summary: Plan of Correction - MHLCS Annual and Complaint

raw_content:
PRINTED: 05/15/2024
FORM APPROVED

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (%1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED
MHL011-203 B. WING 05/13/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
REUTER COTIAGE 111 COMPTON DRIVE
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE | DATE
DEFICIENCY) |
V.000 INITIAL COMMENTS Vv 000 V114 - Correction - Residential |
Director will initiate fire and disaster |
An annual and complaint survey was completed drills in the current quarter during |
on May 13, 2024. The complaint was each shift |
| substantiated (Intake #NC00216640). A
| deficiency was cited. V114 - Prevention - Quality Assurance
Jo mm ; Manager will create a calendar with
| This facility is licensed for the following service automated reminders prompting fire
category: 10A NCAC 27G .1700 Residential and disaster drills with a minimum of
Treatment Staff Secure for Children or once per shift per quarter.

| Adolescents.
V114 - Monitoring - Quality Assurance
Manager will have reminders from the
automated calendar system to review
that a fire or disaster drill was
completed. Additionally, once per

|

| This facility is licensed for 6 and has a current
| census of 6. The survey sample consisted of

| audits of 4 current clients.

V 114 27G .0207 Emergency Plans and Supplies Vv 114 quarter, the Quality Assurance
Manager will complete an audit of the

10A NCAC 27G .0207 EMERGENCY PLANS record of fire and disaster drills. Any
AND SUPPLIES deficiencies found in internal
(a) Awritten fire plan for each facility and monitoring will be followed-up with a
area-wide disaster plan shall be developed and plan of correction.
shall be approved by the appropriate local
authority.

(b) The plan shall be made available to all staff |
and evacuation procedures and routes shall be |
posted in the facility.

(c) Fire and disaster drills in a 24-hour facility
shall be held at least quarterly and shall be
repeated for each shift. Drills shall be conducted
under conditions that simulate fire emergencies.
(d) Each facility shall have basic first aid supplies
accessible for use.

RECEIVED
JUL U8 2024

This Rule is not met as evidenced by: DHSR-MH Licensure Sect
Based on interviews and record reviews, the
facility failed to hold fire and disaster drills at least
Division of Health Service Regulation
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

STATE FORM anne SPU611 tf continuation sheet 1 of 2

PRINTED: 05/15/2024
FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: REBUILDING COMPLETED

MHL011-203 BEWING 05/13/2024

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

111 COMPTON DRIVE
ASHEVILLE, NC 28806

(x4) 1D Ty SUMMARY STATEMENT OF DEFICIENCIES ID ] PROVIDER'S PLAN OF CORRECTION (xs)

REUTER COTTAGE

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

Vv 114 Continued From page 1 v114

quarterly for each shift. The findings are:

Review on 5/7/24 and 5/8/24 of the facility's fire
and disaster drill log revealed:

-No documentation of fire drills on first shift for
third quarter 2023 (July-September).

-No documentation of fire drills on first shift for

_ fourth quarter 2023 (October-December).

_ -No documentation of fire drills on first shift for

_ first quarter 2024 (January-March).

-No documentation the clients were present for
disaster drills on first shift for third and fourth |
quarter 2023 (July-December). |

Interview on 5/9/24 with the Residential
Supervisor revealed:

-Staff determined when fire drills were completed. |
-Was responsible to make sure drills were
completed.

Interview on 5/13/24 with the Residential Director
revealed:

-"| make sure they (fire drills) are done."
-"Documenting that it (disaster drills) is happening
on campus but not necessarily in the cottage."

Interview on 5/13/24 with the Chief Compliance |
Officer revealed:

-Was the responsibility of the Residential Director
to make sure drills were completed correctly.
-The Quality Assurance Manager would check the
fire and disaster drill logs.

Interview on 5/13/24 with the Quality Assurance
Manager revealed:
-Disaster drills were completed even if no clients
were present.in the. facility.

| -Would alternate who was responsible for

| completing the fire drills.

Division of Health Service Regulation

STATE FORM ose SPUG11 If continuation sheet 2 of 2


state: NC

facility_name: Reuter Cottage

raw_content:
PRINTED: 05/15/2024
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

MHL011-203 8. WING 05/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
411 COMPTON DRIVE
ASHEVILLE, NC 28806
(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)
——
INITIAL COMMENTS 114 - Correction - Residential
Director will initiate fire and disaster
An annual and complaint survey was completed drills in the current quarter during
on May 13, 2024. The complaint was each shift.
substantiated (Intake #NC00216640). A
deficiency was cited.

REUTER COTTAGE

V114 - Prevention - Quality Assurance
Manager will create a calendar with
autornated reminders prompting fire
and disaster drills with a minimum of
once per shift per quarter.

This facility is licensed for the following service
category: 10A NCAC 27G .1700 Residential
Treatment Staff Secure for Children or
Adolescents.

V114 - Monitoring - Quality Assurance
Manager will have reminders from the
automated calendar system to review
that a fire or disaster drill was
completed. Additionally, once per
27G .0207 Emergency Plans and Supplies quarter, the Quality Assurance

Manager will complete an audit of the
10A NCAC 27G .0207 EMERGENCY PLANS record of fire and disaster drills. Any

AND SUPPLIES

(a) Awritten fire plan for each facility and
area-wide disaster plan shall be developed and
shall be approved by the appropriate local
authority.

(b) The plan shall be made available to all staff
and evacuation procedures and routes shall be
posted in the facility.

(c) Fire and disaster drills in a 24-hour facility
shail be held at least quarterly and shall be
repeated for each shift. Drills shall be conducted
under conditions that simulate fire emergencies.
({d) Each facility shall have basic first aid supplies
accessible for use.

This facility is licensed for 6 and has a current
; census of 6, The survey sample consisted of
audits of 4 current clients.

deficiencies found in internal
monitoring will be followed-up with a
plan of correction.

This Rule is not met as evidenced by:
Based on interviews and record reviews, the
facility failed to hold fire and disaster drills at least

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

STATE FORM sag SPU611 if continuation sheet 1 of 2

Division of Health Service R

STATEMENT OF DEFICIENCIES:
AND PLAN OF CORRECTION

(X41) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHL011-203

(X2) MULTIPLE CONSTRUCTION

A. BUILDING:

B, WING

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE
111 COMPTON DRIVE

REUTER COTTAGE
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX |
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG

Continued From page 1

quarterly for each shift. The findings are:

Review on 5/7/24 and 5/8/24 of the facility's fire
| and disaster drill log revealed:

-No documentation of fire drills on first shift for
third quarter 2023 (July-September).

| -No documentation of fire drills on first shift for
| fourth quarter 2023 (October-December).

-No documentation of fire drills on first shift for
first quarter 2024 (January-March).

-No documentation the clients were present for
disaster drills on first shift for third and fourth
quarter 2023 (July-December).

Interview on 5/9/24 with the Residential
Supervisor revealed:

-Staff determined when fire drills were completed.
-Was responsible to make sure drills were
completed.

Interview on 5/13/24 with the Residential Director
revealed:

-"| make sure they (fire drills) are done."
"Documenting that it (disaster drills) is happening
on campus but not necessarily in the cottage.”

Interview on 5/13/24 with the Chief Compliance
Officer revealed:

-Was the responsibility of the Residential Director
to make sure drills were completed correctly.
-The Quality Assurance Manager would check the
fire and disaster drill logs.

Interview on 5/13/24 with the Quality Assurance
Manager revealed:

-Disaster drills were completed even if no clients
were present in the facility.

-Would alternate who was responsible for
completing the fire drills.

v114

PRINTED: 05/15/2024
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

05/13/2024

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

DEFICIENCY)

Division of Health Service Regulation
STATE FORM

e809 SPU611

If continuation sheet 2 of 2

PRINTED: 05/15/2024
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

MHLO011-443 8. WING 05/13/2024

NAME OF PROVIDER OR SUPPLIER,

STREET ADDRESS, CITY, STATE, ZIP CODE

882 ELIADA HOME ROAD

ELIADA TREATMENT CENTER

(x4) 1D
PREFIX
TAG

ASHEVILLE, NC 28806

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

Vv 000,

INITIAL COMMENTS

An annual survey was completed on May 13,
2024. Deficiencies were cited.

The facility is licensed for the following service
category: 10A NCAC 27G .1700 Residential
Treatment Staff Secure for Children and
Adolescents.

This facility is licensed for 8 and has a current
census of 4. The survey sample consisted of
audits of 2 current clients and 1 former client.

27G .0207 Emergency Plans and Supplies

410A NCAC 27G .0207 EMERGENCY PLANS
AND SUPPLIES

(a) A written fire plan for each facility and
area-wide disaster plan shail be developed and
shall be approved by the appropriate local
authority.

(b) The pian shall be made available to all staff
and evacuation procedures and routes shall be
posted in the facility.

(c) Fire and disaster drills in a 24-hour facility
shall be held at least quarterly and shall be
repeated for each shift. Drills shall be conducted
under conditions that simulate fire emergencies.
(d) Each facility shall have basic first aid supplies
accessible for use.

This Rule is not met as evidenced by:

Based on record reviews and interviews, the
facility failed to hold fire and disaster drills at least
quarterly for each shift. The findings are:

Division of Health Service Regulation

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

STATE FORM

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

339

V114 - Correction - Residential Director
will initiate fire and disaster drills in the
current quarter during each shift.

V114 - Prevention - Quality Assurance
Manager will create a calendar with
automated reminders prompting fire and
disaster drills with a minimum of once
per shift per quarter.

V114 - Monitoring - Quality Assurance
Manager will have reminders from the
automated calendar system to review
that a fire or disaster drill was
completed. Additionally, once per
quarter, the Quality Assurance Manager
will complete an audit of the record of
fire and disaster drills. Any deficiencies
found in internal monitoring will be
followed-up with a plan of correction.

V131 - Correction - PQI Department
Staff will complete an audit of staff files
and HR Staff will complete registries for
any found to be deficient.

V131 - Prevention - Chief Compliance
Officer will create a process map of the
hiring/onboarding process with the HR
Recruiter with the registries included as
astep. Training will be completed by
the PQI and HR department heads to
ensure the HR Recruiter understands
the process for running registries and
documenting results in HR files. A
checklist of file requirements will be
created by CCO showing registries as a
required document that will be signed
off for each new hire.

TITLE

D7F611

If continuation sheet 1 of 3

PRINTED: 05/15/2024
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

B. WING

MHL011-443

05/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

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

ELIADA TREATMENT CENTER

Continued From page 1 vine V131 - Monitoring - HR Director will

Review on 5/7/24 and 5/8/24 of the facility's fire conduct regular checks of new hire HR |

| and disaster drill log revealed: files. This process will include
-No documentation of fire drills on first shift for checking that registries have been run
third quarter 2023 (July-September). in each file. Additionally, once per
-No documentation of fire drills on first shift for quarter, the PQI RISE intern will
fourth quarter 2023 (October-December). complete an audit of a sample of HR
-No documentation of fire drills on first shift for files which will include new hires, staff
first quarter 2024 (January-March). who had a work anniversary in the last
-No documentation the clients were present for quarter, and staff terminated in the last
| disaster drills on first shift for third and fourth quarter. Any deficiencies found in
quarter 2023 (July-December) and first quarter internal monitoring will be followed-up
2024 (January-March). with a plan of correction.

| Interview on 5/13/24 with the Residential Director
revealed:

-"I make sure they (fire drills) are done.”
-"Documenting that it (disaster drills) is happening
on campus but not necessarily in the cottage."

Interview on 5/13/24 with the Chief Compliance
Officer revealed:

| -Was the responsibility of the Residential Director
to make sure drills were completed correctly.
-The Quality Assurance Manager would check the
fire and disaster drill logs.

Interview on 5/13/24 with the Quality Assurance
Manager revealed:

-Disaster drills were completed even if no clients
were present in the facility.

-Would alternate who was responsible for
completing the fire drills.

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

Division of Health Service Regulation
STATE FORM sess o7F611 I continuation sheet 2 of 3

PRINTED: 05/15/2024
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

MHLO11-443 8. WING 05/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

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

ELIADA TREATMENT CENTER

Continued From page 2

health care facility or service, every employer ata
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 record review and interview the facility
failed to complete the Health Care Personnel
Registry (HCPR) check prior to hire. The findings
are:

Review on 5/9/24-5/10/24 of Former Staff (FS)
#2's record revealed:

-Date of Hire: 1/8/24.

~Date of HCPR check: 5/7/24.

Interview on 5/13/24 with the Chief Compliance
Officer revealed:

-Human Resources was responsible for
completing and filing the HCPR checks.
-HCPR checks had been completed for other
staff hired the same day as FS #2.

1
Division of Health Service Regulation
STATE FORM 299 D7F611 If continuation sheet 3 of 3

inspection_type: MHLCS Annual and Complaint

document_type: Plan of Correction


summary: Statement of Deficiency - MHLCS Annual and Complaint

raw_content:
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHLO011-203

A. BUILDING:

111 COMPTON DRIVE
ASHEVILLE, NC 28806

REUTER COTTAGE

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 05/15/2024

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

05/13/2024

(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 114

INITIAL COMMENTS

An annual and complaint survey was completed
on May 13, 2024. The complaint was
substantiated (Intake #NC00216640). A
deficiency was cited.

This facility is licensed for the following service
category: 10A NCAC 27G .1700 Residential
Treatment Staff Secure for Children or
Adolescents.

This facility is licensed for 6 and has a current
census of 6. The survey sample consisted of
audits of 4 current clients.

27G .0207 Emergency Plans and Supplies

10A NCAC 27G .0207 EMERGENCY PLANS
AND SUPPLIES

(a) Awritten fire plan for each facility and
area-wide disaster plan shall be developed and
shall be approved by the appropriate local
authority.

(b) The plan shall be made available to all staff
and evacuation procedures and routes shall be
posted in the facility.

(c) Fire and disaster drills in a 24-hour facility
shall be held at least quarterly and shall be
repeated for each shift. Drills shall be conducted
under conditions that simulate fire emergencies.
(d) Each facility shall have basic first aid supplies
accessible for use.

This Rule is not met as evidenced by:
Based on interviews and record reviews, the
facility failed to hold fire and disaster drills at least

Division of Health Service Regulation

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

STATE FORM

V 000

Vv 114

6899

SPU611

TITLE

(X6) DATE

If continuation sheet 1 of 2

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHLO011-203

(X2) MULTIPLE CONSTRUCTION

A. BUILDING:

111 COMPTON DRIVE

PRINTED: 05/15/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

05/13/2024

quarterly for each shift. The findings are:

Review on 5/7/24 and 5/8/24 of the facility's fire
and disaster drill log revealed:

-No documentation of fire drills on first shift for
third quarter 2023 (July-September).

-No documentation of fire drills on first shift for
fourth quarter 2023 (October-December).

-No documentation of fire drills on first shift for
first quarter 2024 (January-March).

-No documentation the clients were present for
disaster drills on first shift for third and fourth
quarter 2023 (July-December).

Interview on 5/9/24 with the Residential
Supervisor revealed:

-Staff determined when fire drills were completed.
-Was responsible to make sure drills were
completed.

Interview on 5/13/24 with the Residential Director
revealed:

-"| make sure they (fire drills) are done."
-"Documenting that it (disaster drills) is happening
on campus but not necessarily in the cottage."

Interview on 5/13/24 with the Chief Compliance
Officer revealed:

-Was the responsibility of the Residential Director
to make sure drills were completed correctly.
-The Quality Assurance Manager would check the
fire and disaster drill logs.

Interview on 5/13/24 with the Quality Assurance
Manager revealed:

-Disaster drills were completed even if no clients
were present in the facility.

-Would alternate who was responsible for
completing the fire drills.

Division of Health Service Regulation
STATE FORM

6809

REUTER COTTAGE
ASHEVILLE, NC 28806
(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 114] Continued From page 1 Vv 114

If continuation sheet 2 of 2

document_type: Statement of Deficiency


raw_content:
PRINTED: 05/19/2023

FORM APPROVED
Division of Health Service Re
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHLO011-203 05/17/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
111 COMPTON DRIVE
REUTER COTTAGE
ASHEVILLE, NC 28806
(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 complaint survey was completed
on 5/17/23. The complaint was unsubstantiated
(intake #NC00200624). No deficiencies were
cited.

This facility is licensed for the following service
category: 10A NCAC 27G. 1700 Residential
Treatment Staff Secure for Children or
Adolescents.

This facility is licensed for 6 and currently has a
census of 6. The survey sample consisted of
audits of 3 current clients.

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

STATE FORM

6899

916W11

TITLE (X6) DATE

If continuation sheet 1 of 1


summary: Statement of Deficiency - MHLCS Follow-up

raw_content:
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHLO011-203

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

STREET ADDRESS, CITY, STATE, ZIP CODE
111 COMPTON DRIVE

PRINTED: 11/08/2021

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

R
11/03/2021

A limited follow-up survey for the Type A1 rule
violation was completed on November 3, 2021.
This was a limited follow-up survey, only 10A
NCAC 27G.1701 Scope (V293), 10A NCAC
27G.0204 Competencies and Supervision of
Paraprofessionals (V110), 10A NCAC 27G.0205
Assessment and Treatment/Habilitation or
Service Plan (V112), and 10A NCAC 27E.0108
Training in Seclusion, Physical Restraint, and
Isolation Time-Out (V537) were reviewed for
compliance.

The following were brought back into compliance:

10A NCAC 27G.1701 Scope (V293), 10A NCAC.
27G.0204 Competencies and Supervision of
Paraprofessionals (V110), 10A NCAC 27G.0205
Assessment and Treatment/Habilitation or
Service Plan (V112), and 10A NCAC 27E.0108
Training in Seclusion, Physical Restraint, and
lsolation Time-Out (V537). No deficiencies were
cited.

This facility is licensed for the following service
category: 10A NCAC 27G.1700 Residential
Treatment Staff Secure for Children or
Adolescents.

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

STATE FORM

6899

PPVX11

TITLE

REUTER COTTAGE
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000) INITIAL COMMENTS Vv 000

(X6) DATE

If continuation sheet 1 of 1

inspection_type: MHLCS Follow-up