENCED TO THE APPROPRIATE

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

(x5)
COMPLETE
DATE

DEFICIENCY)

V 109} Continued From page 4 V 109

black B***h."

-"Whatever you saw on the video is what
happened. | think she (QP) just lost her cool for a
minute. That kid (Client #1) would push and push
and push."

-Did not hear the QP and Client #1 arguing with
each other.

-Did not know if Client #1 sustained any injuries.

Interview on 4/28/25 the QP revealed:

-On 3/14/25, Client #1 kept using the saying
"clock that tea" and in a jokingly way she said "I
will."

-"| walked over to his desk and tickled him and he
wiggled out of his chair. | was playing with him, |
wasn't trying to harm him."

-"I'm not that kind of person to harm children."
-"It was a playful interaction."

-Denied telling Client #1 "Don't start with me
today, I'm the wrong one."

-Denied Client #1 was standing in his chair yelling
"Dummy."

-Did not pull Client #1 out of his chair on to the
floor.

Interview on 4/22/25 with the HR Director
revealed:
-The QP was suspended from the day program
pending investigation on 3/27/25.

-The QP worked with another program while
under investigation.
-The internal investigation took place from
3/27/25 to 3/31/25.
-The QP was put on a 60 day performance plan.
-The QP had to retake TCI training, "Handle with
Care" on 3/31/25.

Interview on 4/29/25 with the Vice President of
Performance Improvement revealed:

-Did not have a lot of details about the incident
Division of Health Service Regulation

STATE FORM

6899 KUZI11

If continuation sheet 5 of 11

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL060968 B. WING

NAME OF PROVIDER OR SUPPLIER
6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE CHARLOTTE, NC 28211

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/10/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
04/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

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

(X4) ID
PREFIX
TAG

ID
PREFIX
TAG

CROSS-REFERENCED TO THE APPROPRIATE

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

(x5)
COMPLETE
DATE

DEFICIENCY)

Vv 109 V 109

Continued From page 5

between the QP and Client #1.

-Verified the QP was allowed to work in another
Program while under investigation for abusing
Client #1.

-The internal investigation was 3/27/25 through
3/31/25.

-The QP was terminated on 4/30/25.

Review on 4/30/25 of the Plan of Protection dated
4/30/25 signed by the Vice President of
Performance Improvement revealed:

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

[QP] was terminated from employment with
[Licensee] on 4/29/2025 and has not worked with
any children since 4/4/2025.

Describe your plans to make sure the above
happens.

Human Resources has removed [QP] access to
all systems and locations effective 4/29/2025."

ient #1 was 9 years old with diagnoses of
ppositional Defiant Disorder and Post Traumatic
ress Disorder. On 3/19//25, Client #1 was seen
na video from 3/14/25 sitting in his chair. The
ualifed Professional got up from her seat,

alked over to Client #1, grabbed him, pulled him
the floor, and then walked back to her seat.
ient #1 got up off the floor and sat in his chair.
his deficiency constitutes a Type B violation

hich is detrimental to the health, safety and
elfare of the clients and must be corrected

ithin 45 days.

=O2RO00

io

2=e2eH50

V 132} G.S. 131E-256(G) HCPR-Notification, V 132

legations, & Protection

Division of Health Service Regulation

STATE FORM 6899

KUZI11

If continuation sheet 6 of 11

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL060968 B. WING

NAME OF PROVIDER OR SUPPLIER
6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE CHARLOTTE, NC 28211

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/10/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
04/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

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

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

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

c. Misappropriation of the property of a
healthcare facility.

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

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

Facilities must have evidence that all alleged
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 reviews and interviews, the
facility failed to protect clients during an
investigation of abuse, neglect or exploitation.
The findings are:

Division of Health Service Regulation

STATE FORM 6899

KUZI11

(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 V 132

If continuation sheet 7 of 11

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL060968 B. WING

NAME OF PROVIDER OR SUPPLIER
6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE CHARLOTTE, NC 28211

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/10/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
04/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Review on 4/21/25 of the Qualified Professional's
(QP) personnel record revealed:

-Date of hire 2/28/22

-Job Title QP.

Review on 4/21/25 at 12:00pm of the Facility's
Video Footage dated 3/14/25 revealed:

-Client #1 was seen sitting in his chair.

-The QP got up from her seat, walked over to
Client #1, pulled him to the floor and then walked
back to her seat.

-Client #1 got up off the floor and sat in his chair.

Review on 4/16/25 of the North Carolina Incident
Response Improvement System (IRIS) revealed:
-On 3/19/25 while reviewing video footage in
reference to another incident, the Program
Supervisor saw the QP walk over to Client #1 and
pushed him out of his chair on 3/14/25.

-Client #1 fell to the floor.

-The QP walked back over to her seat and Client
#1 got up and sat in his chair.

Review on 4/21/25 of the facility's document titled
"Internal Review Findings of Fact Summary-
3.31.24: Incident 3.19.25" revealed:

-"Allegation: While reviewing video for another
Internal Investigation, program manager saw staff
(QP) pull client (Client #1) off a desk and ‘throw
the to the floor.'"

-"The video shows the staff member (QP)
approaching the youth (Client #1) after an
exchange of words and then the youth is on the
floor. The video is dark."

-"The youth (Client #1) is repeatedly saying
‘dummy.’ The staff member (QP) can be heard
saying 'Don't start with me today, I'm the wrong
one.' After the physical exchanged the youth
challenged the staff verbally to which she stated,
‘| just did something about it.’ "

Division of Health Service Regulation

STATE FORM

6899 KUZI11

(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 7 V 132

If continuation sheet 8 of 11

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL060968 B. WING

NAME OF PROVIDER OR SUPPLIER
6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE CHARLOTTE, NC 28211

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/10/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
04/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

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

(X4) ID
PREFIX
TAG

ID
PREFIX
TAG

CROSS-REFERENCED TO THE APPROPRIATE

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

(x5)
COMPLETE
DATE

DEFICIENCY)

V 132 V 132

Continued From page 8

-"The cause of the incident is seen as staff
member (QP) exacting revenge on the youth
(Client #1) for challenging her. Staff was
reactionary.”

-"Recommendations: It is recommended that the
staff member (QP) be on a 60-day Performance
Improvement Plan during which time she
completed TCI (therapeutic crisis intervention)
refresher training with a concentration on Handle
with Care concepts that assist with being
proactive and utilizing verbal de-escalation
techniques as well as positive engagement
strategies."

Interview on 4/21/25 with the Program Supervisor
revealed:

-On 3/19/25 he was reviewing video footage in
reference to another incident when he came upon
footage of the QP pushing Client #1 out of his
chair on 3/14/25.

-Completed the NC IRIS report and reported the
incident to Human Resources (HR) on 3/20/25.
-HR did the internal investigation (3/27/25-
3/31/25).

-Did not question the QP.

-Did not know the outcome of the internal
investigation.

-Client #1 did not sustain any injuries.

Attempted interview on 4/25/25 with Client #1
revealed:

-His legal guardian would not consent to an
interview because Client #1 "does not speak
good english and he has trouble following
conversations."

Interview on 4/28/25 with Staff #2 revealed:
-Did not remember a lot of the details of the
incident between the QP and Client #1 on
3/14/25.

Division of Health Service Regulation

STATE FORM

6899 KUZI11

If continuation sheet 9 of 11

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL060968 B. WING

NAME OF PROVIDER OR SUPPLIER
6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE CHARLOTTE, NC 28211

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/10/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
04/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

-Remembered Client #1 was disrupting the other
clients and "talking back, calling staff names like
black B**ch."

-"Whatever you saw on the video is what
happened. | think she (QP) just lost her cool for a
minute. That kid (Client #1) would push and push
and push."

-Did not hear the QP and Client #1 arguing with
each other.

Interview on 4/28/25 the QP revealed:

-On 3/14/25 Client #1 kept using the saying "clock
that tea" and in a jokingly way she said "I will."

-"| walked over to his desk and tickled him and he
wiggled out of his chair. | was playing with him, |
wasn't trying to harm him."

-"I'm not that kind of person to harm children."

-"It was a playful interaction."

-Denied telling Client #1 "Don't start with me
today, I'm the wrong one."

-Denied Client #1 was standing in his chair yelling
"Dummy."

-Did not pull Client #1 out of his chair on to the
floor.

-Could not recall which days she worked between
3/27/25 and 3/31/25.

Interview on 4/22/25 with the HR Director
revealed:

-The QP was suspended from the day program
pending investigation on 3/27/25.

-The QP worked with another program while
under investigation.

-The internal investigation took place from
3/27/25 to 3/31/25.

-Did not know the QP was not supposed to work
with any clients while under investigation.

-"| thought the suspension was just for the day
program."

Division of Health Service Regulation

STATE FORM 6899

KUZI11

(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 9 V 132

If continuation sheet 10 of 11

PRINTED: 09/10/2025

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL060968 B. WING 04/30/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE
CHARLOTTE, NC 28211
(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 10 V 132

Interview on 4/29/25 with the Vice President of
Performance Improvement revealed:

-Did not have a lot of details about the incident
between the QP and Client #1.

-Verified the QP was allowed to work in another
Program while under investigation for abusing
Client #1.

-The internal investigation was 3/27/25 through
3/31/25.

-The QP was terminated on 4/29/25.

Division of Health Service Regulation
STATE FORM 6899 KUZI11 If continuation sheet 11 of 11


state: NC

facility_name: Alexander Youth Network - Charlotte Day Treatment

summary: Statement of Deficiency - MHLCS Complaint

raw_content:
Division of Health Service Regulation

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

MHL060968

NAME OF PROVIDER OR SUPPLIER

A. BUILDING:

6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1

CHARLOTTE, NC 28211

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 10/07/2024

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

10/01/2024

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

ID
PREFIX
TAG

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

DEFICIENCY)

(xs)
COMPLETE
DATE

V 000} INITIAL COMMENTS

Acomplaint survey was competed on 10-1-24
The complaints were unsubstantiated
(#NC00221991, #NC00222010). Deficiencies
were cited.

This facility is licensed for the following service

category: 10A NCAC 27G. 1400 Day Treatment
for Children and Adolescents with Emotional or
Behavior Disturbance.

This facility is licensed for 0 and currently has a
census of 26. The survey sample consisted of
audits of 2 current clients.

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

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

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

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

(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

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

STATE FORM

V 000

V 536

6899

2VUA11

TITLE

(X6) DATE

If continuation sheet 1 of 7

Division of Health Service Regulation

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

MHL060968

NAME OF PROVIDER OR SUPPLIER

A. BUILDING:

6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1

CHARLOTTE, NC 28211

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/07/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

10/01/2024

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 536 | Continued From page 1 V 536

behavior) on those objectives and measurable
methods to determine passing or failing the
course.

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

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

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

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

(2) recognizing and interpreting human
behavior;

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

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

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

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

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

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

(9) positive behavioral supports (providing

means for people with disabilities to choose
activities which directly oppose or replace
behaviors which are unsafe).

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

Division of Health Service Regulation
STATE FORM

6809

2VUA11

If continuation sheet 2 of 7

Division of Health Service Regulation

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

MHL060968

NAME OF PROVIDER OR SUPPLIER

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1

A. BUILDING:

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/07/2024

STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
CHARLOTTE, NC 28211

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

10/01/2024

review/request this documentation at any time.
(i) Instructor Qualifications and Training
Requirements:

need for restrictive interventions.

by scoring a passing grade on testing in an
instructor training program.

(3) The training shall be

objectives, measurable testing (written and by

measurable methods to determine passing or
failing the course.

service provider plans to employ shall be

to Subparagraph (i)(5) of this Rule.

reducing and eliminating the need for restrictive
interventions at least one time, with positive
review by the coach.

Division of Health Service Regulation
STATE FORM

(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

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

(2) Trainers shall demonstrate competence

competency-based, include measurable learning

observation of behavior) on those objectives and

(4) The content of the instructor training the

approved by the Division of MH/DD/SAS pursuant

(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,

6809

2VUA11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 536 | Continued From page 2 V 536

If continuation sheet 3 of 7

Division of Health Service Regulation

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

MHL060968

NAME OF PROVIDER OR SUPPLIER

A. BUILDING:

6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1

CHARLOTTE, NC 28211

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/07/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

10/01/2024

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 536] Continued From page 3 V 536

(7) Trainers shall teach a training program
aimed at preventing, reducing and eliminating the
need for restrictive interventions at least once
annually.

(8) Trainers shall complete a refresher
instructor training at least every two years.

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

(1) Documentation shall include:

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

(B) when and where attended; and

(C) instructor's name.

(2) The Division of MH/DD/SAS may

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

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

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

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

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

This Rule is not met as evidenced by:

Based on interviews, one of one audited staff
(Staff #1) failed to demonstrate competency in
the use of alternatives to restrictive interventions.
The findings are:

Division of Health Service Regulation
STATE FORM

6809

2VUA11

If continuation sheet 4 of 7

Division of Health Service Regulation

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

MHL060968

NAME OF PROVIDER OR SUPPLIER

A. BUILDING:

6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1

CHARLOTTE, NC 28211

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/07/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

10/01/2024

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 536 | Continued From page 4 V 536

Review on 9-26-24 of Staff #1's record revealed:
-Hire date on 2-15-19.
-Handle With Care Refresher; 4-4-24,
Calming Children in Crisis, 3-7-19.

Review on 9-26-24 of Client #1's record revealed:
-Admitted 7-30-24.
-11 years old.
-Diagnoses of Oppositional Defiance
Disorder and Post Traumatic Stress Disorder.

Review on 9-26-24 of Internal Investigation dated
9-12-24 revealed:

-Summary of Incident: Client was
dysregulated and went to the quiet room where
he was upset. Staff observed something in his
hand and asked him to give it to the staff. He
stated that staff pushed him into the wall when he
refused to give up the item.

-Allegation: Client [Client #1] alleges that
staff [Staff #1] pushed him in his chest into the
wall.

-Findings of Fact: The internal panel review
team assessed and determined the following
items to be facts related to this incident based on
the review of the record, procedures, statements
from staff/clients and video:

-[Client #1] was in the calming room with 2
other clients.

-[Client #1] was in crisis, screaming, yelling.

-[Staff #1] responded to the noise and asked
him to stop.

-[Client #1] did not comply with requests.

-[Client #1] had something in his hand he
refused to give to staff.

-In an attempt to get the item the client made
contact with the wall.

-Cause of the Incident: Poor de-escalation
strategies utilized.

Division of Health Service Regulation
STATE FORM

6809

2VUA11

If continuation sheet 5 of 7

Division of Health Service Regulation

PRINTED: 10/07/2024

FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL060968 10/01/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1
CHARLOTTE, NC 28211
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 536 | Continued From page 5 V 536

Interview on 9-23-24 with Client #1 revealed:

-"| was yelling hitting the wall, throwing
yourself against the wall."

-Staff #1 pushed him by the stomach against
the wall and his back hit the wall.

-He doesn't remember Staff #1 asking for
what was in his hand.

- He stated that the Director of the Transition
House was also in the room.

-He did not get hurt.

Interview on 9-18-24 and 9-23-24 with Client #2
revealed:
-He was in the calming room with Client #1.
-Client #1 was walking around, banging on
walls.
-Staff #1 pushed Client #1 by his shoulders.
-Staff #1 pushed Client #1 into a corner.
-Client #1 was hurt and was crying.

Interview on 9-18-24 with Staff #1 revealed:

-Client #1 and Client #2 were in the calming
room.

-Both Clients were banging on the wall.

-She went in to the calming room and asked
him to calm down.

-Client #1 said he would not and that he
wished he was dead and wanted to kill himself.

-Client #1 had something in his hand, and
since he was making suicidal threats, she felt that
she needed to know what it was.

-She approached him and he jumped back
and hit the wall.

-Client #1 dropped what was in his hand and
when Staff #1 saw that it was just a fidget
spinner, she left the calming room.

-"I never even touched him."

Interview on 9-23-24 with Staff #2 revealed:

Division of Health Service Regulation
STATE FORM

6809

2VUA11

If continuation sheet 6 of 7

Division of Health Service Regulation

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

MHL060968

NAME OF PROVIDER OR SUPPLIER

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1

A. BUILDING:

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/07/2024

STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
CHARLOTTE, NC 28211

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

10/01/2024

-She directed both Client #1 and Client #2
into the calming room.

-Client #1 was throwing things at the wall and
banging the wall. Client #2 had calmed down.

-Client #1 was throwing himself against the
wall.

-Staff #1 came in and asked him the stop.

-Staff #1 told Client #1 to "just chill" and that
he was aggravating her clients.

-Client #1 had something in his hand and
Staff #1 was trying to take it from him.

-Client #1 back into the wall trying to get
away.

-Staff #2 saw Client #1's arm jerk into the wall
several times, but did not see the final time when
Client #1's back hit the wall.

-Staff #1 did grab Client #1's hand, and Client
#1 jerked away.

Interview on 9-23-24 with the Director of the
Transition Home revealed:

-He was not in the calming room when Client
#1 was having a behavior.

Division of Health Service Regulation
STATE FORM

6809

2VUA11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 536] Continued From page 6 V 536

If continuation sheet 7 of 7

inspection_type: MHLCS Complaint

document_type: Statement of Deficiency


raw_content:
PRINTED: 03/06/2024

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL060968 B. WING 03/05/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE CHARLOTTE, NC 28211

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000} INITIAL COMMENTS V 000

Acomplaint survey was completed on
03/05/2024. The complaint was unsubstantiated
(Intake #NC00213140). No deficiencies were
cited.

This facility is licensed for the following service
category: 10A NCAC 27G .1400 Day Treatment
for Children and Adolescents with Emotional or
Behavioral Disturbances.

This facility has a current census of 35. The
survey sample consisted of audit of 1 current
client.

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

STATE FORM 6899 45BH11 If continuation sheet 1 of 1


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

raw_content:
Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

PRINTED: 09/08/2023

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

MHL060968

6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1
CHARLOTTE, NC 28211

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

) DATE SURVEY
COMPLETED

R-C
08/30/2023

A complaint and follow up survey was completed
on 8-30-23. The complaints were
unsubstantiated (Intake #'s NC00205944 and #
NC00205942). No deficiencies were cited.

This facility is licensed for the following service
category: 10A NCAC 27G .1400 Day Treatment
For Children And Adolescents With Emotional Or
Behavioral Disturbances.

This facility has a current census of 32. The
survey sample consisted of audits of 4 current
clients.

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

STATE FORM

6899

VHOZ11

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

DEFICIENCY)
V 000) INITIAL COMMENTS Vv 000

TITLE

(X6) DATE

If continuation sheet 1 of 1

inspection_type: MHLCS Annual and Follow-up


raw_content:
Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL060968

A. BUILDING:

6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1
CHARLOTTE, NC 28211

(X2) MULTIPLE CONSTRUCTION

PRINTED: 02/27/2023

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

02/20/2023

(x4) ID
PREFIX
TAG

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

ID
PREFIX
TAG

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

(xs)
COMPLETE
DATE

V 000!

V 184

INITIAL COMMENTS

Acomplaint survey was completed on 2-20-23.
The complaint was substaniated (#NC00195555).
Deficiencies were cited.

This facility is licensed for the following service
category: 10A NCAC 27G 1400 Day Treatment
for Children and Adolescents with Emotional or
Behavioral Disturbances.

This facility has a current census of 19. The
survey sample consisted of audits of one former
client.

27G .1401 Day Tx Child/Adol - Scope

10A NCAC 27G .1401 SCOPE

(a) Day treatment is a day/night facility for
children and adolescents who are emotionally
disturbed which coordinates educational activities
and intensive treatment while allowing the
individual to live at home or in the community.

(b) This service is designed to increase the
ability of a child or adolescent to relate to others
and function appropriately within the community
while serving as an intervention to prevent
hospitalization or placement outside the home or
community.

(c) It shall provide a therapeutic environment as
well as other activities which may include
individual therapy, group therapy, recreational
therapy, language communication skills
development, social skills development,
pre-vocational service, vocational training, service
to parents, and individual advocacy.

(d) The client's educational activities may be
provided in this facility or in another educational
setting, such as regular classes or special
education programs within a typical school
setting.

Division of Health Service Regulation

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

STATE FORM

V 000

V 184

6899

HNSH11

TITLE

(X6) DATE

If continuation sheet 1 of 4

Division of Health Service Regulation

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

MHL060968

NAME OF PROVIDER OR SUPPLIER

A. BUILDING:

6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1

CHARLOTTE, NC 28211

(X2) MULTIPLE CONSTRUCTION

PRINTED: 02/27/2023

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

02/20/2023

(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 184] Continued From page 1 V 184

(e) Treatment, services, and discharge plans
provided by day treatment programs shall be
coordinated with other individuals and agencies
within each client's local system of care.

(f) Day treatment facilities may include
before/after school and summer facilities, and
early intervention.

This Rule is not met as evidenced by:
Based on record reviews and interviews the
facility failed to provide a therapeutic
environment. The findings are:

Review on 2-19-23 of youtube video entitled "Evil
caretaker tries to kill grandma" revealed:

-Caretaker was taking care of elderly,
diabetic, blind woman.

-Caretaker gave woman who was not
supposed to have any sugar full sugar soda.

-Caretaker did not let the woman
communicate with her daughter.

-Caretaker persuaded woman to change her
will, leaving everything to the caretaker.

-Daughter finally shows up at the house and
the caretakers friend pulls a gun on them as the
caretaker reveals she was also giving the woman
sugar pills to try to kill her.

-The daughter gets the gun and calls the
police.

Interview on 2-15-23 with Client #2 revealed:
-They had watched a movie about a
caretaker.
-"It was bout a mean lady that was like her
nurse, she was trying to kill her so she could get
her money. The mean lady wouldn't let her speak

Division of Health Service Regulation
STATE FORM

6809

HNSH11

If continuation sheet 2 of 4

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL060968

A. BUILDING:

6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1
CHARLOTTE, NC 28211

(X2) MULTIPLE CONSTRUCTION

PRINTED: 02/27/2023

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

02/20/2023

to her daughter. The daughter found out and the
mean lady went to jail."

- "It was kinda about the right thing to do,
what not to do."

Interview on 2-15-23 with Client #3 revealed:
-She didn't remember a movie about a blind

woman being given sugar, but did remember a

movie about an elderly woman getting bullied.

Interview on 2-16-23 with Staff #1 revealed:
-They had watched a youtube video about an
elderly woman and her caretaker.
-She stated that they were inspirational
movies that were to teach the kids what they
should and should not be doing.

Interview on 1-23-23 with Former Client #1's
Mother/Guardian revealed:

-He daughter attended the day program
approximately 3 days, from the end of November
to the first week of December.

- Her daughter said there was a youtube
video about home nurse aide. "The nurse was
trying to kill the old blind lady with sugar and
soda, and there was a gun in it and they were
trying to kill the old lady."

-Her daughter has a recording device with her
to protect her.

-She had listened to the whole video and she
could hear her daughter asking what it was.

-She did not think the movie was appropriate
for children.

Interview on 2-15-23 with the Program Supervisor
revealed:

-He had only been the Program Supervisor
for approximately one month.

-He approved the movies and the facility had
a movie policy.

Division of Health Service Regulation

STATE FORM

6809

HNSH11

(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 184] Continued From page 2 V 184

If continuation sheet 3 of 4

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL060968

6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1
CHARLOTTE, NC 28211

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 02/27/2023

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

02/20/2023

PROVIDER'S PLAN OF CORRECTION

-He was unaware of the movies and videos
that were shown before he became the Program
Supervisor.

Division of Health Service Regulation
STATE FORM

6809

HNSH11

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID (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 184] Continued From page 3 V 184

If continuation sheet 4 of 4


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

raw_content:
PRINTED: 03/13/2020

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
MHL060968 03/10/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1
CHARLOTTE, NC 28211
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000} INITIAL COMMENTS V 000

An annual, follow up and complaint survey was
completed on 3-10-20. The complaints were
substantiated (HNC00160961, #NC00161079,
#NC00160996). No deficiencies were cited.

This facility is licensed for the following service
category: 10A NCAC 27G. 1400 Day Treatment
for Children and Adolescents With Emotional or
Behavioral Disturbances.

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

STATE FORM

6899

AGPQ11

TITLE (X6) DATE

If continuation sheet 1 of 1

inspection_type: MHLCS Annual, Complaint, and Follow-up


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

raw_content:
Division of Health Service Regulation

PRINTED: 10/04/2019
FORM APPROVED

Allegations, & Protection

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

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

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

c. Misappropriation of the property of a
healthcare facility.

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

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

Facilities must have evidence that all alleged

Division of Health Service Regulation

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

STATE FORM

6899

NUNC11

TITLE

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
R
MHL060968 10/02/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1
CHARLOTTE, NC 28211
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000} INITIAL COMMENTS V 000
A complaint and follow up survey was completed
on October 2, 2019. The complaint was
unsubstantiated (Intake #NC 00156517).
Deficiencies were cited.
The facility is licensed for the following service
category: 10A NCAC 27G .1400 Day Treatment
for Children and Adolescents with Emotional or
Behavioral Disturbances.
V 132} G.S. 131E-256(G) HCPR-Notification, V 132

(X6) DATE

If continuation sheet 1 of 12

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/04/2019
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL060968 10/02/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1
CHARLOTTE, NC 28211
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 132] Continued From page 1 V 132

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

This Rule is not met as evidenced by:

Based on interview and record review, the facility
failed to investigate all allegations of abuse and
failed to protect clients from harm while the
investigation was in progress affecting 2 of 3
audited staff.

Review on 10/2/19 of Client #1's record revealed:
-Admission date of 3/14/19;

-Diagnoses of Attention Deficit Hyperactivity
Disorder, Disruptive Mood Dysregulation
Disorder, and Oppositional Defiant Disorder;

-11 years old.

Review on 10/2/19 of a Level | Incident Report
dated 8/1/19 revealed:

-Client #1 made an allegation against Staff #5
regarding Staff #5 using a choke hold while on
the van.

Interview on 10/2/19 with Client #1 revealed:
-Was brought into the library by Staff #4 who
grabbed his shirt and pushed him against the

Division of Health Service Regulation
STATE FORM

6809

NUNC11

If continuation sheet 2 of 12

Division of Health Service Regulation

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

MHL060968

NAME OF PROVIDER OR SUPPLIER

A. BUILDING:

6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1

CHARLOTTE, NC 28211

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/04/2019

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R
10/02/2019

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

ID
PREFIX
TAG

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

(xs)
COMPLETE
DATE

V 132] Continued From page 2

wall;

-Was put in a choke hold by Staff #5 while on the
van ride home;

-Dates of the incidents are unknown.

Interview on 10/2/19 with the Supervisor
revealed:

-Had a meeting with Client #1's grandmother at
the end of September, 2019 during which the
grandmother reported the allegations involving
Staff #4 and Staff #5;

-Did not complete an internal investigation and
did not suspend either staff;

-Will ensure to complete an internal investigation
on any allegations of abuse in the future.

Interview on 10/2/19 with the Executive Director
revealed:

-Will work closely with the Supervisor and will
discuss a possible re-arrangement of supervisory
duties to increase the Executive Director's time at
the Day Treatment.

V 318) 130 .0102 HCPR - 24 Hour Reporting

10A NCAC 130 .0102 INVESTIGATING AND
REPORTING HEALTH CARE PERSONNEL

The reporting by health care facilities to the
Department of all allegations against health care
personnel as defined in G.S. 131E-256 (a)(1),
including injuries of unknown source, shall be
done within 24 hours of the health care facility
becoming aware of the allegation. The results of
the health care facility's investigation shall be
submitted to the Department in accordance with
G.S. 131E-256(g).

V 132

V 318

Division of Health Service Regulation
STATE FORM

6809

NUNC11

If

continuation sheet 3 of 12

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/04/2019
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL060968 10/02/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1
CHARLOTTE, NC 28211
(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 318] Continued From page 3 V 318

This Rule is not met as evidenced by:

Based on interview and record review, the facility
failed to notify the Department within 24 hours of

becoming aware of an allegation of abuse against
staff affecting 2 of 3 audited staff.

Review on 10/2/19 of Client #1's record revealed:
-Admission date of 3/14/19;

-Diagnoses of Attention Deficit Hyperactivity
Disorder, Disruptive Mood Dysregulation
Disorder, and Oppositional Defiant Disorder;

-11 years old.

Review on 10/2/19 of a Level | Incident Report
dated 8/1/19 revealed:

-Client #1 made an allegation against Staff #5
regarding Staff #5 using a choke hold while on
the van.

Interview on 10/2/19 with Client #1 revealed:
-Was brought into the library by Staff #4 who
grabbed his shirt and pushed him against the
wall;

-Was put in a choke hold by Staff #5 while on the
van ride home;

-Dates of the incidents are unknown.

Interview on 10/2/19 with the Supervisor
revealed:

-Had a meeting with Client #1's grandmother at
the end of September, 2019 during which the
grandmother reported the allegations involving
Staff #4 and Staff #5;

-Did not complete incident reporting or notification
of the allegations of abuse;

-Will ensure proper notification and
documentation in the future.

Division of Health Service Regulation
STATE FORM

6809

NUNC11

If continuation sheet 4 of 12

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL060968

6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1
CHARLOTTE, NC 28211

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 10/04/2019

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R
10/02/2019

10A NCAC 27G .0603 INCIDENT
RESPONSE REQUIREMENTS FOR

CATEGORY AAND B PROVIDERS

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

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

(2) determining the cause of the incident;
(3) developing and implementing corrective

measures according to provider specified
timeframes not to exceed 45 days;

(4) developing and implementing measures
to prevent similar incidents according to provider
specified timeframes not to exceed 45 days;

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

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

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

(c) In addition to the requirements set forth in

Division of Health Service Regulation
STATE FORM

6809

NUNC11

(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 318] Continued From page 4 V 318
Interview on 10/2/19 with the Executive Director
revealed:
-Will work closely with the Supervisor and will
discuss a possible re-arrangement of supervisory
duties to increase the Executive Director's time at
the Day Treatment.
V 366} 27G .0603 Incident Response Requirments V 366

If continuation sheet 5 of 12

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/04/2019
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL060968 10/02/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1
CHARLOTTE, NC 28211
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 366 | Continued From page 5 V 366

Paragraph (a) of this Rule, Category A and B
providers, excluding ICF/MR providers, shall
develop and implement written policies governing
their response to a level Ill incident that occurs
while the provider is delivering a billable service
or while the client is on the provider's premises.
The policies shall require the provider to respond

by:

(1) immediately securing the client record
by:

(A) obtaining the client record;

(B) making a photocopy;

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

(2) convening a meeting of an internal

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

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

(B) gather other information needed;

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

(D) issue a final written report signed by the
owner within three months of the incident. The
final report shall be sent to the LME in whose
catchment area the provider is located and to the

Division of Health Service Regulation
STATE FORM

6809

NUNC11

If continuation sheet 6 of 12

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/04/2019
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL060968 10/02/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1
CHARLOTTE, NC 28211
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 366 | Continued From page 6 V 366

LME where the client resides, if different. The
final written report shall address the issues
identified by the internal review team, shall
include all public documents pertinent to the
incident, and shall make recommendations for
minimizing the occurrence of future incidents. If
all documents needed for the report are not
available within three months of the incident, the
LME may give the provider an extension of up to
three months to submit the final report; and

(3) immediately notifying the following:

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

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

(C) the provider agency with responsibility

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

(D) the Department;

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

(F) any other authorities required by law.

This Rule is not met as evidenced by:

Based on interview and record review, the facility
failed to implement their written policy governing
their response to incidents

Review on 10/2/19 of Client #1's record revealed:
-Admission date of 3/14/19;

-Diagnoses of Attention Deficit Hyperactivity
Disorder, Disruptive Mood Dysregulation

Division of Health Service Regulation
STATE FORM

6809

NUNC11

If continuation sheet 7 of 12

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL060968

A. BUILDING:

6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1
CHARLOTTE, NC 28211

PRINTED: 10/04/2019
FORM APPROVED

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

COMPLETED

R
10/02/2019

STREET ADDRESS, CITY, STATE, ZIP CODE

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

CROSS-REFERENCED TO THE APPROPRIATE, DATE
DEFICIENCY)

V 366

V 367|

Continued From page 7

Disorder, and Oppositional Defiant Disorder;
-11 years old.

Interview on 10/2/19 with Client #1 revealed:
-Was brought into the library by Staff #4 when he
attempted to elope and Staff #4 who grabbed his
shirt and pushed him against the wall;

-Dates of the incident is unknown.

Interview on 10/2/19 with the Supervisor
revealed:

-Completed a disciplinary write-up for Staff #4's
failure to complete an incident report when Client
#1 attempted to elope and Staff #4 brought Client
#1 to the library to calm down.

Interview on 10/2/19 with the Executive Director
revealed:

-Will work closely with the Supervisor and will
discuss a possible re-arrangement of supervisory
duties to increase the Executive Director's time at
the Day Treatment.

27G .0604 Incident Reporting Requirements

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

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

Division of Health Service Regulation
STATE FORM

V 366

V 367

6809

NUNC11

If continuation sheet 8 of 12

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/04/2019
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL060968 10/02/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1
CHARLOTTE, NC 28211
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 367 | Continued From page 8 V 367

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 III incident reports to the Division of
Mental Health, Developmental Disabilities and
Substance Abuse Services within 72 hours of
becoming aware of the incident. Category A
providers shall send a copy of all level III
incidents involving a client death to the Division of
Health Service Regulation within 72 hours of

Division of Health Service Regulation
STATE FORM

6809

NUNC11

If continuation sheet 9 of 12

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/04/2019
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL060968 10/02/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1
CHARLOTTE, NC 28211
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 367] Continued From page 9 V 367

becoming aware of the incident. In cases of
client death within seven days of use of seclusion
or restraint, the provider shall report the death
immediately, as required by 10A NCAC 26C.
.0300 and 10A NCAC 27E .0104(e)(18).

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

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

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

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

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

(6) a statement indicating that there have

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

This Rule is not met as evidenced by:

Based on interview and record review, the facility
failed to report all Level III incidents to the LME
responsible for the catchment area where
services are provided within 72 hours of
becoming aware of the incident.

Review on 10/2/19 of Client #1's record revealed:
-Admission date of 3/14/19;
-Diagnoses of Attention Deficit Hyperactivity

Division of Health Service Regulation
STATE FORM

6809

NUNC11

If continuation sheet 10 of 12

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/04/2019
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL060968 10/02/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1
CHARLOTTE, NC 28211
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 367 | Continued From page 10 V 367

Disorder, Disruptive Mood Dysregulation
Disorder, and Oppositional Defiant Disorder;
-11 years old.

Review on 10/2/19 of a Level | Incident Report
dated 8/1/19 revealed:

-Client #1 made an allegation against Staff #5
regarding Staff #5 using a choke hold while on
the van.

Review on 10/2/19 of the North Carolina Incident
Response Improvement System revealed:

-No Level Ill incident reports completed on the
allegations of abuse made by Client #1.

Interview on 10/2/19 with Client #1 revealed:
-Was brought into the library by Staff #4 who
grabbed his shirt and pushed him against the
wall;

-Was put in a choke hold by Staff #5 while on the
van ride home;

-Dates of the incidents are unknown.

Interview on 10/2/19 with the Supervisor
revealed:

-Had a meeting with Client #1's grandmother at
the end of September, 2019 during which the
grandmother reported the allegations involving
Staff #4 and Staff #5;

-No Level Ill incident reports were completed
regarding the allegations of abuse.

-Will ensure to complete Level III incident reports
on all allegations of abuse in the future.

Interview on 10/2/19 with the Executive Director
revealed:

-Will work closely with the Supervisor and will
discuss a possible re-arrangement of supervisory
duties to increase the Executive Director's time at
the Day Treatment.

Division of Health Service Regulation
STATE FORM

6809

NUNC11

If continuation sheet 11 of 12

PRINTED: 10/04/2019

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
MHL060968 — 10/02/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1
CHARLOTTE, NC 28211
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

V 367] Continued From page 11 V 367

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

Division of Health Service Regulation
STATE FORM 6809 NUNC11 If continuation sheet 12 of 12

inspection_type: MHLCS Complaint and Follow-up