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

raw_content:
PRINTED: 06/02/2021
FORM APPROVED

Division of Health Service Regulation

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

R
05/27/2021

MHL001-259

STREET ADDRESS, CITY, STATE, ZIP CODE
1227 WESTMORLAND DRIVE

NAME OF PROVIDER OR SUPPLIER

A MOTHER'S LOVE
BURLINGTON, NC 27215

(%4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE

DEFICIENCY)

(x5)
COMPLETE
| DATE

INITIAL COMMENTS

An annual, follow-up and complaint survey was

completed on May 27, 2021. The complaint (intake

#NC00176347) was substantiated. Deficiencies
cited.

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

| 27G .0205 (C-D)
| Assessment/Treatment/Habilitation Plan |

10A NCAC 27G .0205 = ASSESSMENT AND
TREATMENT/HABILITATION OR SERVICE
PLAN

(c) The plan shall be developed based on the
assessment, and in partnership with the client or |
legally responsible person or both, within 30 days of
admission for clients who are expected to receive
services beyond 30 days.

(d) The plan shall include:

(1) client outcome(s) that are anticipated to be
achieved by provision of the service and a projected
date of achievement;

(2) strategies;

(3) staff responsible;

(4) a schedule for review of the pian at least
annually in consultation with the client or legally
responsible person or both;

(8) basis for evaluation or assessment of
outcome achievement; and
(6) written consent or agreement by the client or

responsible party, or a written statement by the
provider stating why such consent could not be
obtained.

Division of Health Service Regulation

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER oP (A! 'S SpMaTURe 7) TITLE (X6) DATE el 7 {2
DbACEP Hed Shu
Med Mailed $ [lula

STATE FORM AEDCi1 if continuation sheet_14 of 19

DHSR - Mental Health

AUG 2 0 2021

Lic. & Cert. Section

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FORM APPROVED

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES. (1) PROVIDER/SUPPLIERICLIA | (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

t ATION NUMBE!
AND PLAN OF CORRECTION IDENTIFICATION NUMBER. ‘A. BUILDING: COMPLETED

R
MHL001-259 05/27/2021

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

1227 WESTMORLAND DRIVE
A MOTHER'S LOVE
BURLINGTON, NC 27215

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE

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

This Rule is not met as evidenced by: Based on 27G .0205 ASSESSMENT AND (tat
interviews and record review, the facility failed to TREATMENT/HABILITATION OR SERVICE

(a) complete an admission assessment for one of PLAN has been corrected and updated to
three audited clients (#1); and (b) include and meet the needs of consumers addressing their
implement strategies to address clients ability to Independent Living Skills and the ability to

earn money affecting two of three audited clients earn monies. Prior consent and written
(#1 and #2). The findings are: approval will be obtained from guardian.

All consumer upon admission will have an
assessment within 3 days of admission to the

(a)Review on 5/25/21 of Client #1's record
program.

revealed:
-Age 13. " ,

hee QP and Program Coordinator will assure
-Admission date of 11/20/20. a Person Centered Plans are revised and
-Diagnoses of Unspecified Depressive Disorder, updated every 30 days to assure consents to
Attention Deficit Hyperactivity Disorder, service needs of consumers. QP will met and
Combined Presentation and Unspecified Anxiety complete the Interpretive summary within 3
Disorder. days of admission for all consumers
-There was no assessment completed by the
facility in client's record.

Interview on 5/27/21 with the Director/Qualified
Professional #3 revealed:

-She was responsible for completing client's initial
assessment.

-She confirmed there was no facility assessment
in client #1's record.

(b)Review on 5/25/21 of Client #1's record
revealed:

| -Age 13.

-Admission date of 11/20/20.
-Diagnoses of Unspecified Depressive Disorder,
| Attention Deficit Hyperactivity Disorder,
Combined Presentation and Unspecified Anxiety
Disorder.

Division of Health Service Regulation
STATE FORM baz AEDC11 If continuation sheet 2 of 20

PRINTED: 06/02/2021
FORM APPROVED

Division of Health Service Regulation

(1) PROVIDER/SUPPLIERICLIA | (x2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

STATEMENT OF DEFICIENCIES.
IDENTIFICATION NUMBER: A. BUILDING: COMPLETED

AND PLAN OF CORRECTION

R

MHLO001-259 05/27/2021

STREET ADDRESS, CITY, STATE, ZIP CODE
1227 WESTMORLAND DRIVE

NAME OF PROVIDER OR SUPPLIER

A MOTHER'S LOVE

BURLINGTON, NC 27215

(x4) 1D | SUMMARY STATEMENT OF DEFICIENCIES ID

PREFIX | (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE
TAG | REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE

DEFICIENCY)

PROVIDER'S PLAN OF CORRECTION (x8)
COMPLETE
DATE

1
v M2) Continued From page 2 vite

-Treatment Plan completed 1/5/21 included the
following goals:

-| want to stay focused, "I want to be able to
focus more to make better decisions for myself.

-| want to improve my overall mood - over
the next 90 days client will demonstrate progress
with increasing her overall mood and how she
feels about herself and others by learning to use
coping skills.

-I want to work on my attitude and not go off
on people when they make me mad. Client will
learn to engage in age appropriate responses
when she does not get her way or is told no.
Client will learn and utilize "I" statements and
other positive communication skills to verbalize
| and process all emotions as need.

Review on 5/25/21 of Client #2's record revealed:
-Age 16.

| -Admission date of 10/24/18.

| -Diagnoses of Oppositional Defiant Disorder,
Major Depressive Disorder, Attention Deficit
Hyperactivity Disorder, Combined Presentation. -
Treatment Plan completed 10/18/20 included the
following goals:

-Client will use social and coping skills that
assist with resolving conflicts with peer relations
-Client will follow directives in the home,

school and community settings.

Interview on 5/25/21 with Client #1 revealed: -
She denied going to the Program Coordinator's
home.

-Staff took them out to eat, to the park and drove
around.

-Denied going to clean staff home.

-She told her therapist she went to the Program
Coordinator's home to clean.

-She told the therapist the Program Coordinator
paid her $15.00.

Division of Health Service Regulation
STATE FORM a AEDC11 If continuation sheet 3 of 20

PRINTED: 06/02/2021

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: COMPLETED
A. BUILDING:
R
MHLO001-259 B. WING 05/27/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1227 WESTMORLAND DRIVE
A MOTHER'S LOVE
BURLINGTON, NC 27215
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
Vv112 Vv 112

Continued From page 3

-She said it didn't happen. She stated, "| have a
weird imagination."

- "| just pretend things happen when they did
not."-She stated, "I now know it would get people in
trouble."

-She mentioned she imagine her barbie doll

| broke her leg.

-She talked to her doll.

-She could not describe what the Program
Coordinator's home looked like.

- "| don't know, it was just an imagination."

Interview on 5/25/21 with Client #2 revealed: -
| She confirmed she went to the Program
Coordinator's home to help clean.
- "It was like volunteer work to get her out the
house and bond with staff."
- "| like to clean."
-She helped pick up a couple of things in the
| house.
-She swept the floor.
-The program coordinator was also helping and
cleaning with her.
| -The program coordinator would reward her with
something to eat, cash and clothes.
-The program coordinator would get us things we
needed.
-She went to the program coordinator's home a
couple of times.
-She did not go to the house for a couple of
months. |
-She told her guardian and said the guardian did
not have a problem with it.

Interview on 5/26/21 with Client #1's Guardian
revealed

-She became client #1's social worker and
guardian in February 2020. |
-Client #1's therapist informed her that she went
to the program coordinator's home.

Division of Health Service Regulation
STATE FORM ees: AEDC11 If continuation sheet 4 of 20

PRINTED: 06/02/2021
FORM APPROVED
Division of Health Service Regulation

(x1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

(x3) DATE SURVEY

(X2) MULTIPLE CONSTRUCTION
COMPLETED

A, BUILDING:

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

R
05/27/2021

MIHL001-259

STREET ADDRESS, CITY, STATE, ZIP CODE
1227 WESTMORLAND DRIVE

NAME OF PROVIDER OR SUPPLIER

A MOTHER'S LOVE

BURLINGTON, NC 27215

(x4) ID | SUMMARY STATEMENT OF DEFICIENCIES i} PROVIDER'S PLAN OF CORRECTION (x6)
PREFIX | (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

| DEFICIENCY)

V 112) Continued From page 4

-She was not aware of the incident prior to client
#1 going to staff's house.

-She had a conversation with the
Director/Qualified Professional #4 on April 13,
2021.

-The conversation with the Director/QP #4
occurred after the incident.

-The group home tried to find creative ways to
allow client #1 to earn an allowance.

-The incident occurred once and some months
ago.

-She did not know the exact date of the
incident. -She thought it was unethical
practices. -She was informed it was not
happening anymore.

Interview on 5/26/21 with Client #2's Guardian

revealed: -She became client #2's guardian

over one year. -The judge approved home study

for client #2 to go the Director/QP #4's home for

a weekend. -It was being arranged the

Director/QP #4 would be client #2's guardian.

-Client #2 would go over on the weekends and

understand that it would be a different role.

-That owner would be a parental figure. -She

was not aware client #2 was going to the

program coordinator’s home to do chores.

-This would have to go through the judge.

-She was not aware client #2 went to the program

coordinator home to earn money.

-She knew client #2 had been wanting to earn

money.

-No one asked her about it or told her about it. -

As an incentive the group home would

compensate the clients for going over and

beyond. |

-If the group home had presented idea to her she
|

would have included it in the home study.

Division of Health Service Regulation
STATE FORM

esse AEDC11 If continuation sheet 5 of 20

PRINTED: 06/02/2021
FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES x4) PROVIDER/SUPPLIERICLIA | (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED

R

MHL001-259 05/27/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1227 WESTMORLAND DRIVE

A MOTHER'S LOVE
BURLINGTON, NC 27215

(%4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x8)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE:
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE:
DEFICIENCY)

Continued From page 5

Interview on 5/25/21 with the Program
Coordinator revealed:

-She worked ‘st shift from 7:00 a.m. - 3 p.m. -

| She admitted to taking client #1 and client #2 to
her home on different occasions.

| -She reported she wanted to give clients the
ability to earn money.

-Client #1 cleaned her home 1 time and client #2
about 3 times.

-Client's would sprinkle carpet fresh on the carpet
and vacuum, swept the kitchen floor, dust and
took out recycle garbage.

- "It was nothing more that client #1 and client #2
did.

| -She provided opportunity to let clients earn cash. -
| The clients were at her home about 1 % or 2 hours
| when they were there.

-She paid client #1 and client #2 $15.00 and
provided lunch.

-She reported client #1 and client #2 agreed. -
Confirmed she did not get approval from the
guardians.

-Client #1's guardian learn of the situation from
her therapist.

-Clients wanted some way to make money. -

| The allowance the facility gave clients was from
$5 and up to $15.00 but based on behaviors.
-Clients had to "level up" to get more money. -
The facility allowance was based on completion
of chores, schoolwork, positive interaction and
no lying and stealing.

-This was during Covid and clients wanted to get
out the house.

-She stopped months ago and when client #1
guardian thought it was a problem.

Interview on 5/26/21 with the Director/Qualified
Professional #3 revealed:

-They tried to get a little creative for clients to
earn extra money.

Division of Health Service Regulation
STATE FORM sss AEDC11 if continuation sheet 6 of 20

PRINTED: 06/02/2021
FORM APPROVED
Division of Health Service Regulation

(x1) PROVIDER/SUPPLIERICLIA | (X2) MULTIPLE CONSTRUCTION
ICATION NI
IDENTIFICATION NUMBER: A. BUILDING:

(X3) DATE SURVEY
COMPLETED

‘STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

R
05/27/2021

MHL001-259

STREET ADDRESS, CITY, STATE, ZIP CODE
1227 WESTMORLAND DRIVE

NAME OF PROVIDER OR SUPPLIER

A MOTHER'S LOVE
BURLINGTON, NC 27216

(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES iP) 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)

Vv 112 | . v112
| Continued From page 6

-During Covid they couldn't get jobs. -It was

one or two weekends the program

coordinator took client #1 and client #2 to

the home.

-Client #1's guardian learned about the situation

through her therapist.

-Client #1 was excited to get out the house and

earn and few dollars.

-Client #2 was given permission to go outside the

home a lot more.

-She did not think the guardians were aware

beforehand.

-She explained the situation to client #1's

guardian.

-Client #1 went one time.

-They just decided it was not a good idea.

-They discussed it during the staff meetings. -

They brought it up at the next staff meeting once

they received the call from client #1s guardian. -

She met with the program coordinator individually

afterwards.

-They also had a staff meeting that following

Thursday.

-She confirmed she knew the program

coordinator took client #1 and client #2 to her

| home.

-She thought it would not be okay if client #1 and

| client #2 was not paid.

| -The facility facilitated other activities for clients to

| earn money and now did not know what was
acceptable.

Interview on 5/26/21 with the Director/QP #4
revealed:

-Clients wanted to do things during Covid.

-They tried to get creative with the clients.

| -They took clients on trips before Covid.

| She learned about client#1 going to the program
| coordinator's home when she received an email

| from the guardian.

Division of Health Service Regulation

STATE FORM 8900 AEDC11 If continuation sheet 7 of 20

PRINTED: 06/02/2021
FORM APPROVED

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (x1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A, BUILDING:

R
05/27/2021

MHLO001-259

STREET ADDRESS, CITY, STATE, ZIP CODE
1227 WESTMORLAND DRIVE

NAME OF PROVIDER OR SUPPLIER

A MOTHER'S LOVE
BURLINGTON, NC 27215

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

DEFICIENCY)

v112 ; vi1i2
| Continued From page 7 |
|
-Client #1 told her therapist she went to the

program coordinator's home to help prepare for
an event.
-The program coordinator paid client #1.
-She did not think it was a big deal.
-She stopped it once she communicated with the
client #1's guardian.
-Client #1 went to the program coordinator's
home one time.
-She was not aware of that client #2 went to the
program coordinators home.
-She knew client #2 was with the program
| coordinator during outings.
-She tried to give clients time with staff on a one-on-
one basis.
| -Client #2 was approved to go to day events. -
The moment she found out about the incident
| with client #1 she stopped it.
-She met with the program coordinator
| individually.
| -She addressed the incident during the staff
meeting the following Thursday after receiving the
email.

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

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

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

a. Neglect or abuse of a resident in a healthcare
facility or a person to whom home care services
as defined by G.S. 131E-136 or hospice services
as defined by G.S. 131E-201 are being provided.

Division of Health Service Regulation
STATE FORM sno AEDC11

If continuation sheet 8 of 20

PRINTED: 06/02/2021
FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES x1) PROVIDER/SUPPLIERICLIA | (%2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

IDENTIFI
AND PLAN OF CORRECTION IDE! 'ICATION NUMBER: A. BUILDING: COMPLETED

R
MHL001-259 05/27/2021

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

1227 WESTMORLAND DRIVE
A MOTHER'S LOVE
BURLINGTON, NC 27215

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

Continued From page 8

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.

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

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

| This Rule is not met as evidenced by:

Based on record review and interview, the facility
failed to assure an allegation of exploitation was
reported to the Health Care Personal Registry
(HCPR). The findings are:

Division of Health Service Regulation
STATE FORM 0508 AEDC11 If continuation sheet 9 of 20

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Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (x1) PROVIDER/SUPPLIER/CLIA | (X2) MULTIPLE CONSTRUCTION
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING

(X3) DATE SURVEY
COMPLETED

R
05/27/2021

MHLO001-259

STREET ADDRESS, CITY, STATE, ZIP CODE
1227 WESTMORLAND DRIVE

NAME OF PROVIDER OR SUPPLIER

A MOTHER'S LOVE
BURLINGTON, NC 27215

(%4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION
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 V 132 G.S. §131E-256 HEALTH CARE

Gontifiied From’page 8 PERSONNEL REGISTRY will receive a report | (o/ (7/21
| Review on 5/25/21 of Client #1's record revealed: on allegations of exploitations from the facility

-Age 13. when any allegations is made on a staff

-Admission date of 11/20/20. member for exploitation on any consumer.

-Diagnoses of Unspecified Depressive Disorder,
Attention Deficit Hyperactivity Disorder,

Combined Presentation and Unspecified Anxiety
Disorder.

Director and QP will assure the allegations and
of exploitation are investigated and reported to
the HCPR as required.

Review on 5/25/21 of Client #2’s record revealed:
-Age 16.

-Admission date of 10/24/18.

-Diagnoses of Oppositional Defiant Disorder,
Major Depressive Disorder, Attention Deficit

| Hyperactivity Disorder, Combined Presentation.

Review on 5/25/21 of the Complaint dated 4/3/21
revealed:

- "[{Client #1] reported that the [Program
Coordinator] took [Client #1] and another [Client
#2] to their home and paid [Client #1] and [Client
#2] $15.00 to clean. [Client #1] and [Client #2]
reported [Client #1] and [Client #2] volunteered to
clean."

- "The [Director/Qualified Professional] was
notified and reported that [Client #1] and [Client #2]
could work and volunteer to earn money when
supervised by the [Director/Qualified
Professional] and [Program Coordinator]. The
chores were minimal and not strenuous."

-The facility did not report the allegation to HCPR.

Interview on 5/27/21 with the Director/Qualified
Professional #3 revealed:

-She was responsible for notifying HCPR.
-She did not understand the problem with client's
earning funds.

-She reported the goal was to improve clients
independent living skills and self-esteem. |
-The facility facilitated other activities for clients to
earn money and now did not know what was

Division of Health Service Regulation
STATE FORM ene: AEDC11 if continuation sheet 10 of 20

PRINTED: 06/02/2021
FORM APPROVED
Division of Health Service Regulation

(x1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

(X3) DATE SURVEY

(X2) MULTIPLE CONSTRUCTION
COMPLETED

A. BUILDING:

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

R
05/27/2021

MHL001-259

STREET ADDRESS, CITY, STATE, ZIP CODE
1227 WESTMORLAND DRIVE

NAME OF PROVIDER OR SUPPLIER

A MOTHER'S LOVE
BURLINGTON, NC 27215

(X4) 1D SUMMARY STATEMENT OF DEFICIENCIES: 1D PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE BATE

DEFICIENCY)

V 132
Continued From page 10

acceptable.
-She confirmed the allegation was not reported to
HCPR.

V 133) V 133
G.S. 122C-80 Criminal History Record Check

G.S. §122C-80 CRIMINAL HISTORY RECORD
CHECK REQUIRED FOR CERTAIN
APPLICANTS FOR EMPLOYMENT.

(a) Definition. - As used in this section, the
term "provider" applies to an area authority/county
program and any provider of mental health,
developmental disability, and substance abuse
services that is licensable under Article 2 of this
Chapter.

(b) Requirement. - An offer of employment by
a provider licensed under this Chapter to an
applicant to fill a position that does not require the
applicant to have an occupational license is
conditioned on consent to a State and national
criminal history record check of the applicant. If the
applicant has been a resident of this State for less |
than five years, then the offer of employment is |
conditioned on consent to a State and national
criminal history record check of the applicant. The
national criminal history record check shall include
a check of the applicant's fingerprints. If the
applicant has been a resident of this State for five
years or more, then the offer is conditioned on
consent to a State criminal history record check of
the applicant. A provider shall not employ an
applicant who refuses to consent to a criminal
history record check required by this section.
Except as otherwise provided in this subsection,
within five business days of making the
conditional offer of employment, a provider shall
submit a request to the Department of Justice
under G.S. 114-19.10 to conduct a criminal history
record check required by this

Division of Health Service Regulation
STATE FORM ee AEDC11 If continuation sheet 11 of 20

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Division of Health Service Regulation

STATEMENT OF DEFICIENCIES. (x1) PROVIDER/SUPPLIERICLIA | (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED

A, BUILDING:

R

MHLO001-259 05/27/2021

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

1227 WESTMORLAND DRIVE
A MOTHER'S LOVE
BURLINGTON, NC 27215

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

Vv 133/ Continued From page 11

| section or shall submit a request to a private

_ entity to conduct a State criminal history record

| check required by this section. Notwithstanding

G.S. 114-19.10, the Department of Justice shall

return the results of national criminal history

record checks for employment positions not

covered by Public Law 105-277 to the

| Department of Health and Human Services,

| Criminal Records Check Unit. Within five

business days of receipt of the national criminal

history of the person, the Department of Health

and Human Services, Criminal Records Check

| Unit, shall notify the provider as to whether the

| information received may affect the employability

of the applicant. In no case shall the results of

the national criminal history record check be

| shared with the provider. Providers shall make

| available upon request verification that a criminal
history check has been completed on any staff

| covered by this section. A county that has

| adopted an appropriate local ordinance and has
access to the Division of Criminal Information
data bank may conduct on behalf of a provider a

| State criminal history record check required by

this section without the provider having to submit

a request to the Department of Justice. In such a

case, the county shall commence with the State

criminal history record check required by this

section within five business days of the

conditional offer of employment by the provider.

All criminal history information received by the

provider is confidential and may not be disclosed,

except to the applicant as provided in subsection

(c) of this section. For purposes of this

subsection, the term “private entity" means a

business regularly engaged in conducting

criminal history record checks utilizing public

records obtained from a State agency.

(c) Action. - If an applicant's criminal history

Division of Health Service Regulation
STATE FORM ne AEDC11 if continuation sheet 12 of 20

PRINTED: 06/02/2021
FORM APPROVED
Division of Health Service Regulation

(x1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

STATEMENT OF DEFICIENCIES.
AND PLAN OF CORRECTION

R
05/27/2021

MHL001-259

STREET ADDRESS, CITY, STATE, ZIP CODE
1227 WESTMORLAND DRIVE

NAME OF PROVIDER OR SUPPLIER

A MOTHER'S LOVE
BURLINGTON, NC 27215

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

DEFICIENCY)

Continued From page 12

record check reveals one or more convictions of
a relevant offense, the provider shall consider all
of the following factors in determining whether to
hire the applicant:

(1) The level and seriousness of the crime.
(2) The date of the crime.

(3) The age of the person at the time of the
conviction.

(4) The circumstances surrounding the
commission of the crime, if known.

(5) The nexus between the criminal conduct
of the person and the job duties of the position to
be filled.

(6) The prison, jail, probation, parole,
rehabilitation, and employment records of the
person since the date the crime was committed.
(7) The subsequent commission by the
person of a relevant offense.

The fact of conviction of a relevant offense alone
shall not be a bar to employment; however, the
listed factors shall be considered by the provider.
If the provider disqualifies an applicant after
consideration of the relevant factors, then the
provider may disclose information contained in

| the criminal history record check that is relevant
to the disqualification, but may not provide a copy
of the criminal history record check to the
applicant.

(d) Limited Immunity. - A provider and an officer
or employee of a provider that, in good faith,
complies with this section shall be immune from
civil liability for:

(1) The failure of the provider to employ an
individual on the basis of information provided in
the criminal history record check of the individual.
(2) Failure to check an employee's history of
criminal offenses if the employee's criminal
history record check is requested and received in
compliance with this section.

Division of Health Service Regulation
STATE FORM tee AEDC11 If continuation sheet 13 of 20

PRINTED: 06/02/2021
FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (x1) PROVIDER/SUPPLIER/CLIA | (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

ITIFICATI 4
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED

R

MHL001-259 05/27/2021

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

1227 WESTMORLAND DRIVE
A MOTHER'S LOVE
BURLINGTON, NC 27215

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE

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

Continued From page 13

(e) Relevant Offense. - As used in this section,
“relevant offense" means a county, state, or
federal criminal history of conviction or pending
indictment of a crime, whether a misdemeanor or
felony, that bears upon an individual's fitness to
have responsibility for the safety and well-being of
persons needing mental health, developmental
disabilities, or substance abuse services. These
crimes include the criminal offenses set forth in
any of the following Articles of Chapter 14 of the
General Statutes: Article 5, Counterfeiting and
Issuing Monetary Substitutes; Article 5A,
Endangering Executive and Legislative Officers;

| Article 6, Homicide; Article 7A, Rape and Other
Sex Offenses; Article 8, Assaults; Article 10,
Kidnapping and Abduction; Article 13, Malicious
Injury or Damage by Use of Explosive or
Incendiary Device or Material; Article 14, Burglary
and Other Housebreakings; Article 15, Arson and
Other Burnings; Article 16, Larceny; Article 17,
Robbery; Article 18, Embezzlement; Article 19,
False Pretenses and Cheats; Article 19A,
Obtaining Property or Services by False or
Fraudulent Use of Credit Device or Other Means;
Article 19B, Financial Transaction Card Crime
Act; Article 20, Frauds; Article 21, Forgery; Article
26, Offenses Against Public Morality and
Decency; Article 26A, Adult Establishments;
Article 27, Prostitution; Article 28, Perjury; Article
29, Bribery; Article 31, Misconduct in Public
Office; Article 35, Offenses Against the Public
Peace; Article 36A, Riots and Civil Disorders;
Article 39, Protection of Minors; Article 40,
Protection of the Family; Article 59, Public
Intoxication; and Article 60, Computer-Related
Crime. These crimes also include possession or
sale of drugs in violation of the North Carolina
Controlled Substances Act, Article 5 of Chapter
90 of the General Statutes, and alcohol-related

Division of Health Service Regulation
STATE FORM = AEDC11 If continuation sheet 14 of 20

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES x1) PROVIDER/SUPPLIERICLIA

AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

MHL001-259

NAME OF PROVIDER OR SUPPLIER

PRINTED: 06/02/2021
FORM APPROVED

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

1227 WESTMORLAND DRIVE

A MOTHER'S LOVE

(X%4) ID
PREFIX
TAG

BURLINGTON, NC 27215

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

Continued From page 14

offenses such as sale to underage persons in
violation of G.S. 18B-302 or driving while
impaired in violation of G.S. 20-138.1 through
GS. 20-138.5.

(f) Penalty for Furnishing False Information. -
Any applicant for employment who willfully
furnishes, supplies, or otherwise gives false
information on an employment application that is
the basis for a criminal history record check
under this section shall be guilty of a Class A1

| misdemeanor. (g) Conditional Employment. - A

provider may employ an applicant conditionally

| prior to obtaining the results of a criminal history

record check regarding the applicant if both of
the following requirements are met:

(1) The provider shall not employ an applicant
prior to obtaining the applicant's consent for
criminal history record check as required in
subsection (b) of this section or the completed
fingerprint cards as required in G.S. 114-19.10.
(2) The provider shall submit the request for a
criminal history record check not later than five
business days after the individual begins
conditional employment. (2000-154, s. 4; 2001-

| 155, s. 1; 2004-124, ss. 10.19D(c), (h);

2005-4, ss. 1, 2, 3, 4, 5(a); 2007-444, s. 3.)

This Rule is not met as evidenced by:

Based on record review and interview, the facility
failed to ensure the state criminal record check
was ordered within five business days of making
the conditional offer of employment for the
Program Coordinator. The findings are:

Review on 5/27/21 of Program Coordinator's

Division of Health Service Regulation

STATE FORM

e869

AEDC11

COMPLETED

R
05/27/2021

STREET ADDRESS, CITY, STATE, ZIP CODE

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

\f continuation sheet 15 of 20

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1)
AND PLAN OF CORRECTION

PROVIDER/SUPPLIERI/CLIA
IDENTIFICATION NUMBER:

MHLO001-259

NAME OF PROVIDER OR SUPPLIER

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 06/02/2021
FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R

05/27/2021

STREET ADDRESS, CITY, STATE, ZIP CODE

1227 WESTMORLAND DRIVE

A MOTHER'S LOVE

(X4) ID
PREFIX
TAG

BURLINGTON, NC 27215

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

Continued From page 15

personnel record revealed:
- Hire date: 8/3/20.
| - There criminal record check was order 8/20/20.

| Interview on 6/27/21 with the Director/Qualified

| Professional #3 revealed:
-She completed background checks for all new
employees.

| -She confirmed the Program Coordinator's

| criminal record check was ordered after hired
date.

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

27G .0604 Incident Reporting Requirements

10A NCAC 27G .0604 = INCIDENT
REPORTING REQUIREMENTS FOR
CATEGORY A AND 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 II!
incidents and level Il deaths involving the clients
to whom the provider rendered any service within
| 90 days prior to the incident to the LME
| responsible for the catchment area where
| services are provided within 72 hours of
| becoming aware of the incident. The report shall
| be submitted on a form provided by the
| Secretary. The report may be submitted via mail,
_ in person, facsimile or encrypted electronic
| means. The report shall include the following
| information:
| (1) reporting provider contact and identification
| information;
| (2) client identification information;

(3) type of incident;

Division of Health Service Regulation

STATE FORM

8808

AEDC11

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

G.S. 122C-80 Criminal History Record Check

Criminal History Background checks are to
be conducted prior to hiring (within 5 days
of making an conditional offer of
employment. This processed is to ensure
the safety of consumers.

QP will carry out the responsibility of
criminal background checks on all new
hires as required.

(x5)
COMPLETE
DATE

6/17/2021

if continuation sheet 16 of 20

PRINTED: 06/02/2021
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

R

MHL001-259 05/27/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1227 WESTMORLAND DRIVE

A MOTHER'S LOVE
BURLINGTON, NC 27215

(4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE

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

Continued From page 16 27G .0604 Incident Reporting Requirements —_| 6/17/2021

(4) description of incident; sig a
(5) status of the effort to determine the cause eee sche eae ees ane are to
of the incident; and x : the Local Managed Entity/Managed Care
(6) other individuals or authorities notified or Organization (LME/MCO) within 72 hours. This
responding: is to provide full disclosure for the safety of
(b) Category A and B providers shall explain any members.
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 II! incident reports to the Division of
Mental Health, Developmental Disabilities and
Substance Abuse Services within 72 hours of
becoming aware of the incident. Category A
providers shall send a copy of all level III
incidents involving a client death to the Division
of Health Service Regulation within 72 hours of
becoming aware of the incident. In cases of
client death within seven days of use of seclusion
or restraint, the provider shall report the death
immediately, as required by 10A NCAC 26C
.0300 and 10A NCAC 27E .0104(e)(18). (e)
Category A and B providers shall send a report
quarterly to the LME responsible for the
catchment area where services are provided.

Division of Health Service Regulation
STATE FORM sess AEDC11 If continuation sheet 17 of 20

PRINTED: 06/02/2021
FORM APPROVED
Division of Health Service Regulation

(x1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

R
05/27/2021

MHL001-259

STREET ADDRESS, CITY, STATE, ZIP CODE
1227 WESTMORLAND DRIVE

NAME OF PROVIDER OR SUPPLIER

A MOTHER'S LOVE
BURLINGTON, NC 27215

(x5)
COMPLETE

PROVIDER'S PLAN OF CORRECTION

SUMMARY STATEMENT OF DEFICIENCIES.

(EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE
REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

Continued From page 17

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

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

(2) restrictive interventions that do not meet the
definition of a level I! or level Ill 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 || and level II!
incidents that occurred; and
(6) a statement indicating that there have been

no reportable incidents whenever no incidents have
occurred during the quarter that meet any of the

criteria as set forth in Paragraphs (a) and (d) of this |
Rule and Subparagraphs (1) through (4) of this | |
Paragraph. | |

This Rule is not met as evidenced by:

Based on record review and interview the facility
failed to ensure a Level II incident report was
completed and submitted to the Local Managed
Entity/Managed Care Organization (LME/MCO) |
within 72 hours. The findings are:

Review on 5/26/21 of Client #1's record revealed:
-Age 13.

-Admission date of 11/20/20.

-Diagnoses of Unspecified Depressive Disorder,
Attention Deficit Hyperactivity Disorder,
Combined Presentation and Unspecified Anxiety
Disorder.

Division of Health Service Regulation

STATE FORM 6099 AEDC11 if continuation sheet 18 of 20

PRINTED: 06/02/2021
FORM APPROVED

Division of Health Service Regulation

(x1) PROVIDER/SUPPLIERICLIA | (X2) MULTIPLE CONSTRUCTION
IDENTIFICATION NUMBER: A. BUILDING:

(X3) DATE SURVEY
COMPLETED

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

R
05/27/2021

MHL001-259

STREET ADDRESS, CITY, STATE, ZIP CODE
1227 WESTMORLAND DRIVE

NAME OF PROVIDER OR SUPPLIER

A MOTHER'S LOVE
BURLINGTON, NC 27215

SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION
PREFIX (BACH 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 a
DEFICIENCY)

Continued From page 18

Review on 5/25/21 of Client #2's record revealed:
-Age 16.

-Admission date of 10/24/18.

-Diagnoses of Oppositional Defiant Disorder,
Major Depressive Disorder, Attention Deficit
Hyperactivity Disorder, Combined Presentation.

Review on 5/25/21 of the Complaint dated

4/13/21 revealed:

- "[Client #1] reported that the [Program
Coordinator] took [Client #1] and another [Client
#2] to their home and paid [Client #1] and [Client
#2] $15.00 to clean. [Client #1] and [Client #2]
reported [Client #1] and [Client #2] volunteered to
clean.”

- "The [Director/Qualified Professional] was
notified and reported that [Client #1] and [Client #2]
could work and volunteer to earn money when
supervised by the [Director/Qualified |
Professional] and [Program Coordinator]. The |
chores were minimal and not strenuous." -The
facility did not complete an incident report. |

Interview on §/27/21 with the Director/Qualified
Professional #3 revealed:

-She was responsible for completing incident
reports.

-She did not understand the problem with client's
earning funds.

-She reported the goal was to improve clients
independent living skills and self-esteem.

-The facility facilitated other activities for clients to
earn money and now did not know what was.
acceptable.

-She confirmed an incident report was not
completed.

Division of Health Service Regulation
STATE FORM ose AEDC11 If continuation sheet 19 of 20

NC "ALTH AND OF ROY COOPER + Governor

’ HEALT MANDY COHEN, MD, MPH = Secretar
, s y
HEMAN PS ANICES ; so ;
MARK PAYNE » Director, Division of Health Service Regulation

June 3, 2021

Ms. Edith Ward, Director

New Possibilities Home for Children, LLC
813 Trail One

Burlington, NC 27215

Re: Annual, Follow-up and Complaint Survey completed May 27, 2021
A Mother's Love, 1227 Westmoreland Drive, Burlington, NC 27215
MHL #001-259

E-mail Address: newpossibilitieshfc@gmail.com
Intake #NC00176347

Dear Ms. Edith Ward:

Thank you for the cooperation and courtesy extended during the annual, follow-up and
complaint survey completed May 27, 2021. The complaint was substantiated.

As a result of the follow-up survey, it was determined that some of the deficiencies are
now in compliance, which is reflected on the enclosed Revisit Report. Additional
deficiencies was cited during the survey.

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

Type of Deficiencies Found

e Re-cited standard level deficiency.
e All other tags cited are standard level deficiencies.

Time Frames for Compliance

e Re-cited standard level deficiency must be corrected within 30 days from the
exit of the survey, which is June 26, 2021.

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

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

AN EQUAL OPPORTUNITY / AFFIRMATIVE ACTION EMPLOYER

June 3, 2021

A Mother's Love

Ms. Edith Ward, Director

e Standard level deficiencies must be corrected within 60 days from the exit of the
survey, which is July 26, 2021.

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.).

e Indicate what measures will be put in place to prevent the problem from
occurring again.

e Indicate who will monitor the situation to ensure it will not occur again.

e Indicate how often the monitoring will take place.

e Sign and date the bottom of the first page of the State Form.

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

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

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

A follow-up visit will be conducted to verify all violations have been corrected. If we can
be of further assistance, please call Bryson Brown, Team Leader at 919-855-3822.

Sincerely,

Frets Hehe

Frances E. Hicks, MSW
Facility Compliance Consultant |
Mental Health Licensure & Certification Section

Cc: qmemail@cardinalinnovations.org
DHSR@Alliancebhc.org
QM@partnersbhm.org
Pam Pridgen, Administrative Assistant

inspection_type: MHLCS Annual, Complaint, and Follow-up


state: NC

facility_name: A Mother's Love

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

raw_content:
Division of Health Service Regulation

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

MHL001-259

NAME OF PROVIDER OR SUPPLIER

1227 WESTI

A MOTHER'S LOVE

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

BURLINGTON, NC 27215

PRINTED: 06/02/2021

STREET ADDRESS, CITY, STATE, ZIP CODE
MORLAND DRIVE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R
05/27/2021

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

ID
PREFIX
TAG

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

(xs)
COMPLETE
DATE

V 000} INITIAL COMMENTS

An annual, follow-up and complaint survey was
completed on May 27, 2021. The complaint
(intake #NC00176347) was substantiated.
Deficiencies cited.

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

V 112] 27G .0205 (C-D)
Assessment/Treatment/Habilitation Plan

10A NCAC 27G .0205 ASSESSMENT AND
TREATMENT/HABILITATION OR SERVICE
PLAN

(c) The plan shall be developed based on the
assessment, and in partnership with the client or
legally responsible person or both, within 30 days
of admission for clients who are expected to
receive services beyond 30 days.

(d) The plan shall include:

(1) client outcome(s) that are anticipated to be
achieved by provision of the service and a
projected date of achievement;

(2) strategies;

(3) staff responsible;

(4) aschedule for review of the plan at least
annually in consultation with the client or legally
responsible person or both;

(5) basis for evaluation or assessment of
outcome achievement; and

(6) written consent or agreement by the client or
responsible party, or a written statement by the
provider stating why such consent could not be
obtained.

V 000

Vv 112

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

STATE FORM

6808 AEDC11

TITLE

(X6) DATE

If continuation sheet 1 of 19

Division of Health Service Regulation

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

MHL001-259

NAME OF PROVIDER OR SUPPLIER

1227 WESTI

A MOTHER'S LOVE

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

BURLINGTON, NC 27215

PRINTED: 06/02/2021

STREET ADDRESS, CITY, STATE, ZIP CODE
MORLAND DRIVE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

R
05/27/2021

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 112] Continued From page 1 Vv 112

This Rule is not met as evidenced by:

Based on interviews and record review, the
facility failed to (a) complete an admission
assessement for one of three audited clients (#1);
and (b) include and implement strategies to
address clients ability to earn money affecting two
of three audited clients (#1 and #2). The findings
are:

(a)Review on 5/25/21 of Client #1's record
revealed:

-Age 13.

-Admission date of 11/20/20.

-Diagnoses of Unspecified Depressive Disorder,
Attention Deficit Hyperactivity Disorder,
Combined Presentation and Unspecified Anxiety
Disorder.

-There was no assessment completed by the
facility in client's record.

Interview on 5/27/21 with the Director/Qualified
Professional #3 revealed:

-She was responsible for completing client's initial
assessment.

-She confirmed there was no facility assessment
in client #1's record.

(b)Review on 5/25/21 of Client #1's record
revealed:

-Age 13.

-Admission date of 11/20/20.

-Diagnoses of Unspecified Depressive Disorder,
Attention Deficit Hyperactivity Disorder,
Combined Presentation and Unspecified Anxiety
Disorder.

Division of Health Service Regulation
STATE FORM

6809

AEDC11

If continuation sheet 2 of 19

Division of Health Service Regulation

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

MHL001-259

NAME OF PROVIDER OR SUPPLIER

A MOTHER'S LOVE

PRINTED: 06/02/2021

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

STREET ADDRESS, CITY, STATE, ZIP CODE
1227 WEST!

MORLAND DRIVE

BURLINGTON, NC 27215

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R
05/27/2021

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 112] Continued From page 2 Vv 112

-Treatment Plan completed 1/5/21 included the
following goals:

-| want to stay focused, "I want to be able to
focus more to make better decisions for myself.

-| want to improve my overall mood - over the
next 90 days client will demonstrate progress with
increasing her overall mood and how she feels
about herself and others by learning to use
coping skills.

-| want to work on my attitude and not go off
on people when they make me mad. Client will
learn to engage in age appropriate responses
when she does not get her way or is told no.
Client will learn and utilize "I" statements and
other positive communication skills to verbalize
and process all emotions as need.

Review on 5/25/21 of Client #2's record revealed:
-Age 16.

-Admission date of 10/24/18.

-Diagnoses of Oppositional Defiant Disorder,
Major Depressive Disorder, Attention Deficit
Hyperactivity Disorder, Combined Presentation.
-Treatment Plan completed 10/18/20 included the
following goals:

-Client will use social and coping skills that
assist with resolving conflicts with peer relations
-Client will follow directives in the home,

school and community settings.

Interview on 5/25/21 with Client #1 revealed:
-She denied going to the Program Coordinator's
home.

-Staff took them out to eat, to the park and drove
around.

-Denied going to clean staff home.

-She told her therapist she went to the Program
Coordinator's home to clean.

-She told the therapist the Program Coordinator
paid her $15.00.

Division of Health Service Regulation
STATE FORM

6808 AEDC11

If continuation sheet 3 of 19

Division of Health Service Regulation

PRINTED: 06/02/2021
FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
R
MHL001-259 05/27/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1227 WESTMORLAND DRIVE
A MOTHER'S LOVE
BURLINGTON, NC 27215
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

V 112] Continued From page 3

-She said it didn't happen. She stated, "| have a
weird imagination."

- "| just pretend things happen when they did not."
-She stated, "| now know it would get people in
trouble."

-She mentioned she imagine her barbie doll
broke her leg.

-She talked to her doll.

-She could not describe what the Program
Coordinator's home looked like.

- "| don't know, it was just an imagination."

Interview on 5/25/21 with Client #2 revealed:
-She confirmed she went to the Program
Coordinator's home to help clean.

- "It was like volunteer work to get her out the
house and bond with staff."

-"Llike to clean."

-She helped pick up a couple of things in the
house.

-She swept the floor.

-The program coordinator was also helping and
cleaning with her.

-The program coordinator would reward her with
something to eat, cash and clothes.

-The program coordinator would get us things we
needed.

-She went to the program coordinator's home a
couple of times.

-She did not go to the house for a couple of
months.

-She told her guardian and said the guardian did
not have a problem with it.

Interview on 5/26/21 with Client #1's Guardian
revealed:

-She became client #1's social worker and
guardian in February 2020.

-Client #1's therapist informed her that she went
to the program coordinator's home.

Vv 112

Division of Health Service Regulation
STATE FORM

6808 AEDC11

If continuation sheet 4 of 19

Division of Health Service Regulation

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

MHL001-259

(X2) MULTIPLE CONSTRUCTION

A. BUILDING:

PRINTED: 06/02/2021

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

1227 WESTI

A MOTHER'S LOVE

MORLAND DRIVE

BURLINGTON, NC 27215

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R
05/27/2021

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 112] Continued From page 4 Vv 112

-She was not aware of the incident prior to client
#1 going to staff's house.

-She had a conversation with the
Director/Qualified Professional #4 on April 13,
2021.

-The conversation with the Director/QP #4
occurred after the incident.

-The group home tried to find creative ways to
allow client #1 to earn an allowance.

-The incident occurred once and some months
ago.

-She did not know the exact date of the incident.
-She thought it was unethical practices.

-She was informed it was not happening
anymore.

Interview on 5/26/21 with Client #2's Guardian
revealed:

-She became client #2's guardian over one year.
-The judge approved home study for client #2 to
go the Director/QP #4's home for a weekend.

-It was being arranged the Director/QP #4 would
be client #2's guardian.

-Client #2 would go over on the weekends and
understand that it would be a different role.
-That owner would be a parental figure.

-She was not aware client #2 was going to the
program coordinator's home to do chores.

-This would have to go through the judge.

-She was not aware client #2 went to the program
coordinator home to earn money.

-She knew client #2 had been wanting to earn
money.

-No one asked her about it or told her about it.
-As an incentive the group home would
compensate the clients for going over and
beyond.

-lf the group home had presented idea to her she
would have included it in the home study.

Division of Health Service Regulation
STATE FORM

6808 AEDC11

If continuation sheet 5 of 19

Division of Health Service Regulation

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

MHL001-259

NAME OF PROVIDER OR SUPPLIER

A MOTHER'S LOVE

PRINTED: 06/02/2021

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

STREET ADDRESS, CITY, STATE, ZIP CODE
1227 WEST!

MORLAND DRIVE

BURLINGTON, NC 27215

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R
05/27/2021

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 112) Continued From page 5 Vv 112

Interview on 5/25/21 with the Program
Coordinator revealed:

-She worked ‘st shift from 7:00 a.m. - 3 p.m.
-She admitted to taking client #1 and client #2 to
her home on different occasions.

-She reported she wanted to give clients the
ability to earn money.

-Client #1 cleaned her home 1 time and client #2
about 3 times.

-Client's would sprinkle carpet fresh on the carpet
and vacuum, swept the kitchen floor, dust and
took out recycle garbage.

- "It was nothing more that client #1 and client #2
did.

-She provided opportunity to let clients earn cash.
-The clients were at her home about 1 % or 2
hours when they were there.

-She paid client #1 and client #2 $15.00 and
provided lunch.

-She reported client #1 and client #2 agreed.
-Confirmed she did not get approval from the
guardians.

-Client #1's guardian learn of the situation from
her therapist.

-Clients wanted some way to make money.

-The allowance the facility gave clients was from
$5 and up to $15.00 but based on behaviors.
-Clients had to "level up" to get more money.
-The facility allowance was based on completion
of chores, schoolwork, positive interaction and no
lying and stealing.

-This was during Covid and clients wanted to get
out the house.

-She stopped months ago and when client #1
guardian thought it was a problem.

Interview on 5/26/21 with the Director/Qualified
Professional #3 revealed:

-They tried to get a little creative for clients to
earn extra money.

Division of Health Service Regulation
STATE FORM

6808 AEDC11

If continuation sheet 6 of 19

PRINTED: 06/02/2021

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
MHL001-259 05/27/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1227 WESTMORLAND DRIVE
A MOTHER'S LOVE
BURLINGTON, NC 27215
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 112] Continued From page 6 Vv 112

-During Covid they couldn't get jobs.

-It was one or two weekends the program
coordinator took client #1 and client #2 to the
home.

-Client #1's guardian learned about the situation
through her therapist.

-Client #1 was excited to get out the house and
earn and few dollars.

-Client #2 was given permission to go outside the
home a lot more.

-She did not think the guardians were aware
beforehand.

-She explained the situation to client #1's
guardian.

-Client #1 went one time.

-They just decided it was not a good idea.

-They discussed it during the staff meetings.
-They brought it up at the next staff meeting once
they received the call from client #1s guardian.
-She met with the program coordinator
individually afterwards.

-They also had a staff meeting that following
Thursday.

-She confirmed she knew the program
coordinator took client #1 and client #2 to her
home.

-She thought it would not be okay if client #1 and
client #2 was not paid.

-The facility facilitated other activities for clients to
earn money and now did not know what was
acceptable.

Interview on 5/26/21 with the Director/QP #4
revealed:

-Clients wanted to do things during Covid.

-They tried to get creative with the clients.

-They took clients on trips before Covid.

-She learned about client#1 going to the program
coordinator's home when she received an email
from the guardian.

Division of Health Service Regulation
STATE FORM

6809

AEDC11

If continuation sheet 7 of 19

Division of Health Service Regulation

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

MHL001-259

(X2) MULTIPLE CONSTRUCTION

A. BUILDING:

PRINTED: 06/02/2021

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

1227 WESTI

A MOTHER'S LOVE

MORLAND DRIVE

BURLINGTON, NC 27215

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R
05/27/2021

(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 112] Continued From page 7

-Client #1 told her therapist she went to the
program coordinator's home to help prepare for
an event.

-The program coordinator paid client #1.

-She did not think it was a big deal.

-She stopped it once she communicated with the
client #1's guardian.

-Client #1 went to the program coordinator's
home one time.

-She was not aware of that client #2 went to the
program coordinator's home.

-She knew client #2 was with the program
coordinator during outings.

-She tried to give clients time with staff on a
one-on-one basis.

-Client #2 was approved to go to day events.
-The moment she found out about the incident
with client #1 she stopped it.

-She met with the program coordinator
individually.

-She addressed the incident during the staff
meeting the following Thursday after receiving the
email.

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

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

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

a. Neglect or abuse of a resident in a healthcare
facility or a person to whom home care services
as defined by G.S. 131E-136 or hospice services
as defined by G.S. 131E-201 are being provided.

Division of Health Service Regulation
STATE FORM

Vv 112

V 132

6808 AEDC11

If continuation sheet 8 of 19

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL001-259

A MOTHER'S LOVE

(X2) MULTIPLE CONSTRUCTION

A. BUILDING:

MORLAND DRIVE

BURLINGTON, NC 27215

PRINTED: 06/02/2021

STREET ADDRESS, CITY, STATE, ZIP CODE
1227 WEST!

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R
05/27/2021

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

c. Misappropriation of the property of a
healthcare facility.

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

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

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

This Rule is not met as evidenced by:

Based on record review and interview, the facility
failed to assure an allegation of exploitation was
reported to the Health Care Personal Registry
(HCPR). The findings are:

Division of Health Service Regulation
STATE FORM

6808 AEDC11

(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 8 V 132

If continuation sheet 9 of 19

Division of Health Service Regulation

PRINTED: 06/02/2021
FORM APPROVED

Review on 5/25/21 of Client #1's record revealed:
-Age 13.

-Admission date of 11/20/20.

-Diagnoses of Unspecified Depressive Disorder,
Attention Deficit Hyperactivity Disorder,
Combined Presentation and Unspecified Anxiety
Disorder.

Review on 5/25/21 of Client #2's record revealed:
-Age 16.

-Admission date of 10/24/18.

-Diagnoses of Oppositional Defiant Disorder,
Major Depressive Disorder, Attention Deficit
Hyperactivity Disorder, Combined Presentation.

Review on 5/25/21 of the Complaint dated 4/3/21
revealed:

- "[Client #1] reported that the [Program
Coordinator] took [Client #1] and another [Client
#2] to their home and paid [Client #1] and [Client
#2] $15.00 to clean. [Client #1] and [Client #2]
reported [Client #1] and [Client #2] volunteered to
clean."

- "The [Director/Qualified Professional] was
notified and reported that [Client #1] and [Client
#2] could work and volunteer to earn money when
supervised by the [Director/Qualified
Professional] and [Program Coordinator]. The
chores were minimal and not strenuous."

-The facility did not report the allegation to HCPR.

Interview on 5/27/21 with the Director/Qualified
Professional #3 revealed:

-She was responsible for notifying HCPR.

-She did not understand the problem with client's
earning funds.

-She reported the goal was to improve clients
independent living skills and self-esteem.

-The facility facilitated other activities for clients to
earn money and now did not know what was

Division of Health Service Regulation

STATE FORM

6808 AEDC11

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL001-259 05/27/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1227 WESTMORLAND DRIVE
A MOTHER'S LOVE
BURLINGTON, NC 27215
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 132] Continued From page 9 V 132

If continuation sheet 10 of 19

Division of Health Service Regulation

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

MHL001-259

(X2) MULTIPLE CONSTRUCTION

A. BUILDING:

PRINTED: 06/02/2021

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

1227 WESTI

A MOTHER'S LOVE

MORLAND DRIVE

BURLINGTON, NC 27215

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R
05/27/2021

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 132] Continued From page 10 V 132
acceptable.
-She confirmed the allegation was not reported to
HCPR.
V 133] G.S. 122C-80 Criminal History Record Check V 133

G.S. §122C-80 CRIMINAL HISTORY RECORD
CHECK REQUIRED FOR CERTAIN
APPLICANTS FOR EMPLOYMENT.

(a) Definition. - As used in this section, the term
"provider" applies to an area authority/county
program and any provider of mental health,
developmental disability, and substance abuse
services that is licensable under Article 2 of this
Chapter.

(b) Requirement. - An offer of employment by a
provider licensed under this Chapter to an
applicant to fill a position that does not require the
applicant to have an occupational license is
conditioned on consent to a State and national
criminal history record check of the applicant. If
the applicant has been a resident of this State for
less than five years, then the offer of employment
is conditioned on consent to a State and national
criminal history record check of the applicant. The
national criminal history record check shall
include a check of the applicant's fingerprints. If
the applicant has been a resident of this State for
five years or more, then the offer is conditioned
on consent to a State criminal history record
check of the applicant. A provider shall not
employ an applicant who refuses to consent to a
criminal history record check required by this
section. Except as otherwise provided in this
subsection, within five business days of making
the conditional offer of employment, a provider
shall submit a request to the Department of
Justice under G.S. 114-19.10 to conduct a
criminal history record check required by this

Division of Health Service Regulation
STATE FORM

6808 AEDC11

If continuation sheet 11 of 19

Division of Health Service Regulation

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

MHL001-259

(X2) MULTIPLE CONSTRUCTION

A. BUILDING:

PRINTED: 06/02/2021

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

1227 WESTI

A MOTHER'S LOVE

MORLAND DRIVE

BURLINGTON, NC 27215

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R
05/27/2021

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 133] Continued From page 11 V 133

section or shall submit a request to a private
entity to conduct a State criminal history record
check required by this section. Notwithstanding
G.S. 114-19.10, the Department of Justice shall
return the results of national criminal history
record checks for employment positions not
covered by Public Law 105-277 to the
Department of Health and Human Services,
Criminal Records Check Unit. Within five
business days of receipt of the national criminal
history of the person, the Department of Health
and Human Services, Criminal Records Check
Unit, shall notify the provider as to whether the
information received may affect the employability
of the applicant. In no case shall the results of the
national criminal history record check be shared
with the provider. Providers shall make available
upon request verification that a criminal history
check has been completed on any staff covered
by this section. A county that has adopted an
appropriate local ordinance and has access to
the Division of Criminal Information data bank
may conduct on behalf of a provider a State
criminal history record check required by this
section without the provider having to submit a
request to the Department of Justice. In such a
case, the county shall commence with the State
criminal history record check required by this
section within five business days of the
conditional offer of employment by the provider.
All criminal history information received by the
provider is confidential and may not be disclosed,
except to the applicant as provided in subsection
(c) of this section. For purposes of this
subsection, the term "private entity" means a
business regularly engaged in conducting
criminal history record checks utilizing public
records obtained from a State agency.

(c) Action. - If an applicant's criminal history

Division of Health Service Regulation
STATE FORM

6808 AEDC11

If continuation sheet 12 of 19

Division of Health Service Regulation

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

MHL001-259

(X2) MULTIPLE CONSTRUCTION

A. BUILDING:

PRINTED: 06/02/2021

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

1227 WESTI

A MOTHER'S LOVE

MORLAND DRIVE

BURLINGTON, NC 27215

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R
05/27/2021

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 133] Continued From page 12 V 133

record check reveals one or more convictions of
a relevant offense, the provider shall consider all
of the following factors in determining whether to
hire the applicant:

(1) The level and seriousness of the crime.

(2) The date of the crime.

(3) The age of the person at the time of the
conviction.

(4) The circumstances surrounding the
commission of the crime, if known.

(5) The nexus between the criminal conduct of
the person and the job duties of the position to be
filled.

(6) The prison, jail, probation, parole,
rehabilitation, and employment records of the
person since the date the crime was committed.
(7) The subsequent commission by the person of
a relevant offense.

The fact of conviction of a relevant offense alone
shall not be a bar to employment; however, the
listed factors shall be considered by the provider.
If the provider disqualifies an applicant after
consideration of the relevant factors, then the
provider may disclose information contained in
the criminal history record check that is relevant
to the disqualification, but may not provide a copy
of the criminal history record check to the
applicant.

(d) Limited Immunity. - A provider and an officer
or employee of a provider that, in good faith,
complies with this section shall be immune from
civil liability for:

(1) The failure of the provider to employ an
individual on the basis of information provided in
the criminal history record check of the individual.
(2) Failure to check an employee's history of
criminal offenses if the employee's criminal
history record check is requested and received in
compliance with this section.

Division of Health Service Regulation
STATE FORM

6808 AEDC11

If continuation sheet 13 of 19

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL001-259

1227 WESTI

A MOTHER'S LOVE

(X2) MULTIPLE CONSTRUCTION

A. BUILDING:

MORLAND DRIVE

BURLINGTON, NC 27215

PRINTED: 06/02/2021

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R
05/27/2021

(e) Relevant Offense. - As used in this section,
"relevant offense" means a county, state, or
federal criminal history of conviction or pending
indictment of a crime, whether a misdemeanor or
felony, that bears upon an individual's fitness to
have responsibility for the safety and well-being of
persons needing mental health, developmental
disabilities, or substance abuse services. These
crimes include the criminal offenses set forth in
any of the following Articles of Chapter 14 of the
General Statutes: Article 5, Counterfeiting and
Issuing Monetary Substitutes; Article 5A,
Endangering Executive and Legislative Officers;
Article 6, Homicide; Article 7A, Rape and Other
Sex Offenses; Article 8, Assaults; Article 10,
Kidnapping and Abduction; Article 13, Malicious
Injury or Damage by Use of Explosive or
Incendiary Device or Material; Article 14, Burglary
and Other Housebreakings; Article 15, Arson and
Other Burnings; Article 16, Larceny; Article 17,
Robbery; Article 18, Embezzlement; Article 19,
False Pretenses and Cheats; Article 19A,
Obtaining Property or Services by False or
Fraudulent Use of Credit Device or Other Means;
Article 19B, Financial Transaction Card Crime
Act; Article 20, Frauds; Article 21, Forgery; Article
26, Offenses Against Public Morality and
Decency; Article 26A, Adult Establishments;
Article 27, Prostitution; Article 28, Perjury; Article
29, Bribery; Article 31, Misconduct in Public
Office; Article 35, Offenses Against the Public
Peace; Article 36A, Riots and Civil Disorders;
Article 39, Protection of Minors; Article 40,
Protection of the Family; Article 59, Public
Intoxication; and Article 60, Computer-Related
Crime. These crimes also include possession or
sale of drugs in violation of the North Carolina
Controlled Substances Act, Article 5 of Chapter
90 of the General Statutes, and alcohol-related

Division of Health Service Regulation
STATE FORM

6809

AEDC11

(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 133] Continued From page 13 V 133

If continuation sheet 14 of 19

Division of Health Service Regulation

PRINTED: 06/02/2021
FORM APPROVED

offenses such as sale to underage persons in
violation of G.S. 18B-302 or driving while
impaired in violation of G.S. 20-138.1 through
G.S. 20-138.5.

(f) Penalty for Furnishing False Information. - Any
applicant for employment who willfully furnishes,
supplies, or otherwise gives false information on
an employment application that is the basis for a
criminal history record check under this section
shall be guilty of a Class A1 misdemeanor.

(g) Conditional Employment. - A provider may
employ an applicant conditionally prior to
obtaining the results of a criminal history record
check regarding the applicant if both of the
following requirements are met:

(1) The provider shall not employ an applicant
prior to obtaining the applicant's consent for
criminal history record check as required in
subsection (b) of this section or the completed
fingerprint cards as required in G.S. 114-19.10.
(2) The provider shall submit the request for a
criminal history record check not later than five
business days after the individual begins
conditional employment. (2000-154, s. 4;
2001-155, s. 1; 2004-124, ss. 10.19D(c), (h);
2005-4, ss. 1, 2, 3, 4, 5(a); 2007-444, s. 3.)

This Rule is not met as evidenced by:

Based on record review and interview, the facility
failed to ensure the state criminal record check
was ordered within five business days of making
the conditional offer of employment for the
Program Coordinator. The findings are:

Review on 5/27/21 of Program Coordinator's

Division of Health Service Regulation

STATE FORM

6808 AEDC11

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL001-259 05/27/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1227 WESTMORLAND DRIVE
A MOTHER'S LOVE
BURLINGTON, NC 27215
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 133] Continued From page 14 V 133

If continuation sheet 15 of 19

Division of Health Service Regulation

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

MHL001-259

(X2) MULTIPLE CONSTRUCTION

A. BUILDING:

PRINTED: 06/02/2021

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

1227 WESTI

A MOTHER'S LOVE

MORLAND DRIVE

BURLINGTON, NC 27215

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R
05/27/2021

(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 133] Continued From page 15

personnel record revealed:
- Hire date: 8/3/20.
- There criminal record check was order 8/20/20.

Interview on 5/27/21 with the Director/Qualified
Professional #3 revealed:

-She completed background checks for all new
employees.

-She confirmed the Program Coordinator's
criminal record check was ordered after hired
date.

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

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
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;

Division of Health Service Regulation
STATE FORM

V 133

V 367

6808 AEDC11

If continuation sheet 16 of 19

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL001-259

1227 WESTI

A MOTHER'S LOVE

(X2) MULTIPLE CONSTRUCTION

A. BUILDING:

MORLAND DRIVE

BURLINGTON, NC 27215

PRINTED: 06/02/2021

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R
05/27/2021

(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
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.

Division of Health Service Regulation
STATE FORM

6809

AEDC11

(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 16 V 367

If continuation sheet 17 of 19

Division of Health Service Regulation

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

MHL001-259

NAME OF PROVIDER OR SUPPLIER

1227 WESTI

A MOTHER'S LOVE

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

BURLINGTON, NC 27215

PRINTED: 06/02/2021

STREET ADDRESS, CITY, STATE, ZIP CODE
MORLAND DRIVE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

R
05/27/2021

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 367 | Continued From page 17 V 367

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 record review and interview the facility
failed to ensure a Level II incident report was
completed and submitted to the Local Managed
Entity/Managed Care Organization (LME/MCO)
within 72 hours. The findings are:

Review on 5/25/21 of Client #1's record revealed:
-Age 13.

-Admission date of 11/20/20.

-Diagnoses of Unspecified Depressive Disorder,
Attention Deficit Hyperactivity Disorder,
Combined Presentation and Unspecified Anxiety
Disorder.

Division of Health Service Regulation
STATE FORM

6809

AEDC11

If continuation sheet 18 of 19

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL001-259

1227 WESTI

A MOTHER'S LOVE

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

BURLINGTON, NC 27215

PRINTED: 06/02/2021

STREET ADDRESS, CITY, STATE, ZIP CODE
MORLAND DRIVE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

R
05/27/2021

Review on 5/25/21 of Client #2's record revealed:
-Age 16.

-Admission date of 10/24/18.

-Diagnoses of Oppositional Defiant Disorder,
Major Depressive Disorder, Attention Deficit
Hyperactivity Disorder, Combined Presentation.

Review on 5/25/21 of the Complaint dated
4/13/21 revealed:

- "[Client #1] reported that the [Program
Coordinator] took [Client #1] and another [Client
#2] to their home and paid [Client #1] and [Client
#2] $15.00 to clean. [Client #1] and [Client #2]
reported [Client #1] and [Client #2] volunteered to
clean."

- "The [Director/Qualified Professional] was
notified and reported that [Client #1] and [Client
#2] could work and volunteer to earn money when
supervised by the [Director/Qualified
Professional] and [Program Coordinator]. The
chores were minimal and not strenuous."

-The facility did not complete an incident report.

Interview on 5/27/21 with the Director/Qualified
Professional #3 revealed:

-She was responsible for completing incident
reports.

-She did not understand the problem with client's
earning funds.

-She reported the goal was to improve clients
independent living skills and self-esteem.

-The facility facilitated other activities for clients to
earn money and now did not know what was
acceptable.

-She confirmed an incident report was not
completed.

Division of Health Service Regulation
STATE FORM

6809

AEDC11

(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 18 V 367

If continuation sheet 19 of 19

document_type: Statement of Deficiency