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

raw_content:
Division of Health Service Regulation

PRINTED: 05/09/2019
FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED
R
MHL060968 04/30/2019
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
An annual, complaint, and follow up survey was
completed on April 30, 2019. The complaint was
unsubstantiated (Intake # NC150694).
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.
V 120| 27G .0209 (E) Medication Requirements Vv 120

10A NCAC 27G .0209 MEDICATION
REQUIREMENTS

(e) Medication Storage:

(1) All medication shall be stored:

(A) in a securely locked cabinet in a clean,
well-lighted, ventilated room between 59 degrees
and 86 degrees Fahrenheit;

(B) in a refrigerator, if required, between 36
degrees and 46 degrees Fahrenheit. If the
refrigerator is used for food items, medications
shall be kept in a separate, locked compartment
or container;

(C) separately for each client;

(D) separately for external and internal use;

(E) in a secure manner if approved by a physician
for a client to self-medicate.

(2) Each facility that maintains stocks of
controlled substances shall be currently
registered under the North Carolina Controlled
Substances Act, G.S. 90, Article 5, including any
subsequent amendments.

This Rule is not met as evidenced by:
Based on interview, record review, and
observation, the facility failed to maintain secure

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

STATE FORM

6899

GNHM11

TITLE

(X6) DATE

If continuation sheet 1 of 18

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

STATEMENT OF DEFICIENCIES

PRINTED: 05/09/2019

(X2) MULTIPLE CONSTRUCTION

FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL060968 04/30/2019
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 120] Continued From page 1 Vv 120

safe storage of medication 4 of 6 audited current
clients (Clients #2, #3, #4, and #5). The findings
are:

Review on 4/24/19 of Client #2's record revealed:
-Admission date 8/9/18;

-Diagnoses of Circadian Rhythm Sleep Wake
Disorder, Separation Anxiety Disorder, Attention
Deficit Hyperactivity Disorder (ADHD), History of
Physical Abuse;

-8 years old;

-Physician's order dated 12/5/18 for Vyvanse
(treatment of ADHD) 20mg 1 tab at 12:00pm;
-Count sheet for Vyvanse 20mg revealed there
were 8 Vyvanse 20mg pills present on the
morning of 3/21/19. One was administered at
11am on that date;

-Count sheet for Vyvanse 20mg included the
notation dated 3/21/19 "Counted by PI
(Performance Improvement) and count was off by
2 pills" with the signature of the Performance
Improvement Manager (PIM).

Review on 4/24/19 of Client #3's record revealed:
-Admission date 8/6/18;

-Diagnoses of Oppositional Defiant Disorder,
Attention Deficit Hyperactivity Disorder,
Adjustment Disorder;

-6 years old;

-Physician's order dated 10/16/18 for Adderall XR
(treatment of ADHD) 15mg 1 capsule at 12:00pm;
-Count sheet for Adderrall XR 15mg revealed
there were 14 Adderall XR 15mg pills present on
the morning of 3/21/19. One was administered at
11am on that date;

-Count sheet for Adderrall XR15mg included the
notation dated 3/21/19 "Count was off by 1
capsule" with the initials of the PIM.

Review on 4/24/19 of Client #4's record revealed:

Division of Health Service Regulation
STATE FORM

6808 GNHM11

If continuation sheet 2 of 18

Division of Health Service Regulation

PRINTED: 05/09/2019
FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
R
MHL060968 04/30/2019
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 120] Continued From page 2

-Admission date 12/27/18;

-Diagnoses of Adjustment Disorder with Mixed
Disturbance of Emotions/Conduct, Oppositional
Defiant Disorder, Attention Deficit Hyperactivity
Disorder, Autism Spectrum Disorder;

-10 years old;

-Physician's order dated 1/16/19 for
Methylphenidate (treatment of ADHD) 10mg 2
tabs at 10:00am and 2:00pm;

-Count sheet for Methylphenidate 10mg revealed
there were 29 pills in the facility just prior to
review on 3/21/19 by the PIM. The date of
previous administration is unclear because the
dates had been crossed out and whited out;
-Count sheet for Methylphenidate 10mg included
a notation dated 3/21/19 "count off by 6 tablets"
with the initials of the PIM;

-Count sheet for Methylphenidate 10mg revealed
there were 62 pills in the facility just prior to
review on 4/24/19 by the PIM;

-Count sheet for Methylphenidate 10mg included
a notation dated 4/24/19 "counted by PI and
count was off by 4 pills."

Review on 4/24/19 of Client #5's record revealed:
-Admission date 3/11/19;

-Diagnoses of Oppositional Defiant Disorder,
Attention Deficit Hyperactivity Disorder, Childhood
Onset Fluency Disorder (Stuttering);

-13 years old;

-Physician's order dated 4/2/19 for Focalin XR
(treatment of ADHD) 30mg 1 cap at 9:00am and
Focalin 5mg 2 caps at 1:00pm;

-Count sheet for Focalin XR 30mg revealed there
were 12 pills in the facility on 3/21/19. One pill
was administered at 9:00am;

-Count sheet for Focalin XR 30mg included a
notation dated 3/21/19 "Count off by 1 capsule"
with the initials of the PIM;

-Count sheet for Focalin 5mg revealed there was

Division of Health Service Regulation
STATE FORM

Vv 120

6808 GNHM11

If continuation sheet 3 of 18

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/09/2019
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL060968 04/30/2019
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 120] Continued From page 3 Vv 120

47 pills in the facility on 3/21/19. Two pills were
administered at 1:00pm;

-Count sheet for Focalin 5mg included a notation
dated 3/21/19 "count was off by 1 pill" with the
initials of the PIM;

-Count sheet for Focalin 5mg included multiple
cross outs and pill count re-entries on the count
sheet with notations of "correct count" for each
day appearing that medication counts were off for
8 consecutive dates of medication administration
from 3/28/19 through 4/5/19.

Review on 4/24/19 of Staff #10's record revealed:
-Hire date 9/10/18;
-Hired as Mental Health Counselor.

Review on 4/23/19 of the facility's Incident
Reports revealed:

-Level 1 incident report dated 3/21/19 for Client
#2 revealed that during an internal review of
medications, it was discovered that the
medication count was off by 1 pill for Vyvanse
20mg;

-Level 1 incident report dated 3/21/19 for Client
#3 revealed that during an internal review of
medications, it was discovered that the
medication count was off by 1 pill for Adderall
15mg;

-Level 1 incident report dated 3/21/19 for Client
#4 revealed that during an internal review of
medications, it was discovered that the
medication count was off by 5 pills for
Methylphenidate 10mg;

-Level | incident report dated 3/21/19 for Client #5
revealed that during an internal review of
medications, it was discovered that medication
counts were off by 1 pill each for Focalin XR
30mg and Focalin 5mg.

Review on 4/26/19 of the facility's Policy on

Division of Health Service Regulation
STATE FORM

6809

GNHM11

If continuation sheet 4 of 18

Division of Health Service Regulation
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STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/09/2019
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Storage, Disposal and Control of Medications
(Policy 4.8) effective 1/1/1998 with most recent
update on 5/25/10 revealed:

-" ...Schedule II Controlled Medications: (11)
Upon delivery of Schedule II drugs, an authorized
staff member verifies receipt by adding the count
and initials to the Controlled Drugs Record.
Schedule II drugs will be placed in the medication
closet immediately; (12) Schedule II drugs are not
to be removed from locked storage until time of
administration and must be signed out at that
time; (13) Two staff members shall count all
controlled medication on a regular basis verify
count is correct. The two staff members sing the
Controlled Drugs Record signifying count is
accurate. This record is maintained for three
years; (14) If there is a discrepancy in the count,
staff will make every effort to resolve the
discrepancy immediately. If the discrepancy
cannot be resolved, it will be reported through the
Incident Report and accompanying procedures
and recorded on the Controlled Drug Record ..."

Interview on 4/25/19 with Client #2 revealed:
-Takes medication at the facility but does not
know the name of it;

-The medication is "the white pill;"

-Different staff administer medication;
-Never missed receiving his medication.

Interview on 4/25/19 with Client #3 revealed:
-Takes medication at the facility but does not
know the name of it;

-The medication is "the blue pill;"

-Different staff administer medication;
-Never missed receiving his medication.

Interview on 4/25/19 with Client #4 revealed:
-Takes medication at the facility but does not
know the name of it;

Division of Health Service Regulation
STATE FORM

6809

GNHM11

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL060968 04/30/2019
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 120] Continued From page 4 Vv 120

If continuation sheet 5 of 18

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: 05/09/2019

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

R
04/30/2019

(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 120] Continued From page 5 Vv 120

-The medication is the "mint green pill;"
-Different staff administer medication;
-Never missed receiving his medication.

Interview on 4/25/19 with Client #5 revealed:
-Takes medication at the facility;

-Takes "Focalin XR 30;"

-Different staff administer medication;

-Never missed medications at the facility because
the "doctor at mental health send the paperwork."

Interview on 4/25/19 with Staff #10 revealed:
-Began administering medications three weeks
ago;

-When administering controlled substance
medications, must have an additional staff
present as a witness;

-After administering the medication to each client,
the staff must make sure to check if the client
swallowed the medication. Staff must then sign
the Medication Administration Record and the
count sheet for any controlled substance
medications. The staff witness does not sign any
documents.

Interview on 4/25/19 with the Case Manager
revealed:

-When families drop off controlled substance
medications for clients, the medications must be
checked in by staff trained in medication
administration. The controlled substance
medication pills are counted and a Control
Medication Sheet is completed documenting the
number of pills brought to the facility. The staff
and family member each sign the Control
Medication Sheet verifying the number of pills
brought to the facility.

Interview on 4/25/19 with the Executive Director
revealed:

Division of Health Service Regulation
STATE FORM

6809

GNHM11

If

continuation sheet 6 of 18

PRINTED: 05/09/2019

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 04/30/2019
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 120] Continued From page 6 Vv 120

-There should never be any discrepancies
between the number of pills listed on the count
sheet and the actual number of pills present in
the facility;

-There have been discrepancies in the past
several weeks;

-Many staff have administered medications in the
past several weeks;

-Registered Nurses will be assigned to oversee
medication administration, controlled substance
count, and storage of medication at the facility.

Observation on 4/25/19 at approximately
11:00am revealed:

-Medication stored in a cabinet secured with a
large padlock. The medication cabinet is located
behind two locked closet doors.

Review on 4/26/19 of the Plan of Protection
completed by the Executive Director dated
4/26/19 revealed:

"What immediate action will the facility take to
ensure the safety of the consumers in your care?
-At the end of each day, either the Program
Manager or a staff assigned by Program Manager
will check to ensure that all medication counts are
accurate.

-All Charlotte Day Treatment staff will be training
in Medication Administration.

-Each classroom staff will be responsible for their
consumer's medication within their classroom.
One staff will give out the meds (medications),
and the other staff will back them up to ensure
counts are correct.

Describe your plans to make sure the above
happens.

-Once a week, RN (Registered Nurse) will check
medications, medication counts, and MAR
(Medication Administration Record) sheets to
ensure that everything meets protocol.

Division of Health Service Regulation

STATE FORM

6809

GNHM11

If continuation sheet 7 of 18

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: 05/09/2019
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
04/30/2019

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

PROVIDER'S PLAN OF CORRECTION (xs)
(EACH CORRECTIVE ACTION SHOULD BE. COMPLETE

CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

V 120] Continued From page 7

-lf counts are off, the nurse will immediately
report to the Program Manager and the Executive
Director and will complete an incident report."

Accurate count records and secure storage were
not maintained for controlled substance
medications resulting in multiple pills of Adderall,
Methylphenidate, Focalin, and Vyvanse being
unaccounted for. These medications were under
the control and responsibility of the facility and
were prescribed for the treatment of Attention
Deficit Hyperactivity Disorder for clients ranging
from 6 - 13 years old. The medications have a
high potential for diversion and misuse. The
clients were diagnosed with mental health needs
including, but not limited to, Attention Deficit
Hyperactivity Disorder, Oppositional Defiant
Disorder, Adjustment Disorder, and Autism
Spectrum Disorder. Missing controlled substance
medication is detrimental to the clients' health,
safety, and welfare in that only a limited amount
of controlled substance medications can be
dispensed each month. This deficiency
constitutes a Type B rule violation. If the violation
is not corrected within 45 days, an administrative
penalty of $200.00 per day will be imposed for
each day the facility is out of compliance beyond
the 45th day.

V 367] 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

Division of Health Service Regulation
STATE FORM

Vv 120

V 367

6809

GNHM11

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PRINTED: 05/09/2019

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 04/30/2019
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

to whom the provider rendered any service within
90 days prior to the incident to the LME
responsible for the catchment area where
services are provided within 72 hours of
becoming aware of the incident. The report shall
be submitted on a form provided by the
Secretary. The report may be submitted via mail,
in person, facsimile or encrypted electronic
means. The report shall include the following
information:

(1) reporting provider contact and
identification information;

(2) client identification information;

(3) type of incident;

(4) description of incident;

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

(6) other individuals or authorities notified

or responding.

(b) Category A and B providers shall explain any
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

Division of Health Service Regulation
STATE FORM

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If continuation sheet 9 of 18

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/09/2019
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL060968 04/30/2019
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

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

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

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

(2) restrictive interventions that do not meet
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 II incidents to the Local

Management Entity (LME) responsible for the

Division of Health Service Regulation
STATE FORM

6809

GNHM11

If continuation sheet 10 of 18

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/09/2019
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL060968 04/30/2019
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

catchment area where services are provided
within 72 hours of becoming aware of the
incident. The findings are:

Review on 4/24/19 of Client #6's record revealed:
-Admission date 12/6/18;

-Diagnoses of Disruptive Mood Dysregulation
Disorder, Attention Deficit Hyperactivity Disorder,
Major Depressive Disorder, Generalized Anxiety
Disorder, Persistent Depressive Disorder,
Borderline Intellectual Functioning;

-13 years old.

Review on 4/24/19 of Former Client #7's record
revealed:

-Admission date 7/9/18;

-Diagnoses of Nocturnal Enuresis, Other
Specified Trauma or Stressor Disorder, Attention
Deficit Hyperactivity Disorder, Borderline
Intellectual Developmental Disability, Disruptive
Mood Dysregulation Disorder;

- 11 years old.

Review on 4/23/19 of the facility's Incident
Reports revealed:

-Level | incident report dated 3/20/19 regarding
an incident of aggression and suicidal ideation for
Client #6 which resulted in a report to local law
enforcement;

-Level | incident report dated 3/6/19 regarding in
incident of aggression and assault for Former
Client #7 which resulted in a report to law
enforcement and returning the client to the
facility.

Interview on 4/25/19 with the Executive Director
revealed:

-Will make sure all Level Il incident reports are
completed as needed in the future;

-Did not realize the incident involving Former

Division of Health Service Regulation
STATE FORM

6809

GNHM11

If continuation sheet 11 of 18

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/09/2019
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL060968 04/30/2019
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
Client #7 needed to be completed as a Level II
incident;
-Had instructed the staff to complete a Level II
incident for Client #6. It must have been an
oversight that staff did not complete the Level II
report.
V 537] 27E .0108 Client Rights - Training in Sec Rest & V 537

ITO

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

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

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

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

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

Division of Health Service Regulation
STATE FORM

6809

GNHM11

If continuation sheet 12 of 18

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/09/2019
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL060968 04/30/2019
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 537] Continued From page 12 V 537

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

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

(g) Acceptable training programs shall include,
but are not limited to, presentation of:

(1) refresher information on alternatives to
the use of restrictive interventions;

(2) guidelines on when to intervene
(understanding imminent danger to self and
others);

(3) emphasis on safety and respect for the
rights and dignity of all persons involved (using
concepts of least restrictive interventions and
incremental steps in an intervention);

(4) strategies for the safe implementation
of restrictive interventions;
(5) the use of emergency safety

interventions which include continuous
assessment and monitoring of the physical and
psychological well-being of the client and the safe
use of restraint throughout the duration of the
restrictive intervention;

(6) prohibited procedures;

(7) debriefing strategies, including their
importance and purpose; and

(8) documentation methods/procedures.

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

(1) Documentation shall include:

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

(B) when and where they attended; and
(C) instructor's name.

Division of Health Service Regulation
STATE FORM

6809

GNHM11

If continuation sheet 13 of 18

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/09/2019
FORM APPROVED

(X3) DATE SURVEY

(2) The Division of MH/DD/SAS may
review/request this documentation at any time.
(i) Instructor Qualification and Training
Requirements:

need for restrictive interventions.

teaching the use of seclusion, physical restraint
and isolation time-out.

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

(4) 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 (j)(6) of this Rule.

of seclusion, physical restraint and isolation
time-out, as specified in Paragraph (a) of this
Rule.

(8) Trainers shall be currently trained in

Division of Health Service Regulation
STATE FORM

(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
by scoring 100% on testing in a training program

(3) Trainers shall demonstrate competence

competency-based, include measurable learning

observation of behavior) on those objectives and

(5) The content of the instructor training the

approved by the Division of MH/DD/SAS pursuant

(6) Acceptable instructor training programs
shall include, but not be limited to, presentation
of:

(A) understanding the adult learner;

(B) methods for teaching content of the
course;

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

(7) Trainers shall be retrained at least

annually and demonstrate competence in the use

6809

GNHM11

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL060968 04/30/2019
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 537 Continued From page 13 V 537

If continuation sheet 14 of 18

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/09/2019
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL060968 04/30/2019
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 537 Continued From page 14 V 537
CPR.
(9) Trainers shall have coached experience

in teaching the use of restrictive interventions at
least two times with a positive review by the
coach.

(10) Trainers shall teach a program on the
use of restrictive interventions at least once
annually.

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

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

(1) Documentation shall include:

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

(B) when and where they attended; and
(C) instructor's name.

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

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

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

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

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

This Rule is not met as evidenced by:

Based on interview and record review, facility
staff failed to display competency while
implementing physical restraints affecting 1 of 3
audited staff members (Staff #8). The findings
are:

Division of Health Service Regulation
STATE FORM

6809

GNHM11

If continuation sheet 15 of 18

Division of Health Service Regulation

PRINTED: 05/09/2019
FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
R
MHL060968 04/30/2019
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 537] Continued From page 15

Review on 4/24/19 of Client #1's record revealed:
-Admission date 3/4/19;

-Diagnoses of Obsessive Compulsive Disorder,
Other Specific Impulse Control and Conduct
Disorder, Unspecified Schizophrenia Spectrum
and Other Psychotic Disorder, Unspecified
Depression Disorder, Unspecified Attention
Hyperactivity Disorder;

-10 years old.

Interview on 4/25/19 with Client #1 revealed:
-Had not been restrained at the facility;

-Staff #1 grabbed him by the wrist and the neck
the day his most recent Child and Family Team
(CFT) meeting (4/12/19), but he was not grabbed
by his legs or feet.

Review on 4/22/19 of Staff #8's record revealed:
-Hire date 9/12/16;

-Employed as Mental Health Counselor;
-Completed training in Seclusion, Physical
Restraint and Isolation Time-Out on 6/25/18.

Review on 4/22/19 of Staff #9's record revealed:
-Hire date 2/25/19;

-Employed as Mental Health Counselor;
-Completed training in Seclusion, Physical
Restraint and Isolation Time-Out on 3/1/19.

Review on 4/24/19 of the Video Surveillance of
the facility for 4/12/19 at approximately 2:12 pm -
2:20pm revealed:

-2:12pm: Client #1 walked out of the classroom
and was redirected by staff back to the
classroom. Client #1 walked into a large storage
area inside the classroom;

-2:19pm: Staff #8 went to talk with Client #1;
-2:20pm: Staff #8 dragged Client #1 by the feet
out of the classroom storage area and into the

Division of Health Service Regulation
STATE FORM

V 537

6808 GNHM11

If continuation sheet 16 of 18

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/09/2019
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL060968 04/30/2019
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 537] Continued From page 16 V 537

actual classroom area. Staff #9 was at her side
but did not touch Client #1. Client #1 kicked and
attempted to fight with Staff #8. Within minutes,
Client #1 and Staff #8 calmly walked from the
classroom without incident.

Interview on 4/23/19 with Staff #8 revealed:
-Identified job responsibilities to include "provide
strategies and coping skills to manage behaviors
..remove kids when aggressive or upset to
process feelings on what is going on...;"

-Client #1 is an attention-seeking child who has a
history of self-harm, banging his head and
stomping his feet and has a hard time accepting
"NO;"

-When Client #1 was argumentative and upset
demanding to join his CFT meeting prior to the
team being ready, he became upset and refused
to move. Staff #8 "grabbed [Client #1] by his
upper arm and took him back to classroom;"
-Staff #8 and Staff #9 grabbed Client #1 by the
arms and "pulled [Client #1] out of the closet;"
-Client #1 eventually joined the CFT Meeting.

Interview on 4/23/19 with Staff #9 revealed:
-Identified job responsibilities to include "keep
clients in a safe environment and in compliance
with the rules;"

-Client #1 was looking to enter his CFT Meeting
and was upset that the rest of the CFT was not
ready for him to join, so Client #1 went into a
storage area for "quiet time" and refused to leave.
Client #1 began to tantrum and fell to the ground.
Staff #8 grabbed Client #1 by the arm and walked
to another classroom. Staff #9 denied touching
Client #1.

Interview on 4/25/19 with the Executive Director
revealed:
-Staff #8 was suspended regarding another

Division of Health Service Regulation
STATE FORM

6809

GNHM11

If continuation sheet 17 of 18

Division of Health Service Regulation

PRINTED: 05/09/2019

FORM APPROVED

matter;

-Staff #9 was coached regarding the incident;
-Staff will continue to be trained on appropriate
physical restraints.

Division of Health Service Regulation
STATE FORM

6809

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL060968 04/30/2019
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 537] Continued From page 17 V 537

If

continuation sheet 18 of 18


state: NC

facility_name: Alexander Youth Network - Charlotte Day Treatment

summary: Statement of Deficiency - MHLCS Complaint

raw_content:
PRINTED: 08/02/2018

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
Cc
MHL060968 08/02/2018
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

Acomplaint survey was completed on 8/2/18.
The complaint was unsubstantiated (Intake NC #
00141296). 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

KM2C11

TITLE (X6) DATE

If continuation sheet 1 of 1

inspection_type: MHLCS Complaint

document_type: Statement of Deficiency


summary: Statement of Deficiency - MHLCS Annual and Complaint

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: 05/16/2018

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

05/15/2018

(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
(EACH CORRECTIVE ACTION SHOULD BE.
CROSS-REFERENCED TO THE APPROPRIATE,
DEFICIENCY)

(xs)
COMPLETE
DATE

V 000!

Vv 131

INITIAL COMMENTS

An annual and complaint survey was completed
on 5/15/18. The complaint was unsubstantiated
(Intake NC # 00138222). A deficiency was 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.

G.S. 131E-256 (D2) HCPR - Prior Employment
Verification

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

(d2) Before hiring health care personnel into a
health care facility or service, every employer at a
health care facility shall access the Health Care
Personnel Registry and shall note each incident
of access in the appropriate business files.

This Rule is not met as evidenced by:

Based on interview and record review, the facility
failed to ensure that the Health Care Personnel
Registry (HCPR) be accessed and the results
documented prior to an offer of employment for
all employees affecting 1 of 5 audited staff
members (Program Manager). The findings are:

Review on 5/15/18 of the Program Manager's
record revealed:

-Hire date of 11/30/09;

-HCPR completed 12/04/09.

Interview on 5/15/18 with the Human Resource

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

STATE FORM

V 000

Vv 131

6899

DRZJ11

TITLE

(X6) DATE

If continuation sheet 1 of 2

PRINTED: 05/16/2018

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
MHL060968 05/15/2018
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 131] Continued From page 1 Vv 131

Associate revealed:

-The HCPR was completed late;

-It is the policy for all HCPR to be completed prior
to an offer of employment.

Division of Health Service Regulation
STATE FORM

6809

DRZJ11

If continuation sheet 2 of 2

inspection_type: MHLCS Annual and Complaint


summary: Plan of Correction - MHLCS Annual and Complaint

raw_content:
” STATE FORM

PRINTED: 05/16/2018

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
MHLo6ag968 B. WING. 05/15/2018

NAME OF PROVIDER OR SUPPLIER
ALEXANDER YOUTH NETWORK - CHARLOTTE DAYT

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

INITIAL COMMENTS

An annual and complaint survey was completed
on 5/15/18. The complaint was unsubstantiated
(Intake NC # 00138222). A deficiency was 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.

G.S. 131E-256 (D2) HCPR - Prior Employment
Verification

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

(d2) Before hiring health care personnel into a
health care facility or service, every employer at a
health care facility shall access the Health Care
Personnel Registry and shall note each incident
of access in the appropriate business files.

This Rule is not met as evidenced by:

Based on interview and record review, the facility
failed to ensure that the Health Care Personnel
Registry (HCPR) be accessed and the results
documented prior to an offer of employment for
all employees affecting 1 of 5 audited staff
members (Program Manager). The findings are:

Review on 5/15/18 of the Program Manager's
record revealed:

-Hire date of 11/30/09;

-HCPR completed 12/04/09.

Interview on 5/15/18 with the Human Resource
Division of Health Service Regulation

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

Vv 000

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

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

luman resources has since
implemented various auditing measures
to ensure all required pre-employment
background screens are completed prior
o hire. HR completes a double

erification process to hire- one that is
completed by HR Compliance
Associate and the other by the Director
lof HR or designee. The date and staff
initials are documented in the new

12/4/09

5899

V131 Jemployee checklist in their personnel
file.
DHSR - Mental Health
MAY 302018
Lic. & Cert. Section
TITLE (X6) DATE
DRZJ11 if continuation sheet 1 of 2

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
MHL060968

NAME OF PROVIDER OR SUPPLIER

ALEXANDER YOUTH NETWORK - CHARLOTTE DAYT

B. WING _

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING: _

PRINTED: 05/16/2018
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

05/15/2018

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

1D
PREFIX
TAG

V 131] Continued From page 1

Associate revealed:

-The HCPR was completed late;

-It is the policy for all HCPR to be completed prior
to an offer of employment.

V 131

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

IHuman resources has since
implemented various auditing measures
to ensure all required pre-employment
background screens are completed prior
to hire. HR completes a double
erification process to hire- one that is
ompleted by HR Compliance

Associate and the other by the Director
lof HR or designee. The date and staff
initials are documented in the new
employee checklist in their personnel

Division of Health Service Regulation
STATE FORM

6838

If continuation sheet 2 of 2

DR2J11

NC DEPARTMENT OF ROY COOPER - Governor

SEMAN SERV MANDY COHEN, MD,
HUMAN SERVICES MD, MPH * Secretary
Division of Health Service Regulation MARK PAYNE - Director

Mr. Leonard Shinhoster
Alexander Youth Network
6220 Thermal Road
Charlotte, NC 28211

May 17, 2018

Re: Annual and Complaint Survey completed May 15, 2018
Alexander Youth Network — Charlotte Day Treatment, 6220 Thermal Road, Charlotte, NC 28211
MHL # 060-968
E-mail Address: Ishinhoster@alexanderyouthnetwork.org;

bplummer@alexanderyouthnetwork.org
Intake #NC00138222

Dear Mr. Shinhoster:

Thank you for the cooperation and courtesy extended during the annual and complaint survey completed
May 15, 2018. The complaint was unsubstantiated.

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

Type of Deficiencies Found
e Standard level deficiency.

Time Frames for Compliance ;
e Standard level deficiency must be corrected within 60 days from the exit of the survey, which is
June 14, 2018.

What to include in the Plan of Correction

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

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

NC DEPARTMENT OF HEALTH AND HUMAN SERVICES « DIVISION OF HEALTH SERVICE REGULATION
MENTAL HEALTH LICENSURE AND CERTIFICATION SECTION

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

AN EQUAL OPPORTUNITY / AFFIRMATIVE ACTION EMPLOYER

s May 17, 2018
Alexander Youth Network
Mr. Leonard Shinhoster

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

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

A follow up visit will be conducted to verify all violations have been corrected. If we can be of further
assistance, please call Lynn Grier, Team Leader at 704-596-4072.

Sincerely,

CGileweey.

Eileen Sanchez, MA
Facility Compliance Consultant |
Mental Health Licensure-& Certification Section

Co: Rob Robinson, Director, Alliance Behavioral Health LME/MCO
Wes Knepper, Quality Management Director, Alliance Behavioral Health LME/MCO
Trey Sutten, Interim Director, Cardinal Innovations LME/MCO
Onika Wilson, Quality Management Director, Cardinal Innovations LME/MCO
Leza Wainwright, Director, Trillium Health Resources LME/MCO
Kim Keehn, Quality Management Director, Trillium Health Resources LME/MCO
Sarah Stroud, Director, Eastpointe LME/MCO
Jeanette Jordan-Huffam, Quality Management Director, Eastpointe LME/MCO
W. Rhett Melton, Director, Partners Behavioral Healthcare LME/MCO :
Selenna Moss, Quality Management Director, Partners Behavioral Healthcare LME/MCO
Victoria Whitt, Director, Sandhills Center LME/MCO
Carol Robertson, Quality Management Director, Sandhills Center LME/MCO
Brian Ingraham, Director, Vaya Health LME/MCO
Patty Wilson, Quality Management Director, Vaya Health LME/MCO

document_type: Plan of Correction


facility_name: Better Connections Midland Ct.

summary: Statement of Deficiency - MHLCS Annual

raw_content:
Division of Health Service Regulation

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

PRINTED: 09/16/2025
FORM APPROVED

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL074-195 B. WING 09/04/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
3309 MIDLAND COURT
BETTER CONNECTIONS MIDLAND CT GREENVILLE, NC 27833
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000) INITIAL COMMENTS V 000
An annual survey was completed September 4,
2025. No deficiencies were cited.
This facility is licensed for the following service
category 10A NCAC 27G .5600F Supervised
Living: Alternative Family Living in a Private
Residence.
The facility is licensed for 2 and has a current
census of 2. The survey sample consisted of
audits of 2 current clients.
Division of Health Service Regulation
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

STATE FORM

6899 SVKT11 If continuation sheet 1 of 1

inspection_type: MHLCS Annual


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

raw_content:
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES

(X1) PROVIDER/SUPPLIER/CLIA

PRINTED: 09/06/2024
FORM APPROVED

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL074-195 B. WING 09/05/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
3309 MIDLAND COURT
BETTER CONNECTIONS MIDLAND CT
GREENVILLE, NC 27833
(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 and follow up survey was completed
on September 5, 2024. No deficiencies were
cited.
This facility is licensed for the following service
category: 10A NCAC 27G .5600F Supervised
Living:Alternative Family Living in a Private
Residence.
This facility is licensed for 2 and has a current
census of 1. The survey sample consisted of
audits of 1 current client.
Division of Health Service Regulation
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

STATE FORM

6899 DT3Y11 If continuation sheet 1 of 1

inspection_type: MHLCS Annual and Follow-up


summary: Statement of Deficiency - MHLCS Annual

raw_content:
PRINTED: 03/06/2023
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA. (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
MHL074-195 B. WING _____ 02/22/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

3309 MIDLAND COURT

BETTER CONNECTIONS MIDLAND CT GREENVILLE, NC 27833

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

DEFICIENCY)
V 000} INITIAL COMMENTS V 000

An annual Survey was completed on February
22, 2023. A deficiency was cited.

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

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

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

10A NCAC 27G .0303 LOCATION AND
EXTERIOR REQUIREMENTS

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

This Rule is not met as evidenced by:

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

Observation on 2/22/23 at approximately
11:00am during tour of the facility revealed:
-Brown splatter on the wall above the trash can in
the kitchen.

-The blind to the back door had 6 broken slats.
-A window in the living room had a blind with 2
broken slats.

-Client #2 had dust on his wall.

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

STATE FORM 6899 YZ6011 If continuation sheet 1 of 2

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA

(X2) MULTIPLE CONSTRUCTION

PRINTED: 03/06/2023
FORM APPROVED

(X3) DATE SURVEY

Interview on 2/22/23 the Alternative Family Living
Staff stated he understood the facility had to be
maintained in a safe, clean, attractive and orderly
manner.

Interview on 2/22/23 the Qualified Professional
(QP) stated:
The issues would be addressed.

Division of Health Service Regulation

STATE FORM

6899

IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHLO074-195 B. WING 02/22/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
3309 MIDLAND COURT
BETTER CONNECTIONS MIDLAND CT
GREENVILLE, NC 27833
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 736 | Continued From page 1 V 736

YZ6011

If continuation sheet 2 of 2