summary: Statement of Deficiency - MHLCS Follow-up

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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
MHL074-195 BWING 09/02/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
3309 MIDLAND COURT

BETTER CONNECTIONS MIDLAND CT
GREENVILLE, NC 27833

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

V 000} INITIAL COMMENTS V 000

An annual and follow up survey was completed
on September 2, 2021. Deficiencies were cited.

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

27G .0202 (F-l) Personnel Requirements V 108

10A NCAC 27G .0202 PERSONNEL
REQUIREMENTS

(f) Continuing education shall be documented.
(g) Employee training programs shall be
provided and, at a minimum, shall consist of
the following:

(1) general organizational orientation;

(2) training on client rights and confidentiality as
delineated in 10A NCAC 27C, 27D, 27E, 27F
and 10A NCAC 26B;

(3) training to meet the mh/dd/sa needs of the
client as specified in the treatment/habilitation
plan; and

(4) training in infectious diseases

and bloodborne pathogens.

(h) Except as permitted under 10a NCAC 27G
-5602(b) of this Subchapter, at least one staff
member shall be available in the facility at all
times when a client is present. That staff
member shall be trained in basic first aid
including seizure management, currently trained
to provide cardiopulmonary resuscitation and

trained in the Heimlich maneuver or other first DHSR - Mental Health
aid techniques such as those provided by Red

Cross, the American Heart Association or their SEP 27 2021
equivalence for relieving airway obstruction.
(i) The governing body shall develop and ‘ 3
implement policies and procedures for identifying, Lic. & Cert. Section
reporting, investigating and controlling infectious
and communicable diseases of personne! and

Division of Health Service Regulation re ~ =

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIG TURE Qn TITLE \ a 3 oo \ (X6) DATE

CaN

STATE FORM 6899 SBIZ11 If continuation sheet 1 of 27

Division of Health Service Regulation

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

MHLO074-195

NAME OF PROVIDER OR SUPPLIER

BETTER CONNECTIONS MIDLAND CT

(2) MULTIPLE

A. BUILDING:

B WING

CONSTRUCTION

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(X3) DATE SURVEY
COMPLETED

R
09/02/2021

STREET ADDRESS, CITY, STATE, ZIP CODE
3309 MIDLAND COURT
GREENVILLE, NC 27833

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

ID
PREFIX
TAG

Continued From page 1

clients.

This Rule is not met as evidenced by:

Based on record review and interview the
facility failed to ensure 1 of 3 audited staff (#2)
received diabetic training to meet the needs of
a client. The findings are:

Review on 8/24/21, 9/01/21 and 9/02/21 of
client #1's record revealed:

- 42 year-old male admitted 1/01/20.

- Diagnoses included: Type 1 Diabetes Mellitus
with Hyperglycemia, Intellectual/Developmental
Disability, moderate, Paranoid Schizophrenia,
Chronic Kidney Disease, stage 3, Essential
Hypertension, Hyperlipidemia, and Myalgia. -
Physician's orders signed 6/15/21 for Humalog
100 units/milliliters (u/m |) Kwikpen (treats
diabetes) by sliding scale at mealtime if blood
sugar is under 90 inject 0 units, 90-150 inject 6
units, 151 - 200 inject 7 units, over 200 inject 8
units, Lantus (treats diabetes) 100u/ml inject 34
units in each morning regardless of breakfast
intake unless blood sugar is lower than 70:
Januvia 50 milligrams (mg) 1 tablet daily;
Metformin (treats diabetes) 1000 mg 1 tablet
twice daily with meals; check blood sugar four
times daily, before meals and bedtime; signed
8/03/21 for Humulin N 100 units/ml Kwikpen
(treats diabetes) inject 5 units subcutaneously
at suppertime

Review on 8/24/21 of staff #2's personnel record
revealed
- Title of Direct Care Professional

V 108

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

Division of Health Service Regulation
STATE FORM

seg

SBIZ11

If continuation sheet 2 of 27

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

PRINTED: 09/16/2021
FORM APPROVED

(X1) PROVIDER/SUPPLIER/CLIA.
IDENTIFICATION NUMBER:

MHL074-195

(x4) ID
PREFIX
TAG

NAME OF PROVIDER OR SUPPLIER

BETTER CONNECTIONS MIDLAND CT

B.WING

COMPLETED

(X2)MULTIPLE + CONSTRUCTION (x3) DATE SURVEY
A BUILDING ee

R
09/02/2021

STREET ADDRESS, CITY, STATE, ZIP CODE

3309 MIDLAND COURT

GREENVILLE, NC 27833

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

V 108

Vv 112

Continued From page 2

- Hire date of 5/24/19.
- No documentation of training in diabetes
management or diabetes care.

During interview on 8/24/21 staff #2 stated: -
She only worked on weekends if the AFL
Provider needed to be away from the facility. -
As a direct care staff she administered
medications, assisted client #1 to check his
blood sugar and assisted him to administer his
insulin. - She was supposed to have diabetes
training. - She could not remember if she had
completed diabetes training

- She had not worked at the facility in
approximately 2 months

This deficiency is cross referenced into 10A
NCAC 27G .5601 Scope (V289) for a Type A1
tule violation and must be corrected within 23
days.

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 plan at least

ID
PREFIX
TAG

V 108

Vv 112

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

V108
Staff #2 that work with Client #1 has been
trained on diabetes management/insulin
administration.
Prior to any staff working with persons with
diabetes, they will receive training on
diabetes managementinsulin
administration (Human Resource Director,
Staff Development Coordinator, Residential
Director and Qualified Professional). See
attached signature page for training.

Division of Health Service Regulation

STATE FORM

ess

SBIZ11

(x5)
COMPLETE
DATE

!f continuation sheet 3 of 27

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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
MHL074-195 B.WING 09/02/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
3309 MIDLAND COURT

BETTER CONNECTIONS MIDLAND CT
GREENVILLE, NC 27833

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

DEFICIENCY)

$+ |

Continued From page 3 Vv 112

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
This Rule is not met as evidenced by: Vv112 19-25-21
Based on record reviews and interviews the Residential Tx. Plan will be revised to
facility failed to develop and implement goals laddress health and safety need of Client
and strategies based on assessment for 1 of 2 Yet.
clients (#1). The findings are: Going forth, QP will develop goals and
trategies to specifically addi
Review on 8/24/21 and 9/01/21 of client F ividuct hea site eetaty ress tne
#1's record revealed: individual.

- 42 year-old male admitted 1/01/20.

- Diagnoses included: Type 1 Diabetes Mellitus
with Hyperglycemia, Intellectual/Developmental
Disability, moderate, Paranoid Schizophrenia,
Chronic Kidney Disease, stage 3, Essential
Hypertension, Hyperlipidemia, and Myalgia. -
"Risk/Support Needs Assessment" dated
12/08/20 included that client #1 could be easily
victimized; "would let anyone into his home:"
engaged in "risky behaviors" such as leaving his
home in the middle of the night to go to the store
to beg for cigarettes; wearing all black at night so
that he could not be seen by traffic; history of
delusions, paranoia, self-injurious behaviors, and
suicidal ideation; "requires close supervision due

Division of Health Service Regulation
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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
MHL074-195 B.WING 09/02/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
3309 MIDLAND COURT
GREENVILLE, NC 27833

SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)

BETTER CONNECTIONS MIDLAND CT

(x4) 1D

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

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

Continued From page 4 v112

to risk of wandering away."

-"Case Note Entered By [Qualified Professional
(QP)] on 08/31/2021 03:13 PM... Service Date
06/30/2021 . . . "included "Team meeting was
held to discuss . . . [client #1's] placement,
having unsupervised time, and eating schedule.
The team agreed that [client #1] could have up to
2 hours of unsupervised time. Prior to leaving for
his unsupervised time, [client #1] agreed to
check his glucose levels, take a snack and a
bottle of water, and provide staff with his plans.
[Client #1] will also receive a food card to use to
start learning how to manage his funds on a
monthly basis. The team will meet in a couple of
months to assess [client #1's] progress.”
-"Intake/Output" record 6/02/21 8:00 am -
8/31/21 12:30 pm included documentation of
133 meal refusals.

- Physician's orders signed 6/15/21 and 3/18/20
for Humalog 100 units/milliliters (u/ml) Kwikpen
(treats diabetes) by sliding scale at mealtime if
blood sugar is under 90 inject 0 units, 90-150
inject 6 units, 151 - 200 inject 7 units, over 200
inject 8 units; signed 6/15/21 for Lantus (treats
diabetes) 100u/ml inject 34 units in each morning
regardless of breakfast intake unless blood sugar
is lower than 70; Januvia 50 milligrams (mg) 1
tablet daily; Metformin (treats diabetes) 1000 mg
1 tablet twice daily with meals; check blood sugar
four times daily, before meals and bedtime;
signed 8/03/21 for Humulin N 100 units/ml
Kwikpen (treats diabetes) inject 5 units
subcutaneously at suppertime.

- "Admin (Administration) History for [client #1] -
Humalog 100 units/milliliter (ml) Kwikpen"
8/12/21 7:00 pm - 8/31/21 12:36 pm included
documentation of 43 refusals of Humalog 100
units/ml.

- Medication Administration Records (MARs)
June 2021 - August, 2021 included

Division of Health Service Regulation
STATE FORM 6899 $B1Z11 If continuation sheet 5 of 27

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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
MHLO074-195 Baie - 09/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
3309 MIDLAND COURT
BETTER CONNECTIONS MIDLAND CT
GREENVILLE, NC 27833
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES flay 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)
Continued From page 5 Vv 112

documentation of 121 blood sugar check refusals;
documentation of blood sugar levels ranging from
54 at 6:00 pm 8/12/21 to too high for the
glucometer instrument to register at 7:00 am
8/23/21, 7/12/21, and 7/19/21; documentation of
153 refusals of Humalog 100 units/ml.

- "Consultation Form" dated 3/04/21 with signed
Physician's order". . . take Lantus even if he
(client #1) does not eat breakfast;" the
"Consultation Form" was also signed by the
Direct Care Professional, the Residential
Director, and the QP.

-"SCS (Special Consultative Services)
Nutritionist 01/1/21 - 12/31/21 (ISP Program)"
included". . . Goal/Service Individual will receive
specialized consultative services in order to have
a comprehensive nutritional assessment plan
development, training and monitoring/revising
throughout the plan year to promote compliance
with a healthier diet.”

- "Residential Supports . . . 1/1/21-12/31/21 (ISP
[Individual Support Plan] Program) . . . Start
Date 1/01/2021..."

- No goal or strategies to address management
of client #1's Type 1 Diabetes Mellitus with
Hyperglycemia or his refusal to comply with
blood sugar checks, and medication regimen

- No goal or strategies for unsupervised time,
overnight eating, leaving his home during the
night, or the appropriate use of his food card. -
No strategies to address SCS Nutritionist's
recommendations or dietary considerations for
Type 1 Diabetes Mellitus with Hyperglycemia.

During interview on 8/26/21 client #1's
Department of Social Services (DSS) Guardian
Representative stated:

- She attended the 6/30/21 treatment team
meeting via telephone for approximately

one hour.

Division of Health Service Regulation
STATE FORM 6899

SBIZ11

If continuation sheet 6 of 27

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

IDENTIFICATION NUMBER:

MHL074-195
NAME OF PROVIDER OR SUPPLIER

BETTER CONNECTIONS MIDLAND CT
GREENVI

(X1) PROVIDER/SUPPLIER/CLIA

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FORM APPROVED

(X2) MULTIPLE: CONSTRUCTION (X3) DATE SURVEY

A.BUILDING: COMPLETED
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— 09/02/2024

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL
TAG REGULATORY OR LSC IDENTIFYING INFORMATION)
V 112 | Continued From page 6

- The team's approval for client #1 to have
unsupervised time was an attempt to afford
him some "autonomy."

- She agreed to client #1's unsupervised time
despite his history of non-compliance with his
diabetes treatment regimen and history of risky
behaviors.

- She believed that client #1 did not comprehend
his need for supervision because he had lived
independently and had been married prior to his
current AFL placement.

- The team was "trying to meet him in the middle."
- She was concerned for client #1's safety because
“if he refuses his blood sugar checks or
medications there could be a terrible outcome.” -
She acknowledged that the team "can't stop his
behavior."

- She was aware client #1 stayed up at night and
ate and had asked the Alternative Famly Living
(AFL) staff to leave healthy snacks out and
available for client #1.

-"He is difficult to manage. He thinks he knows
more than we do. He wants his independence
and is resistive to treatment. He will say the devil
made him do things."

- She had not spoken with client #1 recently.

During interview on 8/24/21 staff #1 stated client
#1 had “down time" (unsupervised time) but he
did not know how much.

During interview on 8/24/21 staff #2 stated: -
Client #1 had 2 hours of unsupervised time. -
She only worked on weekends when the AFL
Provider needed to be away from the facility. -
She had not worked at the facility in about 2
months.

During interview on 8/24/21 the AFL Provider
stated:

iD
PREFIX
TAG

ee (Ee

Vv 112

STREET ADDRESS, CITY, STATE, ZIP CODE
3309 MIDLAND COURT
LLE, NC 27833

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

(x5)
COMPLETE
DATE

——

Division of Health Service Regulation
STATE FORM

8899

SBIZ11

If continuation sheet 7 of 27

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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
MHLO074-195 B.WING 09/02/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
3309 MIDLAND COURT

BETTER CONNECTIONS MIDLAND CT
GREENVILLE, NC 27833

So
(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)

Continued From page 7

- Client #1 had 2 hours of unsupervised time in
the community and home each day; the
unsupervised time was not included in client
#1's treatment plan

- The treatment team discussed unsupervised
time for client #1 "about a month ago." - Client
#1's Care Coordinator completed the
assessment for unsupervised time, but there
was not a copy of the assessment in client #1's
record.

- Client #1 had unsupervised time for "no more
than a month."

- The team's agreement for client #1 to have
unsupervised time was "more of a verbal

type thing."

- The team agreed that they wanted client #1 to
"be more independent because he's so high
functioning.”

- Client #1 often refused to have his blood

sugar checked and to take his insulin as
ordered. - Client #1 did not refuse his Lantus.

- Client #1 had high blood sugar all his life and felt
"funny" if his blood sugar was low.

- Client #1 slept during the day and stayed

up during the night.
- The QP was responsible for writing the
residential goals, the Care Coordinator
finalized and approved the goals, and
residential staff executed the goals.

- Staff #1 and staff #2 only worked on the
weekends if he needed to be away from
the facility.

During interview on 8/25/21 the Residential
Director stated client #1 was "very high
functioning” and "got his down time sometime
in the last three months or so."

During interview on 8/25/21 the QP stated:
~ She began providing QP services at the facility a

. —
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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
MHLO074-195 al {__09/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
3309 MIDLAND COURT
BETTER CONNECTIONS MIDLAND CT
GREENVILLE, NC 27833
(X4) 1D 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 8 V 112

couple of months ago.

- Treatment plans for the individuals at the facility
were already in place when she assumed the QP
responsibilities.

- Client #1's team developed short range goals
for each service the client received.

- The QP "formulated the plan from long range
goals and team's input;" short term goals were
based on long range goals.

- Other responsibilities of the QP included
ensuring coordination of care and making sure
staff carried out recommendations made by the
clients' Physicians

- Client #1 "demanded" unsupervised time, so
his team agreed for him to have up to 2 hours
per day.

- Client #1 "had a system to follow to make sure
he's safe."

- Client #1's "system" included checking client
#1's blood sugar, keeping his glucometer with
him, taking a bottle of water and a snack with
him and letting staff know where he was going. -
Client #1 also agreed to let the AFL staff know
when he got up in the night and when he ate; -
"He was supposed to take Humalog when he ate
something and not cook in the middle of the
night. But he hasn't followed through with any of
that."

- Client #1 had 3 scheduled meals each day. -
"In [client #1's] mind he eats one meal a day, but
he eats one meal during the day because he
hasn't been eating breakfast or lunch; he gets up
in middle of night and eats and is not taking
anything (insulin as ordered) for that."

- "We've been working on that. We want a third
shift person that could stay up and manage
[client #1] through the night."

- "[Client #1] has had friends come over to bring
him money - it happened last week, at midnight;
[AFL staff] happened to get up and heard a

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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
MHL074-195 BAY NG _ 09/02/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
3309 MIDLAND COURT

BETTER CONNECTIONS MIDLAND CT
GREENVILLE, NC 27833

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

Continued From page 9 Vv 112

commotion; if he hadn't gotten up, he

would never have known."

- A person, whom client #1 identified as a friend,
came to the facility to give client #1 some money;
client #1 went outside and got into his friend's
car. - Client #1's friend didn't enter the facility; the
AFL staff went out to the car, client #1 was given
money by the friend and came back into the
facility without incident.

- Client #1 had been "refusing medications for

a very, very long time; I'm not sure an extra
staff will be an improvement on that but it's
worth a try.”

- Client #1 "takes his glucometer everywhere he
goes, including into the community and to the day
program so his blood sugar should be checked
and medications administered accordingly." - The
frequency of client #1's nutritional therapy
increased from once a month to twice a month. -
"It's worth the effort; he's been meeting with her
(the Nutritionist) for at least all of this year (2021)
and he hasn't done a single thing she has
suggested."

- "He doesn't want to feel like he's being micro-
managed or treated like a child; he had life
experiences; he was married and had at least 1
child; he is struggling a lot with the changes in
his life; he's not calling the Care Coordinator as
often as he once was so that's good."

- Client #1 wanted to be more independent. -
Client #1's unsupervised time started 6/30/21. -
"We were trying to put structure to what he was
already doing; he would walk to the store; he
was banned from the [a chain discount store]
due to a previous incident that occurred there."

- No revisions were made to short range goals as
a result of the 6/30/21 team meeting

- She was not sure if the Care Coordinator made
any revisions to the long range goals.

- Residential plans were updated if there was a

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STATE FORM 6ae9 SBIZ11 If continuation sheet 10 of 27

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R
MHL074-195 B.WING ___ = 09/02/2021

STREET ADDRESS, CITY, STATE, ZIP CODE
3309 MIDLAND COURT
GREENVILLE, NC 27833

NAME OF PROVIDER OR SUPPLIER

BETTER CONNECTIONS MIDLAND CT

——__________
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (XS)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 112) Continued From page 10 Vv 112

significant change in the client's life.

During interview on 9/02/21 the Clinical
Director stated:

- Client #1 was once married and had a child
and had difficulty adjusting to the changes in his
life. - When team meetings were held, the team
focused on honoring client #1's rights.

- Client #1 would verbalize that it was his choice
to eat one meal per day.

- She understood and agreed that it was
incumbent on the Licensee to ensure client

#1's safety

- Negative consequences of client #1's continued
refusals of insulin and extremely high blood sugar
readings were discussed with him.
- "We've talked with him about all this."

- She agreed that there were no goals or
strategies to address management of client v118
#1's Type 1 Diabetes Mellitus with
Hyperglycemia; his refusal to comply with blood
sugar checks and medication regimen,
unsupervised time, overnight eating, leaving his
home during the night, and the appropriate use
of his food card; she also agreed there were no
strategies to address nutritional counseling or
dietary considerations for Type 1 Diabetes
Mellitus with Hyperglycemia included in his
treatment/habilitation plan.

Medications will be entered into electronic |g.25-24
MAR upon receipt of medication(s) in the
lhome by Residential Directors.

Provide retraining on Electronic MAR to
Residential Directors on adding and
removing discontinued medication,
reviewing medication orders against MAR
to ensure match, reviewing medication
jadministration to ensure medications are
being administered as ordered.

This deficiency is cross referenced into 10A NCAC ? ‘ .
27G 5601 Scope (v289) for a Type A1 rule Staff to receive medication administration
violation and must be corrected within 23 days. training

Protocol in place to contact Endocrinologist
V 118 27G .0209 (C) Medication Requirements Vv 118 See sitachea rindlog

10A NCAC 27G .0209 MEDICATION
REQUIREMENTS
(c) Medication administration:

Division of Health Service Regulation
STATE FORM 89g SBIZ11 If continuation sheet 11 of 27

PRINTED: 09/16/2021
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
09/02/2021

MHL074-195 B.WING:

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
3309 MIDLAND COURT
GREENVILLE, NC 27833

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

DEFICIENCY)
Se Se eee

Continued From page 11 Vv 118

BETTER CONNECTIONS MIDLAND CT

(1) Prescription or non-prescription drugs shall
only be administered to a client on the written
order of a person authorized by law to prescribe
drugs.

(2) Medications shall be self-administered by
clients only when authorized in writing by the
client's physician.

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

(A) client's name;

(B) name, strength, and quantity of the drug;
(C) instructions for administering the drug;
(D) date and time the drug is administered; and
(E) name or initials of person administering the
drug.

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

This Rule is not met as evidenced by:

Based on record reviews, observations and
interviews the facility failed to ensure medications
were administered as ordered by a physician for 1
of 2 clients (#1). The findings are: |

Division of Health Service Regulation
STATE FORM 6899 SBI211 If continuation sheet 12 of 27

PRINTED: 09/16/2021
FORM APPROVED

Division of Health Service Regulation

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

(X2)MULTIPLE ~~ CONSTRUCTION (x3) DATE SURVEY
A.BUILDING COMPLETED

R
09/02/2021

B.WING

MHLO074-195

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
3309 MIDLAND COURT

BETTER CONNECTIONS MIDLAND CT
GREENVILLE, NC 27833

(X4) 1D 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)

Continued From page 12 Vv 118

Review on 8/24/21, 9/01/21 and 9/02/21 of client
#1's record revealed

- 42 year-old male admitted 1/01/20.

- Diagnoses included: Type 1 Diabetes Mellitus
with Hyperglycemia, Intellectual/Developmental
Disability, moderate, Paranoid Schizophrenia,
Chronic Kidney Disease, stage 3, Essential
Hypertension, Hyperlipidemia, and Myalgia. -
Physician's orders signed 6/15/21 and 3/18/20
for Humalog 100 units/milliliters (u/ml) Kwikpen
(treats diabetes) by sliding scale at mealtime if
blood sugar is under 90 inject 0 units, 90-150
inject 6 units, 151 - 200 inject 7 units, over 200
inject 8 units; Lantus (treats diabetes) 100u/ml
inject 34 units in each morning regardless of
breakfast intake unless blood sugar is lower than
70, Januvia 50 milligrams (mg) 1 tablet daily;
Metformin (treats diabetes) 1000 mg 1 tablet
twice daily with meals; check blood sugar four
times daily, before meals and bedtime; signed
8/03/21 for Humulin N 100 units/ml Kwikpen
(treats diabetes) inject 5 units subcutaneously at
suppertime.

- "Consultation Form" dated 8/03/21 with signed
Physician's order to "Decrease Lantus (treats
diabetes) to 25 units in AM..."

Review on 8/24/21 of client #1's August 2021
MAR revealed:

- Transcription for Humalog 100 units/m! Kwikpen
according to sliding scale with documentation of
medication administration beginning 8/12/21 7:00
pm.

- No documentation Humalog 100 units/ml!
Kwikpen was administered 8/11/21 - 8/12/21, with
no documented explanation for the omissions. -
Transcription for blood sugar checks 4 times daily
with documented blood sugar levels of 314 7:00
am 8/11/21, 379 7:00 am 8/12/21, and 187 8:00
pm 8/12/21.

Division of Health Service Regulation
STATE FORM 6898 SBIZ11 If continuation sheet 13 of 27

PRINTED: 09/16/2021
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
09/02/2021

B.WING

MHLO74-195

STREET ADDRESS, CITY, STATE, ZIP CODE
3309 MIDLAND COURT
GREENVILLE, NC 27833

NAME OF PROVIDER OR SUPPLIER

BETTER CONNECTIONS MIDLAND CT

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES 1) 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)

Continued From page 13 Vv 118

- Transcription for Humulin N 100 units/m!|
Kwikpen according to sliding scale with
documentation of medication administration
beginning 8/13/21 7:00 pm.

- No documentation Humulin N 100 units/m!
Kwikpen was administered 8/03/21 - 8/08/21

or 8/10/21 - 8/12/21, with no documented
explanation for the omissions.

- Documentation of client #1's refusal of the
Humulin N Kwikpen at 5:00 pm 8/09/21. -
Transcription for Lantus 100 units/ml inject 34
units in the morning; take daily each morning
regardless of breakfast intake unless glucose is
less than 70; no documentation of blood glucose
levels less than 70; the AFL provider's initials

that 34 units Lantus were injected daily 8/4/21 -
8/20/21 and 8/23/21 - 8/24/21.

- No transcription for Lantus 100 units/ml inject 25
units in the morning

Observation on 8/24/21 at approximately 11:00
am of client #1's medications on hand
revealed: - Lantus 100 units/ml inject 34 units
in the morning; ". . . take Lantus daily each
morning regardless of breakfast intake" unless
blood sugar level is less than 70, dispensed by
the pharmacy 7/23/21.

- No Lantus 100 units/ml inject 25 units in

the morning.

During interview on 8/24/21 client #1 stated:
- He took his medications "just about" every day
with staff assistance.

- He went to the doctor the week prior to

the survey.

- Emergency Medical Services came to the facility
once in the past because he "passed out
because of my diabetes" but he chose not to go
to the hospital.

Division of Health Service Regulation
STATE FORM 6899 SBIZ11 If continuation sheet 14 of 27

PRINTED: 09/16/2021
FORM APPROVED

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X3) DATE SURVEY
COMPLETED

A. BUILDING
R
MHL074-195 B.WING {09/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

3309 MIDLAND COURT
GREENVILLE, NC 27833
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION

BETTER CONNECTIONS MIDLAND CT

(x5)

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

V 118} Continued From page 14 Vv 118

During interview on 8/24/21 the Alternative Family
Living (AFL) Provider stated

- There was “some kind of discrepancy"

with client #1's insurance when the Humulin

N Kwikpen was ordered.

- The Humulin N Kwikpen was not delivered

to the facility until 8/10/21 or 8/11/21.

- The pharmacy was supposed to take the
Humulin N Kwikpen off the MAR since it was

not available but mistakenly removed Humalog
Kwikpen from the MAR.

- It was not protocol to contact a medical
provider when client #1's blood sugar was high;
the pharmacist saw the blood sugar levels on the
electronic MAR.

- There was no order to seek medical attention
for client #1 when his blood sugar level was
high. - The first time client #1's blood sugar was
too high to be registered by the glucometer, he
called the Registered Nurse who told him to just
administer client #1's insulin as ordered.

- He was told to make sure client #1 had plenty of
water available.

- Client #1's blood sugar "did not stay high, it was
high mainly in the mornings because [client #1]
liked to stay up at night" and would eat during the
night.

- Client #1 told him he (client #1) had high

blood sugar all his life and he felt "funny" if his
blood sugar was low.

During interview on 8/25/21 the Residential
Director stated:

- Some of his responsibilities included
reviewing medications, making sure staff "sign
off’ on medications and following up on
Physicians’ Consultation forms.

- If client #1 refused medications more than two
consecutive days he called the nurse and
asked for advice.

Division of Health Service Regulation
STATE FORM aso SBIZ11 If continuation sheet 15 of 27

PRINTED: 09/16/2021

/ 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
MHL074-195 Bane 09/02/2021

STREET ADDRESS, CITY, STATE, ZIP CODE
3309 MIDLAND COURT
GREENVILLE, NC 27833

NAME OF PROVIDER OR SUPPLIER

BETTER CONNECTIONS MIDLAND CT

(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)

Continued From page 15 Vv 118

-"| just want to make sure he's safe. | talk to him
about staying safe."

-"He (client #1) is adamant about getting out of
the system. . . we can't force him to do anything
... he sabotages things; he knows what's going
on, he eats so much at night that his blood
sugar readings are so different."

- He advised the AFL staff to set an alarm for
every 3 hours to check on client #1 overnight. -
Client #1's unsupervised time was not at night.
- He could not force client #1 to comply with
medications or blood sugar checks.

During interview on 8/25/21 the Qualified
Professional stated:

- Her responsibilities included ensuring
coordination of care and making sure staff carried
out recommendations made by the Physicians. -
Client #1's team met to discuss his eating in
middle of night; client #1 agreed to let the AFL
staff know when he got up and when he ate: ".
he was supposed to take Humalog when he ate
something and not cook in the middle of the
night."

- Client #1 has 3 scheduled meals ". . . in [client
#1's] mind he eats 1 meal a day, but he eats1
meal during the day because he hasn't been
eating breakfast or lunch; he gets up in middle of
night and eats and is not taking anything for
that." - She wanted a 3rd shift awake staff to
“manage” client #1 during the night.

- Client #1 had been refusing medications for

“a very, very long time" and she was not sure

an extra staff would be effective.

- Client #1 "takes his glucometer everywhere he
goes, including into the community and to the day
program so his blood sugar should be checked,
and medications administered accordingly."

Due to the failure to accurately document

Division of Health Service Regulation
STATE FORM 6899 SBIZ11 If continuation sheet 16 of 27

Division of Health Service Regulation

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

MHL074-195

(X2) MULTIPLE
A.BUILDING:

B.WING

CONSTRUCTION

PRINTED: 09/16/2024
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
09/02/2021

NAME OF PROVIDER OR SUPPLIER

BETTER CONNECTIONS MIDLAND CT

STREET ADDRESS, CITY, STATE, ZIP CODE
3309 MIDLAND COURT
GREENVILLE, NC 27833

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

(X4) ID
PREFIX
TAG

| ID

PREFIX
TAG

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

DEFICIENCY)

Vv 118) Continued From page 16

medication administration it could not be
determined if the client received his medications
as ordered by the physician.

This deficiency has been cited 3 times since the
original cite on March 28, 2018.

This deficiency is cross referenced into 10A
NCAC 27G .5601 Scope (V289) fora Type A1
tule violation and must be corrected within 23
days.

27G .5601 Supervised Living - Scope

10A NCAC 27G .5601 SCOPE

(a) Supervised living is a 24-hour facility which
provides residential services to individuals in a
home environment where the primary purpose
of these services is the care, habilitation or
rehabilitation of individuals who have a mental
illness, a developmental disability or disabilities,
or a substance abuse disorder, and who require
supervision when in the residence.

(b) A supervised living facility shall be licensed if
the facility serves either:

(1) one or more minor clients; or

(2) two or more adult clients.

Minor and adult clients shall not reside in the
same facility.

(c) Each supervised living facility shall be
licensed to serve a specific population as
designated below:

(1) “A" designation means a facility which
serves adults whose primary diagnosis is mental
illness but may also have other diagnoses;

(2) “B" designation means a facility which
serves minors whose primary diagnosis is a
developmental disability but may also have other
diagnoses;

Division of Health Service Regulation
STATE FORM

Vv 118

Vv 289

(x5)
COMPLETE
DATE

SBIZ11

If continuation sheet 17 of 27

Division of Health Service Regulation

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

MHL074-195

(x2) MULTIPLE

A.BUILDING:

B.WING

CONSTRUCTION

NAME OF PROVIDER OR SUPPLIER

BETTER CONNECTIONS MIDLAND CT

GREENVI

STREET ADDRESS, CITY, STATE, ZIP CODE
3309 MIDLAND COURT
LLE, NC 27833

PRINTED: 09/16/2021
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
09/02/2021

(X4) ID
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL
TAG REGULATORY OR LSC IDENTIFYING INFORMATION)

Continued From page 17

(3) "C" designation means a facility which
serves adults whose primary diagnosis is a
developmental disability but may also have
other diagnoses;

(4) "D" designation means a facility which
serves minors whose primary diagnosis is
substance abuse dependency but may also
have other diagnoses;

(5) "E" designation means a facility which
serves adults whose primary diagnosis is
substance abuse dependency but may also
have other diagnoses; or

(6) "F" designation means a facility in a
private residence, which serves no more than
three adult clients whose primary diagnoses is
mental illness but may also have other
disabilities, or three adult clients or three minor
clients whose primary diagnoses is
developmental disabilities but may also have
other disabilities who live with a family and the
family provides the service. This facility shall be
exempt from the following rules: 10A NCAC 27G
-0201 (a)(1),(2),(3),(4),(5)(A)&(B); (6); (7)
(A),(B),(E),(F).(G),(H); (8); (11); (13); (15); (16):
(18) and (b); 10A NCAC 27G .0202(a),(d),(g)(1)
(i); 10A NCAC 27G .0203; 10A NCAC 27G
.0205 (a),(b); 10A NCAC 27G .0207 (b),(c); 10A
NCAC 27G .0208 (b),(e); 10A NCAC 27G
0209[(c)(1) - non-prescription medications only]
(d)(2),(4); (€) (1)(A),(D),(E);()i(g); and 10A
NCAC 27G .0304 (b)(2),(d)(4). This facility shall
also be known as alternative family living or
assisted family living (AFL).

This Rule is not met as evidenced by:
Based on record reviews, observations and
Division of Health Service Regulation

STATE FORM

SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
————
V 289
6899 SBIZ11 If continuation sheet 18 of 27

Division of Health Service Regulation

(X4) ID
PREFIX
TAG

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

BETTER CONNECTIONS MIDLAND CT

PRINTED: 09/16/2021
FORM APPROVED

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

MHL074-195

STREET ADDRESS, CITY, STATE, ZIP CODE
3309 MIDLAND COURT
GREENVILLE, NC 27833

(2)MULTIPLE CONSTRUCTION [X2) DATE SURVEY

A BUILDING: COMPLETED
R

— 09/02/2021

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

]

Continued From page 18

interviews, the facility failed to ensure care
and habilitation designed to meet the needs of
the individuals served affecting 1 of 2 clients
(#1). The findings are:

Cross reference 10A NCAC 27G .0202
Personnel Requirements (tag v108). Based on
record review and interview the facility failed to
ensure 1 of 3 staff (#2) received diabetic training
to meet the needs of a client.

Cross reference 10A NCAC 27G .0205
Assessment and Treatment/Habilitation or
Service Plan (tag v112). Based on record
reviews and interviews the facility failed to
develop and implement goals and strategies
based on assessment for 1 of 2 clients (#1).

Cross reference 10A NCAC 27G .0209
Medication Requirements (tag v118). Based on
record reviews and interviews the facility failed
to ensure medications were administered as
ordered by a physician for 1 of 2 clients (#1).

Cross Reference 10A NCAC 27G .5603 Operations (tag
v291). Based on record reviews and interviews the facility
failed to maintain coordination between the facility operator
and the professionals who are responsible for the client's
treatment affecting 1 of 2 clients (#1).During interview on
8/24/21 the Alternative Family

Living (AFL) Provider stated:

- He lived at the facility.

- Staff #1 and staff #2 worked on the weekends if

he needed to be away from the facility.

- He worked with client #1 during the week.

- The Licensee paid the rent for the facility.

- The facility was one of several properties the

Licensee rented

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

DEFICIENCY)
ee |

V 289

\v289

Staff #2 that work with Client #1 has been trained on
\diabetes management/insulin administration

Prior to any staff working with persons with diabetes,
hey will receive training on diabetes
|management/insulin administration (Human Resource
Director, Staff Development Coordinator, Residential
Director and Qualified Professional). See attached
signature page for training

Residential Tx. Plan will be revised to address health
land safety need of Client #1

|Going forth, QP will develop goals and strategies to
specifically address the individual health and safety
Ineeds of individual

Medications will be entered into electronic MAR upon
receipt of medication(s) in the home by Residential
(Directors

Provide retraining on Electronic MAR to Residential
Directors on adding and removing discontinued
Imedication, reviewing medication orders against MAR
‘0 ensure match, reviewing medication administration
(0 ensure medications are being administered as
jordered.

\Staff to receive medication administration training.
Protocol in place to contact Endocrinologist. See
lattached.

(QPs will complete Physician Consultation form to
horoughly describe what is going on with individual
prior to appointment with Endocrinologist. Diabetic
readings will be attached to consultation form.

{QP will complete collaborative notes in reference to
lappointments and team meetings related to persons
health and safety

Division of Health Service Regulation

STATE FORM

6899

SBIZ11

(XS)
COMPLETE
DATE

'f continuation sheet 19 of 27

PRINTED: 09/16/2021
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
MHL074-195 B.WING 09/02/2021

STREET ADDRESS, CITY, STATE, ZIP CODE
3309 MIDLAND COURT
GREENVILLE, NC 27833

NAME OF PROVIDER OR SUPPLIER

BETTER CONNECTIONS MIDLAND CT

(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 289 | Continued From page 19 V 289

During interview on 8/25/21 the Residential
Director stated the Licensee paid the rent for
the facility.

During interview on 9/01/21 the Chief Financial
Officer stated:

- The AFL Provider lived at the facility.

- Other paid staff worked only when the AFL staff
needed to be away.

- The manner in which the facility was operated
had not changed.

- The way the facility was operated had never
been cited as a deficiency before.

- The facility was one of several properties the
Licensee rented.

- The facility met the definition of Supervised
Living for Alternative Family Living.

Review on 8/31/21 of the Plan of Protection
dated 8/31/21 completed by the Quality
Assurance/Chief Executive Officer, the Chief
Financial Officer, and the Clinical Director
revealed:

-"What immediate action will the facility take to
ensure the safety of the consumers in your care?
There will always be a staff available that has the
appropriate training for the person (diabetes
training). Ensure short range goals (specialized
consultation goal provided) reflect his issues
related to diabetes (diet, management of diabetes,
blood sugar trends, etc.). His current setting is a
licensed AFL with sleep staff, the team will
discuss a more appropriate placement for 24-hour
supervision. Periodic bed checks nightly and
document times he checks in Therap. If he does
refuse medication, ensure documentation is noted
on the MAR and continue to notify doctor of
medication refusal."

- "Describe your plans to make sure the above

Division of Health Service Regulation
STATE FORM 6899 SBIZ11 If continuation sheet 20 of 27

Division of Health Service Regulation

PRINTED: 09/16/2021
FORM APPROVED

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

MHLO074-195

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

NAME OF PROVIDER OR SUPPLIER

BETTER CONNECTIONS MIDLAND CT

STREET ADDRESS, CITY, STATE, ZIP CODE
3309 MIDLAND COURT
GREENVILLE, NC 27833

(X2)MULTIPLE
A.BUILDING:

CONSTRUCTION (X3) DATE SURVEY

COMPLETED

R
09/02/2021

B.WING

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL
TAG REGULATORY OR LSC IDENTIFYING INFORMATION)

ID PROVIDER'S PLAN OF CORRECTION (x5)

PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

V 289| Continued From page 20

for his safety/care."

Schizophrenia, Moderate

happens. QP will review documentation daily in
Therap for periodic bed checks at night, when
refusal of medication is noted, ensure MARS are
documented daily. Collaboration notes to be
completed as incidents occur. Ongoing
meetings to discuss progress or lack of progress

Client #1 had diagnoses which included Paranoid

Intellectual/Developmental Disability, Type 1
Diabetes Mellitus with Hyperglycemia, Stage 3
Chronic Kidney Disease, and Essential
Hypertension. Client #1 had a known long-term
history of medication non-compliance, non-
compliance with physician's recommendations,
and a history of risky behaviors such as leaving
the facility in the middle of the night to walk toa
store. He also refused to comply with dietary
recommendations from his nutritionist, frequently
eating only one meal per day and staying up at
night and eating without consideration of his
diabetes. Staff at the facility were asleep
overnight. Client #1's blood glucose level was
ordered to be checked four times daily and insulin
administered according to a sliding scale. Client
#1 refused to have his blood glucose level
checked 121 times between June 2021 and
August 2021. His blood glucose readings ranged
from a low of 54 to so high the glucometer was
unable to record a reading. June 15, 2021 - August
24, 2021, he refused administration of his
Humulog and Humulin 135 times; he refused
administration of his Lantus 13 times, his
Metformin 15 times, and his Januvia 10 times.
Client #1 was approved by his treatment team to
have 2 hours of unsupervised time in the
community and home despite his known
noncompliance with treatment recommendations.
None of these issues were included in his

V 289

|

Division of Health Service Regulation
STATE FORM

6899 $BiZ11 If continuation sheet 21 of 27

PRINTED: 09/16/2021
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
MHLO74-195 B.WING 09/02/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
3309 MIDLAND COURT
BETTER CONNECTIONS MIDLAND CT
GREENVILLE, NC 27833
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ] ID PROVIDER'S PLAN OF CORRECTION (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 21 V 289

treatment plan and there was no coordination of
care with client #1's Endocrinologist regarding
seeking emergency medical care or treatment
when his blood glucose levels were extremely
high. Staff #2 had no documented training in
diabetes care. The facility's failures to ensure
client #1's medical and behavioral needs were
addressed in his treatment plan; administration
of his medications as ordered; and staff training
in diabetes care constitute serious neglect. This
deficiency constitutes a Type A1 rule violation
for serious neglect and must be corrected
within 23 days. An administrative penalty of
$2000.00 is imposed. If the violation is not
corrected within 23 days, and additional
administrative penalty of $500 per day will be
imposed for each day the facility is out of
compliance beyond the 23rd day.

V291| 27G .5603 Supervised Living - Operations Vv 291

10A NCAC 27G .5603 OPERATIONS

(a) Capacity. A facility shall serve no more than
six clients when the clients have mental illness or
developmental disabilities. Any facility licensed
on June 15, 2001, and providing services to more
than six clients at that time, may continue to
provide services at no more than the facility's
licensed capacity.

(b) Service Coordination. Coordination shall be
maintained between the facility operator and the
qualified professionals who are responsible for
treatment/habilitation or case management.

(c) Participation of the Family or Legally
Responsible Person. Each client shall be

provided the opportunity to maintain an ongoing
relationship with her or his family through such
means as visits to the facility and visits outside

the facility. Reports shall be submitted at least

.

Division of Health Service Regulation
STATE FORM 6899 SBIZ11 If continuation sheet 22 of 27

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

PRINTED: 09/16/2021
FORM APPROVED

(X1) PROVIDER/SUPPLIERI/CLIA
IDENTIFICATION NUMBER:

(X2) MULTIPLE.
A.BUILDING

B.WING

CONSTRUCTION

MHL074-195

(x4) ID
PREFIX
TAG

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

3309 MIDLAND COURT
GREENVILLE, NC 27833

BETTER CONNECTIONS MIDLAND CT

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

Continued From page 22

annually to the parent of a minor resident, or the
legally responsible person of an adult resident.
Reports may be in writing or take the form of a
conference and shall focus on the client's
progress toward meeting individual goals. (d)
Program Activities. Each client shall have
activity opportunities based on her/his choices,
needs and the treatment/habilitation plan.
Activities shall be designed to foster community
inclusion. Choices may be limited when the
court or legal system is involved or when health
or safety issues become a primary concern

This Rule is not met as evidenced by:

Based on record reviews and interviews the
facility failed to maintain coordination between the
facility operator and the professionals who are
responsible for the client's treatment affecting 1 of
2 clients (#1). The findings are:

Review on 8/24/21 and 9/01/21 of client

#1's record revealed

- 42 year-old male admitted 1/01/20.

- Diagnoses included: Type 1 Diabetes Mellitus
with hyperglycemia, Intellectual/Developmental
Disability, moderate, Paranoid Schizophrenia,
chronic kidney disease, stage 3, essential
hypertension, hyperlipidemia, and myalgia. -
“Intake/Output" record 6/02/21 8:00 am -

8/31/21 12:30 pm included documentation of
133 meal refusals.

- "Admin (Administration) History for [client #1] -
Humalog 100 units/ml Kwikpen" 8/12/21 7:00 pm -
8/31/21 12:36 pm included documentation of 43
refusals of Humalog 100units/ml (ordered 6/15/21
to be administered by sliding scale at mealtime). -
"Consultation Form” dated 3/04/21 with signed
Endocrinologist's order". . . take Lantus even if]

ID
PREFIX
TAG

V 291

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

V291
(QPs will complete Physician Consultation
form to thoroughly describe what is going
on with individual prior to appointment with
Endocrinologist. Diabetic readings will be
attached to consultation form.

(QP will complete collaborative notes in
reference to appointments and team
meetings related to persons health and
safety.

Division of Health Service Regulation

STATE FORM

ease

SBIZ11

(X3) DATE SURVEY
COMPLETED

09/02/2021

(x5)
COMPLETE
DATE

If continuation sheet 23 of 27

Division of Health Service Regulation

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

MHL074-195

NAME OF PROVIDER OR SUPPLIER

BETTER CONNECTIONS MIDLAND CT

(X2) MULTIPLE: CONSTRUCTION

A BUILDING

B.WING

PRINTED: 09/16/2021
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
09/02/2021

STREET ADDRESS, CITY, STATE, ZIP CODE

3309 MIDLAND COURT

GREENVI

(x4) 1D
PREFIX
TAG

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

Vv 291

Continued From page 23

he does not eat breakfast," the - "Consultation
Form" was also signed by the Direct Care
Professional, Residential Director, and Qualified
Professional (QP).

- No documentation of discussion with the
Endocrinologist regarding client #1's frequent
refusal of diabetes medications and blood sugar
level checks or clarification of when to seek
medical attention for client #1 for elevated blood
sugar levels

- Physician's orders signed 6/15/21 and 3/18/20
for Humalog 100 units/milliliters (u/ml) Kwikpen
(treats diabetes) by sliding scale at mealtime if
blood sugar is under 90 inject 0 units, 90-150
inject 6 units, 151 - 200 inject 7 units, over 200
inject 8 units; signed 6/15/21 for Lantus (treats
diabetes) 100 u/ml inject 34 units in each morning
regardless of breakfast intake unless blood sugar
is lower than 70; Januvia 50 milligrams (mg) 1
tablet daily; Metformin (treats diabetes) 1000 mg
1 tablet twice daily with meals; check blood sugar
four times daily, before meals and bedtime;
signed 8/03/21 for Humulin N 100 units/ml
Kwikpen (treats diabetes) inject 5 units
subcutaneously at suppertime.

Review on 8/24/21 of client #1's Medication
Administration Records (MARs) June 2021 -
August 2021 revealed:

- Documentation of 121 blood sugar

check refusals.

- Documentation of blood sugar levels ranging
from 54 at 6:00 pm 8/12/21 to too high for the
glucometer instrument to register at 7:00 am
8/23/21, 7/12/21, and 7/19/21.

- Documentation of 152 refusals of Humalog.
- Documentation of 9 refusals of Humulin N. -
Documentation of 15 refusals of Metformin. -
Documentation of 13 refusals of Lantus. -
Documentation of 10 refusals of Januvia.

1D
PREFIX
TAG

V 291

LLE, NC 27833

DEFICIENCY)

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

Division of Health Service Regulation

STATE FORM

e899

SBIZ11

If continuation sheet 24 of 27

PRINTED: 09/16/2021
FORM APPROVED

Division of Health Service Regulation

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

(2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
A.BUILDING: COMPLETED

R
8. WING. | 09/02/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
3309 MIDLAND COURT

GREENVILLE, NC 27833

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION

MHL074-195

BETTER CONNECTIONS MIDLAND CT

(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 291 | Continued From page 24 Vv 291

During interview on 8/24/21 the Alternative Family
Living (AFL) Provider stated:

- The first time the glucometer registered an error
reading because client #1's blood sugar was too
high to read, he contacted the Licensee's
Registered Nurse who instructed him to give
client #1 insulin as ordered.

~ Neither client #1's primary care provider nor his
Endocrinologist gave instructions to seek medical
attention for high blood sugar levels.

- He was told to make sure there was plenty of
water available to client #1 when his blood

sugar level was high.

- Client #1's blood sugar "never stays high;" it was
high in the mornings because client #1 stayed up
and ate during the night.

- Client #1 did not refuse to take his Lantus;

Lantus was a long acting medication and helped

to keep client #1's blood sugar level "consistent."

- Client #1 had high blood sugar “all his life” and

he "felt funny" when his blood sugar was low.

During interview on 8/25/21 the QP stated some
of her responsibilities included ensuring
coordination of care and making sure staff carried
out recommendations made by the Physicians.

During interview on 9/02/21 the Clinical Director
stated:
- Client #1's August 3, 2021 Endocrinology
appointment prompted a team meeting in August.
- Client #1's team consisted of his Department of
Social Services Guardian, Local Management
Entity Care Coordinator, the QP, and the AFL
staff.
- The team discussed client #1's medical and
behavioral needs.

This deficiency is cross referenced into 10A

Division of Health Service Regulation
STATE FORM 6899 SBIZz11 If continuation sheet 25 of 27

PRINTED: 09/16/2021
FORM APPROVED

Division of Health Service Regulation

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

CONSTRUCTION (X3) DATE SURVEY

COMPLETED

(X2) MULTIPLE
A. BUILDING

R
09/02/2021

B.WING

MHL074-195

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
3309 MIDLAND COURT
GREENVILLE, NC 27833

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES. ID 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)

BETTER CONNECTIONS MIDLAND CT

Vv 291 | Continued From page 25

NCAC 27G .5601 Scope (v289) for a Type A‘ rule
violation and must be corrected within 23 days.

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

10A NCAC 27G .0303 LOCATION AND.
EXTERIOR REQUIREMENTS

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

odor.

This Rule is not met as evidenced by: 736 11-2-21
Based on observation and interviews the facility RD will complete monthly house

was not maintained in a clean, attractive checks to address cleanliness and

manner. The findings are: need for repairs. Work orders will

Observation on 8/24/21 at approximately 1:20 pm be completed when repairs are

of the facility revealed: needed in homes.

- Heavy dried food splatter on the ceiling of the

eee. tesur Pisa act ' Agency will notify landlord of needed}
- The laminate surface of the kitchen counter Fos P

near the sink was scuffed and faded. hae d Kitchen counter near sink

- Heavy dark stains to the carpet throughout (scuffed and faded).

the facility.

- Damage consistent with water damage to (Carpet will be shampooed. Contact

the:nall- batnream wall will be made with landlord to inquire

During interview on 8/24/21 the Alternative about having carpet replaced.

Family Living staff stated he and the clients
worked together to keep the facility clean

During interview on 9/01/21 the Quality
Assurance/Chief Executive Officer stated the
stains in the carpet had been cleaned but kept

Division of Health Service Regulation
STATE FORM 6899 SBIZ11 If continuation sheet 26 of 27

PRINTED: 09/16/2021

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
MHL074-195 B.WING 09/02/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
3309 MIDLAND COURT
GREENVILLE, NC 27833

(X4) 10 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)

BETTER CONNECTIONS MIDLAND CT

V 736 | Continued From page 26

coming back. The only way to eliminate the
stains was to replace the carpet.

Division of Health Service Regulation
STATE FORM 6899 SBIZ11 If continuation sheet 27 of 27

Name (Orig User Email Join Time Leave Time Duration (! Guest Recording Consent

Charletta Bcbasnight@ ###HHHHH HHHHHHHH 148 No Y
deborah gc dgorham@ ##HHHHHH HHHHHHHH 140 No Y
Glenn Simr glennsimm ###HH##H HHAHHHHH 4 Yes
Glenn Simr glennsimm #######HH HHHHHHHH 117 Yes Y
Teairra Mo teairraS87« #iitititittt §HititiHHHt 1 Yes
Teairra Mo teairraS87( #itititiittt HitititHtititt 4 Yes
Zinia Holle, zholley@di ######HH HHAHHHHH 2 Yes
Robin Snearsnead@be #ii###HH HHHHHHHH 1 Yes
Zinia Holle) zholley@qi ####HHHH HHHHHHHH 3 Yes
Robin Snearsnead@be ####HHHH HHHHHHHE 114 Yes Y
Zoom user lovmuffinG ##HHHHHH HHHHHHHH 1 Yes
Zoom user lovmuffin@ ###HHHHH HHHHHHHH 5 Yes
Teairra Mo teairraS87( ####HHHH #HHHHHHHH 1 Yes
zholley HHHRHHHH #HHHHHHHH 1 Yes
zholley HHHHHHHH HHHHHHHH 110 Yes Y
denise HHHHHHHH HHHRHHHH 1 Yes
denise HHHHHHHH HHHHHHHH 55 Yes
Better Con jwilllams@ #####H#H## #HHHHHHHH 2 No
Better Con jwilllams@ ####H#H### HHHHHHHH 105 No ¥
Joey Davis joeydaviso: #HHHHHHH HHHHHHHH 1 Yes
Joey Davis joeydavis9: #HHHHHHH HHHHHHHH 104 Yes Y
Telisha Clemons HHHHHHHH HHHHHHHH 1 Yes
Telisha Clemons HHHHHHHH HH HH HHH 103 Yes Y
Nelle Kinse nellekinsey ######## HHHHHHHH 1 Yes
Nelle Kinse nellekinsey #######HH H#HHHHHHH 84 Yes Y
nellie k HHHHHHHH HHHHHHHH 1 Yes
nellie k HHHHHHHH HHHHHHHH 94 Yes ¥
valerie hunter HaHHHHHH HHHHHHHE 1 Yes
valerie hunter HHHHHHHH HHH 78 Yes Y
Teairra Mo teairraS87( #HHHHHHH #HHHHHHHH 31 Yes
Teairra Mo teairraS87( ##HHHHHH #HHHHHHHH 45 Yes
Nelle Kinse nellekinsey HHHHHHHH #HHHHHHH 1 Yes
Nelle Kinse nellekinsey ###HHHHH #HH#HHHHAH 6 Yes
Nelle Kinse nellekinsey HHHHHHHH #HHHHHHH 5 Yes
Teairra Mo teairraS87( HHHHHHHH H#tHHHHHH 37 Yes ¥

® DOKRSWD e SEARS ww, WSroan Saced

Adding Medication Orders

While the best practice is to allow your pharmacy to enter medication orders for you into
their dispensing software, which will then populate into QuickMAR, situations sometimes
arise where the facility finds it necessary to add these types of orders themselves.

Adding a medication order is very similar to adding any other type of order, but there are a
few important differences to note. Here's what adding a medication looks like within

QuickMAR:

1. Select a resident, click on the "Add" button above the orders list, and select
"Medication."

Prefile Orsers Info Oreers Tasks

Add
—_y

Treatment

Vital Sign

Medication
Medication PRI
Medication
LISINOPRIL 10 MG TAB... Macication
LOPERAMIDE 2MG TA... Medication

Pick From List

Start typing in the name of the medication If it pops up in the list, select it; this means we

can run an interaction check on this medication Fo

®

Print Options

If the name of the medication does not immediately appear, click on "Show Alll.” If it still
does not appear, you can add it anyway, but we won't be able to run an interaction check
on that medication for you.

Enter the diagnosis if that is required by your state or organization.

Designate that it is coming from a source (sources are defined within your
settings) other than your primary pharmacy

"'* New Order" 7 \|=

NOTE: This is very important, since doing this will prevent facility staff from
accidentally requesting a refill from your primary pharmacy when they are not the
ones filling/managing that medication.

Add instructions as to how to administer the medication and a schedule that
matches the instructions.

“* New Order

Adjust the end date, if necessary.

Soar +" New Order ***

Print Options

Save the order.

tii

S
ll

Everysring *** New Order ***

: If not all of the resident's orders are in the Medi-Span database, you may see a
screen like this alerting you to the fact that we were unable to run interactions on one or
more of the resident's medications.

STATUS: OUT OF FACILITY

Choosing the status 'OUT OF FACILITY’ will allow a user to perform the same function as
suspending all medications. When selecting this status be sure to enter a return date. If you
are not sure of a return date you will need to select 'ENTER RETURN DATE LATER’. This
option will allow this box to reappear when the resident returns and you select the status of
‘IN FACILITY". If you skip this step then the MAR will result in missed meds for the time
period the resident was out of the facility.

Marking a Resident Out of Facility

Using the Status field on the resident's Profile tab, you can mark a resident as Out of
Facility.

If you choose Out of Facility, you'll need to indicate more information:

¢ Start of absence

e End of planned absence 'ENTER RETURN DATE LATER'

e Reason for absence such as hospital, respite, jail ... anytime that meds will be
suspended from being given ...so not a home visit because you would be
providing meds to be given later

Resident will appear in the med pass but will not be pickable, and will be clearly labeled with
the Out of Facility tag

When the resident returns, you need to change the status from Out of Facility to Active or In
Facility again. The dialog box will appear where you can indicate exactly when the resident

returned.

The MAR will reflect the absence, with a note. And dashes will appear in the MAR boxes
during the time the resident was OOF.

Med Pass Progress

The dashboard lets you view the information for any single cart, or for the whole facility. Just

use the drop-down menu above the tabs to make your selection.

CAL carts
|All

|

The Med Pass Progress tab shows how far along you are to completing the med pass
within your facility. The white background area indicates med rounds that have already
passed. The gray background shows med rounds still to come.

All Carts

Med Pass Progress

Admin Time Items Due Items Remaining % Complete
[ Ce 1 | oO] | 100 %
7AM 8 1 87%
BAM a i o ~| 100 % “|
9AM CU 0 100%
| 10 AM [ a 0 - 100 %
TT AM 3 _ in oO 100 % |
12M | Bw oo 100 %
1M [ 6 7 0 [100%
22M 2 0 100%
| 3PM — 5 to 4 “| ae
4PM 28 to Z 10%
“52M 40 9 ar
[ OM 1 I ot mC

Recognizing and Clearing Alerts

Alerts will help you stay on track with your med pass
Purpose of Alerts

Alerts are friendly reminders that you've forgotten to document something, so that you don’t
end the day with holes in your MAR.

¢ For items with a single admin time (e.g. 8:00 am), alters indicate that those items

are “overdue.”
« For items with a time range for administration (e.g. 6:00-10:00 am), alerts indicate
that you are approaching the end of your administration window.

Recognizing Alerts - Look for the Dot

Alerts will show up in two locations:

eo
e.
ae

deers Hi] Meu disposition

Receive Meds

Billing

Demo Py ( CareSuite

1 Within the Med Pass

o © &
~ P

On the Pass Meds button

On the resident's information tile

2 On the clock icon at the top of your screen

Clearing Alerts - Go to the Clock

While you can clear alerts by going to the affected med pass from the Pass Meds button, it
is sometimes difficult to tell which pass is being affected that way. For example, if it is 2:30
in the afternoon, it may be difficult to tell at first glance whether the Noon or the AM pass
has a late med.

So, the fastest, easiest way to clear alerts is to go to the in the top, right-hand side of
your screen. A box like this will then tell you:

e Who needs attention

You can go straight to the med pass for this person by clicking on the “Go To Med Pass”
button.

"E: This will NOT take you only to the specific meds that are overdue, but rather to the
broad, med pass window that is affected by the alerts

“PejtenSte

Allergios

Jaformational Orders
NR

NOTATION |

Then complete the pass as you would any other :

Reviewing and Approving Orders — Quickmar

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Articles in this section

e Reviewing ar Vi r

° About the Review Meds Henle

e Adding a New rt esident
¢ Adding a Bosch Order el a Liat of Orders
° ‘Addi g Vitals

° ing dicati ders

e ing Short-term

e Bar Codes

e Change History for an Order

e Changing the Order Type

See more
Reviewing and Approving Orders

e | year ago
¢ Updated

Follow

Green Flag Orders:

Approve: will allow an order to be administered

Reject: order will either be discontinued immediately (start date same as end date) or for a future date (start date and
end date differ) . f you chose this action- the Pharmacy will lose ownership of that order.

https://support.quickmar.com/hc/en-us/articles/360034 123 154-Reviewing-and-Approving-Orders[9/22/2021 7:20:34 PM]

Reviewing and Approving Orders — Quickmar
Red Flag Orders:

Needs Attention!

Yellow Flag Orders:

Discontinued- please review and approve.

Edit an Order

Flag could require an edit/fix before order can be approved.

Unlock an Order

CAUTION!! Unlocking an order could affect your MAR! Please discuss with your pharmacy whether to Unlock OR
Discontinue and re-add.

Only QuickMAR Support or the Pharmacy can unlock orders.

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Recently viewed articles
e Di inuing ¢

Related articles

¢ Completing a Routine Med Pass

e Editing an Order

¢ Locked Orders and Unlocking Orders
e Understanding the Types of Orders

Comments

https://support.quickmar.com/hc/en-us/articles/360034 123 154-Reviewing-and-Approving-Orders(9/22/2021 7:20:34 PM]

Reviewing and Approving Orders — Quickmar

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https://support.quickmar.com/he/en-us/articles/360034123 | 54-Reviewing-and-Approving-Orders[9/22/2021 7:20:34 PM1

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Green Flag Orders:
Approve: will allow an order to be administered

Reject: order will either be discontinued immediately (start date same as end date) or fora
future date (start date and end date differ) .

PREDNISONE 2.53 TAB Gz

Approve and Reject Buttons wil! appear for all new orders

Pata oto Tete TO THRE

ed

Remember to hit Save! | oa

Red Flag Orders:

Needs Attention

Review needed for
this DC’d order

Check to make sure this is a valid DC notification

NEXIUM 40 MG CAPSULE

Edit an Order

Flag could require an edit/fix
before order can be approved.

PREDNISONE

TAD

Start and End Dates:
If pharmacy owns the order, click
on blue pencil to make changes

Note: changes may revert when medication is re-ordered

hanges to the Schedule: : _ |

lick on the time or details drop down to edit | z

Oe Eat ‘If additional times are nee: ui he +Add ; can
= ee eee Button, or the X to delete a time |

Order Management

e All orders to be sent by fax to Dempsey’s LTC Pharmacy
Kinston either by yourself or directly from the prescriber.
This applies in all cases except in situations where a
medication is needed immediately, and a back pharmacy is
used. In this situation you will need to manually enter the
order in Quick MAR and provide just a copy to Dempsey’s
for their reference (see instructions)

e Dempsey’s’ Fax number is (252) 686-5055. Contact is
Morgan Walker: morgan@kinstonpharmacy.com or cell (252) 286-

1794 during normal business hours
e Once the order is entered in Quick MAR it will have a
Green Flag noting it needs to be reviewed. Reviewing
an order includes: (see instructions Flags and Tags)
o Ensuring the name, dosage, frequency, and
routine are all entered as written on the order
o Ensuring start and stop dates and times are
consistent with when the medication will first be

administered

o Approve the order entry once everything has
been reviewed and is accurate AND you have the
medication on hand, and it is ready to be
administered

o DO NOT approve an order if you to do not have
the medication on hand to administer. Approving

a green flag signals that the medication is ready
to be given and will populate on the MAR. If
you're not ready to start the medication and you
approve it this will create holes in your MAR.
e A doctor's appt or a discharge from a hospital are
good indicators that there may be a medication
change coming, new order or discontinued order that
you need to be on the look out for.

o Hospital Discharges- always review the discharge
medication list for any medications that were
DCd, changed or new. Always send a copy to
Morgan. This is helpful because the hospitals
don't send DC orders so Morgan will need to see
what has changed upon discharge follow up with
an email

Discontinued Medications- If a hospital has DCd a
medication upon discharge it is important to
Discontinue the medication in Quick MAR so that it
doesn't continue to be administered. You can simply
do this by adjusting the Stop Date and Save. This will
create a Yellow Flag indicating that the DCd med
needs to be approved. Discontinued meds will

continue to show in the med pass until approved.
e If a doctor's office has DCd a med, please ask for a DC
order. DC orders should be sent to Dempsey’s like all

If you have questions or are not sure about an order or consult
start with your supervisor and if the QP is also unsure you can
contact Denise Hawkes, Robin Snead, Nurse Karen, Hiram
Grady, and we can assist with any questions.

Hiram Grady- hiramgrady @lahicomedical.org or 252-559-5901

Karen Farley- 910-330-6475

9/23/21, 9:50 AM MedAssure—Passing Meds Offline - Quickmar

by PointClickCare

MedAssure—Passing Meds Offline

MedAssure—Passing Meds Offline

MedAssure is the QuickMAR feature that lets you continue to pass meds, even when the internet is down. MedAssure is mostly a
background feature that will have little impact on your day-to-day use of QuickMAR. However, there are a few important changes,
and things you ought to watch for and be aware of, so that you use QuickMAR properly.

Enabling MedAssure

MedAssure is designed only to enable passing meds when offline. Therefore, it is best if it is enabled only on the computers that
typically are used to pass meds.

https://support.quickmar. com/hc/en-us/articles/2357 36847-MedAssure-Passing-Meds-Offline

114

9/23/21, 9:50 AM MedAssure—Passing Meds Offline - Quickmar

Administrative computers, such as those used by the DON or Supervisor, or any home computer using QuickMAR®
best if MedAssure is NOT enabled.

perform

To Enable or Disable MedAssure, go to the Admin/Options menu and set the checkbox as appropriate.

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Forcing MedAssure

As an Administrator, you can also enable MedAssure on some other machine, without being physically logged in to that machine.

You can also Force MedAssure to be enabled and prevent it fram being disabled by anyone but an administrator.
https://support.quickmar.com/hc/en-us/articles/235736847-MedAssure-Passing-Meds-Offline 2/4

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PARADIGM, INC.

CERTIFICATE OF COMPLETION

Presented to

Joey Davis

For Successfully Demonstrating Competency and Completing

MEDICATION ADMINISTRATION

9/22/2021

= AS: Ler)

Saxon T Barnett, BSN, a, jastenctar

PARADIGM, INC.

CERTIFICATE OF COMPLETION

Presented to

Demetrius Everett

For Successfully Demonstrating Competency and Completing

MEDICATION ADMINISTRATION

9/22/2021

PARADIGM, INC.

CERTIFICATE OF COMPLETION

Presented to

Anthony Davis

For Successfully Demonstrating Competency and Completing

MEDICATION ADMINISTRATION

9/22/2021

ay, Ke Ls

- Barnett, BSN. RN-Trainin Instructor

Physicians East P.A. - Endocrinology

1006 WH Smith Bivd Suite - EDC
Greenville, NC 27834
2524136683 Fax: 2528300558

09/02/2021

Medication orders.

1. If blood sugar is over 500 or below 40, contact primary MD. If blood sugar is over 500 and he is
having emesis, send to emergency department.

2. If unconcious from hypoglycemia, give shot of Gvoke.

3. Change Lantus to to 30 units in pm at supper time.

4. Discontinue Humalog.

5. Start Humulin R insulin before meals by sliding scale: if blood sugar 90-150: 6 units, 151-200, 8
units, over 200: 8 units.

4. Discontinue morning Lantus.

5. Discontinue metformin.

6. Start metformin XR, 750 mg, 2 tablets at supper.

7. Discontinue Humulin N insulin.

Mark L. Warren, M.D., F.A.C.E.

qn

Physicians East P.A. - Endocrinology September 2, 2021
1006 WH Smith Blvd Suite - EDC Greenville, NC 27834 Page 1
2524136683 Fax: 2528300558 Rx Refill

ee

09/02/2021 - Rx Refill
Provider: Mark Warren MD
Location of Care: Physicians East P.A. - Endocrinology

Prescription:
Medic Alert bracelet for Diabetes Mellitus type 1

Mark L. Warren, M.D., F.A.C.E.

Electronically Signed by Mark Warren MD on 09/02/2021 at 1:21 PM

Mer

Vyec ewe ai, anmiee

Individual Name
Medicaid Number
Date of Birth

Better Connections, Inc.

Residential Supports 4 AFL 09/23/2021- 12/31/21 (ISP

Program)

Form ID

Time Zone
Status

Entered By
Submitted By
Approved By
Last Updated By

Provider Program
@ Individual Name
ISP Program Name

Start Date
End Date

Target Completion
Date

Location

Long Term Objective

Goal/Service

&

a2

ISP-BCINC-KBQ4R84XVFJSD
US/Eastern

Denise Hawkes, Lead QP on 09/22/2021 11:48 AM
Denise Hawkes, Lead QP on 09/22/2021 05:36 PM
Denise Hawkes, Lead QP on 09/23/2021 01:29 PM
Denise Hawkes, Lead QP on 09/23/2021 01:46 PM

Residential Supports (Midland Court)

Residential Supports 4 AFL 09/23/2021- 12/31/21
09/23/2021
12/31/2021
12/31/2021

Residence/Community

ii receive the support and assistance necessary to maintain his
overall health, safety and well-being.

ill receive the support necessary to complete his activities of daily
living.

jal] will attend physician appointments.
1b. Daily. ill comply with medication regimens and follow doctor orders

as prescribed to better control his diabetes and to help improve his A1C

1c. Dailys will be receptive to eating healthy nutritional meals and

snacks to better control his diabetes and improve his A1C.

id Before leaving his home for 2 hours of unsupervised time in the community,
ill check his blood sugar and take his diabetes emergency supplies

with him for health and safety.

1e. When expecting visitors during the day or night vi alert his staff

about his visitor coming to see him for safety concerns

1f. ill utilize his coping skills instead of getting angry.

1g will communicate his feelings and frustrations to his staff.

Ji. ill participate in safety drills at home.

1g will display safe behaviors in the home

2a will bath, brush teeth and perform all other oral hygiene activities
dail

2b. will keep a neat appearance.

2c. will keep his living area clean.

2d. will complete laundry duties as needed.

2e. will budget his monthly funds so that they last throughout the month.
2f. ill use his unsupervised time during the day light hours instead of

night fall hours for safety precautions

Therap

Generated from Therap ‘ISP Program’ by Charletta Basnight, Better Connections, Inc. on 09/23/2021

01:49 PM.

Page 1 of 13

Individual Name
Medicaid Number
Date of Birth

Better Connections, Inc.

Reason for ISP
Program

Criteria for
Completion

Materials Required

Individual requires 24 hour placement

Add any other justification for RS services here from plan

based on goal statement and progress on goals

as noted in goal statement

Client Specifics:

1. DIAGNOSES: F20.0-Paranoid Schizophrenia

F71 Moderate IDD

E10.65 Type 1 Diabetes Mellitus with Hyperglycemia Z79.4 Long Term
(Current) Use of Insulin

110 Essential (Primary) Hypertension

E78.5 Hyperlipidemia, unspecified

Z91.11 Patient's Noncompliance with Dietary Regimen M79.10 Myalgia,
Unspecified Site N18.3 Chronic Kidney Disease, Stage 3 (Moderate)
286.14 Personal History of Methicillin Resistant Staphylococcus Aureus
Infection (MRSA)

279.899 Other Long Term (Current) Drug Therapy

L85.3 Xerosis

L28.0 Lichen Simplex Chronicus

2. MODE OF COMMUNICATION :Verbal

3. ANY PHYSICAL LIMITATIONS: Ambulatory

4. BEHAVIORIAL iSSUESSRMEEFecuires support because he can be
victimized. Others have talked him into giving them his things, such as his
shoes, in the past. has a history of being sexually abused as a
child and as an adult. equires support to participate in activities
because of issues with anger control, depression. issues with past substance
abuse, and other mental health concerns, as been hospitalized «
several times. Most recently, he was hospitalized from September 2018
through Jan; 19 at Vidant Medical Center in Greenville due to

» depression lhas a history of being treated for alcohol abuse. He admits

to using marijuana in the past. He denies using illegal drugs now]

diagnosed with schizophrenia. He does present with delusional or paranoid
thoughts. At times, he feels that others are jealous of him due to his musical
abilities and want him dead. also feels that people sit in their cars and
watch his home. He requires support to take his medications to prevent these
thoughts from becoming overwhelming. lhas engaged in self-injurious «
behaviors in the past. He saw another resident engage in cutting behaviors,
and she told him it felt . He then tried it himself. He does not engage in this

» behavior anymore] is not suicidal at this time, but he has a history of

suicidal ideation per his psychological evaluation. He has not exhibited any
sexual behaviors or sexually assaulted anyone

5. MEDICAL CONCERNS: Type 1 diabetes, MRSA, Hypertension,
Hyperlipidemia, Myalgia, Chronic Kidney Disease stage 3 (moderate), Xerosis,

implex Chronucus
ae: sensitive skin. Sometimes laundry detergent causes him to itch. His
rescribes a cream when this occurs. He is also allergic to all forms of
penicillin. lt causes his face and mouth to swell; however, his airway does not

become obstructed.
6. INDIVIDUAL IS ABLE TO SELF MEDICATE: No

6 7. ADAPTIVE EQUIPMENT: lhas a glucometer to check his blood sugar

levels. He has glucose testing strips.
8. SERVICES RECEIVED:
Residential Supports 3

Community Networking

Day Supports

SCS

Therap Generated from Therap ‘ISP Program’ by Charletta Basnight, Better Connections, Inc. on 09/23/2021

01:49 PM.

Page 2 of 13

Individual Name
Medicaid Number
Date of Birth

Better Connections, Inc.

Frequency
Schedule

Comment

Maximum Number of
Times a Day

Allow collection of
multiple task scores
for a single day

Scoring Method

Default Score

Task Scoring
Comments

Baseline Dates From

To

Schedule And Frequency: Daily; Frequency Of Documentation: each time goal

is run

10

Yes

Innovations Level of Independence
|= Independent= Goal Met

G= Gesture/1 Met

G= Gesture/2 Not Met

VP= Verbal Prompt/1 Met

VP= Verbal Prompt/2 Not Met

M= Model/1 Met

M= Model/2 Not Met

PA = Physical Assistance/1 Met

PA = Physical Assistance/2 Not Met
R=Refused/2 Not Met

NA= Not Applicable

None

Therap ® Generated from Therap 'ISP Program’ by Charletta Basnight, Better Connections, Inc. on 09/23/2021

01:49 PM.

Page 3 of 13

Better Connections, Inc.

Individual Name
Medicaid Number

Date of Birth
Loni Description Baseline Score
I= Independent= Goal
Met 0%
G= Gesture/1 Met 0%
G= Gesture/2 Not Met
0%
VP= Verbal Prompt/1
Met 0%
VP= Verbal Prompt/2
9
efa a. attend all physician appointments each time as Not eae Met 0%
Health scheduled. M= Model/2 Not Met
0%
PA = Physical
Assistance/1 Met 0%
PA = Physical
Assistance/2 Not Met
0%
R=Refused/2 Not Met
0%
NA= Not Applicable
0%
l= Independent= Goal
Met 0%
G= Gesture/1 Met 0%
G= Gesture/2 Not Met
0%
VP= Verbal Prompt/1
Met 0%
VP= Verbal Prompt/2
e tb. Daily i comply with medication regimens and follow Not Met 0%
Health doctor orders as prescribed to better control his diabetes and to M= Model/1 Met 0%
help improve his A1C M= Model/2 Not Met
0%
PA = Physical
Assistance/1 Met 0%
PA = Physical
Assistance/2 Not Met
0%
R=Refused/2 Not Met
0%
NA= Not Applicable
0%
l= Independent= Goal
Met 0%
G= Gesture/1 Met 0%
e 1c. Daily, be receptive to eating healthy nutritional G= Gesture/2 Not Met
Health meals and snacks to better control his diabetes and improve his 0%
AIC. VP= Verbal Prompt/1
Met 0%
VP= Verbal Prompt/2
Not Met 0%

M= Model/1 Met 0%
M= Model/2 Not Met

Therap Generated from Therap ‘ISP Program’ by Charletta Basnight, Better Connections, Inc. on 09/23/2021 Page 4 of 13
01:49 PM

Better Connections, Inc.

Individual Name
Medicaid Number

Date of Birth
Nia Description Baseline Score
0%
PA = Physical
Assistance/1 Met 0%
PA = Physical
Assistance/2 Not Met
0%
R=Refused/2 Not Met
0%
NA= Not Applicable
0%
I= Independent= Goal
Met 0%
G= Gesture/1 Met 0%
G= Gesture/2 Not Met
0%
VP= Verbal Prompt/1
Met 0%
VP= Verbal Prompt/2
® 1d. Before leavi is home for 2 hours of unsupervised time in the Not Met 0%
Copin aan check his blood sugar and take his M= Model/1 Met 0%
9 diabetes emergency supplies with him for health and safety. M= Model/2 Not Met
0%
PA = Physical
Assistance/1 Met 0%
PA = Physical
Assistance/2 Not Met
0%
R=Refused/2 Not Met
0%
NA= Not Applicable
0%
I= Independent= Goal
Met 0%
G= Gesture/1 Met 0%
G= Gesture/2 Not Met
0%
VP= Verbal Prompt/1
Met 0%
VP= Verbal Prompt/2
9
e 1e. When expecting visitors during the day or right alert Mousa Met 0%
Behavior his staff about his visitor coming to see him for safety concern M= Model/2 Not Met
0%
PA = Physical
Assistance/1 Met 0%
PA = Physical
Assistance/2 Not Met
0%
R=Refused/2 Not Met
0%
NA= Not Applicable
0%
we tf: ill successfully use learned coping skills to manage l= Independent= Goal
Safety frustration and stress at least 5 out of 7 days a week Met 0%

G= Gesture/1 Met 0%

Therap’ Generated from Therap 'ISP Program’ by Charletta Basnight, Better Connections, Inc. on 09/23/2021 Page 5 of 13
01:49 PM

Better Connections, Inc.

Individual Name
Medicaid Number
Date of Birth

Task rrr 7
Naiie Description Baseline Score

G= Gesture/2 Not Met
0%

VP= Verbal Prompt/1
Met 0%

VP= Verbal Prompt/2
Not Met 0%

M= Model/1 Met 0%
M= Model/2 Not Met
0%

PA = Physical
Assistance/1 Met 0%
PA = Physical
Assistance/2 Not Met
0%

R=Refused/2 Not Met
0%

NA= Not Applicable
0%

|= Independent= Goal
Met 0%

G= Gesture/1 Met 0%

G= Gesture/2 Not Met
0%

VP= Verbal Prompt/1

Met 0%

VP= Verbal Prompt/2

9
e ‘of. communicate his feelings to staff and allow staff to Nas remy Met 0%
Safety assist him through feelings of frustrations at least 3 times per week. M= Model/2 Not Met

0%

PA = Physical
Assistance/1 Met 0%
PA = Physical
Assistance/2 Not Met
0%

R=Refused/2 Not Met
0%

NA= Not Applicable
0%

|= Independent= Goal
Met 0%

G= Gesture/1 Met 0%

G= Gesture/2 Not Met
0%
VP= Verbal Prompt/1

e wo participate in all safety drills each time drills are Met 0%
Safety hel& VP= Verbal Prompt/2

Not Met 0%

M= Model/1 Met 0%
M= Model/2 Not Met
0%

PA = Physical
Assistance/1 Met 0%
PA = Physical
Assistance/2 Not Met

Therap’ Generated from Therap ‘ISP Program’ by Charletta Basnight, Better Connections, Inc. on 09/23/2021 Page 6 of 13
01:49 PM.

Better Connections, Inc.

Individual Name
Medicaid Number

Date of Birth
Laid Description Baseline Score
0%
R=Refused/2 Not Met
0%
NA= Not Applicable
0%
l= Independent= Goal
Met 0%
G= Gesture/1 Met 0%
G= Gesture/2 Not Met
0%
VP= Verbal Prompt/1
Met 0%
VP= Verbal Prompt/2
9
« a perform daily hygiene activities daily i.e. bath daily Me wet O% 9
m ‘ = Model/1 Met 0%
Hygiene and brush teeth 2x daily etc. M= Model/2 Not Met
0%
PA = Physical
Assistance/1 Met 0%
PA = Physical
Assistance/2 Not Met
0%
R=Refused/2 Not Met
0%
NA= Not Applicable
0%
I= Independent= Goal
Met 0%
G= Gesture/1 Met 0%
G= Gesture/2 Not Met
0%
VP= Verbal Prompt/1
Met 0%
VP= Verbal Prompt/2
@ 2b a. wear clean clothes and maintain a neat appearance Not Met 0%
Chores 7oO lays a week will refrain from any dangerous or M= Model/1 Met 0%
hazardous behaviors at home 7 out of 7 days a week M= Model/2 Not Met
0%
PA = Physical
Assistance/1 Met 0%
PA = Physical
Assistance/2 Not Met
0%
R=Refused/2 Not Met
0%
NA= Not Applicable
0%
|= Independent= Goal
Met 0%
= 9
* cd clean his room and perform other assigned daily G= Gesture/1 Met 0%
Chores chores at least 5 out of 7 days a week. G= Gesture/2 Not Met
0%
VP= Verbal Prompt/1
Met 0%

Therap’ Generated from Therap ‘ISP Program’ by Chareta Basnight Better Connections, inc. on 09/23/2021 Page 7 of 13

Better Connections, Inc.

Individual Name
Medicaid Number
Date of Birth

Task Tose 7
Name Description Baseline Score

VP= Verbal Prompt/2
Not Met 0%

M= Model/1 Met 0%
M= Model/2 Not Met
0%

PA = Physical
Assistance/1 Met 0%
PA = Physical
Assistance/2 Not Met
0%

R=Refused/2 Not Met
0%

NA= Not Applicable
0%

|= Independent= Goal
Met 0%

G= Gesture/1 Met 0%

G= Gesture/2 Not Met
0%

VP= Verbal Prompt/1
Met 0%

VP= Verbal Prompt/2
Not Met 0%

« 2d i complete laundry duties at least once a week M= Model/1 Met 0%
M= Model/2 Not Met
0%

PA = Physical
Assistance/1 Met 0%
PA = Physical
Assistance/2 Not Met
0%

R=Refused/2 Not Met
0%

NA= Not Applicable
0%

I= Independent= Goal
Met 0%

G= Gesture/1 Met 0%

Budgeting

G= Gesture/2 Not Met
0%
VP= Verbal Prompt/1
Met 0%
VP= Verbal Prompt/2
@ 2e. After receiving monthly ince A budget his funds in a Not Met 0%
Budget manner that would allow him to have funds at least 3 out of the 4 M= Model/1 Met 0%

weeks in the month. M= Model/2 Not Met
0%
PA = Physical
Assistance/1 Met 0%
PA = Physical
Assistance/2 Not Met
0%
R=Refused/2 Not Met
0%
NA= Not Applicable
0%

Therap Generated from Therap 'ISP Program’ by aaron rie Better Connections, Inc. on 09/23/2021 Page 8 of 13.

Better Connections, Inc.

Individual Name
Medicaid Number
Date of Birth

Task ee
Name Description Baseline Score
l= Independent= Goal
Met 0%
G= Gesture/1 Met 0%

G= Gesture/2 Not Met
0%

VP= Verbal Prompt/1

Met 0%

VP= Verbal Prompt/2

9
@ 2f. will use his unsupervised time during the day light hours Not Met 0% o
Safet instead of night fall hours for safety precautions M= Modell Met 0%
y 9 yp M= Model/2 Not Met
0%
PA = Physical
Assistance/1 Met 0%
PA = Physical
Assistance/2 Not Met
0%
R=Refused/2 Not Met
0%
NA= Not Applicable
0%

a fi p ‘ cl 123):
Tierap Generated from Therap ‘ISP Program! by Charitta oe Better Connections, Inc. on 09/23/2021 Page 9 of 13

Better Connections, Inc.

Individual Name
Medicaid Number
Date of Birth

Description
@ 1a. Staff will assist th transportation and with communicating concerns during physician
appointments.

@ 1b. Staff will administer medications as prescribed. Staff will inform emacth the importance of taking
« medications. is a Diabetic with Type 1 Diabetes 1 Uncontrolled. Staff will remin of the
« importance of taking his medication and his blood sugar levels sti refuses his medication staff
* will document "R" for refusal on the MAR. Staff assist wit following his EMERGENCY PROTOCOL
from his physiciaj
Staff will Monitor! sugar levels
For Type 1 diabe will make sure, monitor blood sugar before meals and before bedtime.
Staff will assist with checking his blood sugars if he notice symptoms of low blood sugar. Those
symptoms include:
Hunger.
Shakiness or nervousness.
Sweating.
Dizziness or light-headedness.
Sleepiness.
Confusion.
Difficulty speaking.
Anxiety.
Weakness.
Staff will assist th checking his blood sugars if he notice symptoms of HIGH blood sugar. Those
symptoms inclua®
Dehydration
Feeling Porched
Diarrhea
Frequent Urination
Unclear vision
Light headiness

e will he censity healthy foods. Staff will assist with preparing healthy meals for
«| lis diagnosed with Type | diabetes Uncontrolled. Staff will offer meals and snacks that are diabetic
niendly. Staff will follow the recommendations of the Nutritionist. I refuses meals this will bea

documented in Therap.

1d. Staff will provide assistance or prompting cues for pack his diabetic supply bage
* Staff will assist/prompt {EEE to check his blood sugar before he starts his 2 hours unsupervised time.
¢ Gai follow his NCY PROCTOCAL if blood sugars are to LOW or to HIGH
q Staff will acsictprompt als check his diabetic bag to make sure all supplies are in his bag. (
lucometer, bottle(s) of water, and snack(s), and emergency contact information
i let staff know where he is going
Staff will assist/prompt with wearing his Diabetic ID Bracelet

«te. ii
Telephone his friend(s) ahead of time
and ask his friend (s) when they would like a visit wi alert his staff concerning the arranged visit
with his friend(s)
After each visit, Staff will assistprompl ith setting a time for the next visit
a" use good judgment on best times Tor his friend(s) to visit that does not interfere with treatments,
Or personal activities.
Staff will assist/promptEE about his friend(s) just showing up without a call in advance and without

h ing another time.
will be respectful to others in the home
© 1f. Staff will encouraged | use hi ing skills when staff notices upset or getting
upset.1e. Staff will be open to listening tofilllllexpress his concerns and frustrations. Staff will

Therap’ Generated from Therap 'ISP Program’ by Charts Basnight Better Connections, Inc. on 09/23/2021 Page 10 of 13

Better Connections, Inc.

Individual Name
Medicaid Number
Date of Birth

Description
encouragd_ilig talk out his frustrations and concerns.

1g. Staff will coach i. needed through safety drills. Staff re-cirec i needed.

th. Staff will coach in how to avoid safety hazards at home i.e. using microwave, appliances,
locking doors at night, not opening doors for strangers etc.

2a. Staff will remind/prompt flo take baths daily, brush teeth 2x a day and complete other hygiene
duties.

2b. Staff will assicis needed to ensure he keeps a neat appearance. ex: clean clothes, clothes in
good condition, haircut etc..

2c. Staff will remind/promp(‘o clean his room and complete household chores

2d. Staff will assist vith operating the washer and dryer. Staff will coaci on how to use the
machines.

2e. Staff will assist J witn budgeting his funds. Staff will give coaching and advice on how to bargain
shop and save money.

2f. Staff will remind cbout using his unsupervised time during the day light hours instead of night fall

hours for safety ns
Staff will educate] concerning the danger and safety of leaving the home at night fall without
informing staff

*

EVV Supporting No
Document

Billable ISP Program Default Yes

Therap Generated from Therap 'ISP Program’ by chat Reenlatit Better Connections, Inc. on 09/23/2021 Page 11 of 13

Better Connections, Inc.

Individual Name
Medicaid Number
Date of Birth

Type of Service
Provider

ISP Program Author Todd Davis, QP
Time Duration Format Begin Time and End Time
Are Begin Time and No
End Time or Time

Duration required for
data collection?

Allow data collection Yes
with Time Overlap

Location for data Optional
collection

Editable Service Yes
Provider for data
collection?

Are Other Comments No
required for data
collection?

Attach File(s) Nothing Attached

Attach Image(s)

Therap Generated from Therap ‘ISP Program’ by id radi Better Connections, Inc. on 09/23/2021 Page 12 of 13

Better Connections, Inc.

Individual Name
Medicaid Number
Date of Birth

Signature

Unable to obtain written signature due to COVID-19 State of Emergency requiring social distancing. Services have had to be
adjusted/flexible in order to meet DHHS/CDC recommendations related to the Coronavirus.

QP obtained verbal consent on 9/23/2021 von TG sen via telephone
Date 7 Title

Signature
Signature Date Name Title
Reviewed By
Signature Date Name Title
Signature Date Name Title

Therap Generated from Therap ‘ISP Program’ by eae Banat Better Connections, Inc. on 09/23/2021 Page 13 of 13

BETTER CONNECTIONS, INC.

315 CLIFTON STREET
GREENVILLE, NC 27858
OFFICE: 252-814-2118

FAX NUMBER: 252-689-6013

FACSIMILE TRANSMITTAL SHEET

To:

DANA LOUISE REEVES

DATE:
9-33-21

FAX NUMBER:
9197158078 bo bac ee

TOTAL NUMBER OF PAGES INCLUDING COVER: ] O
FROM: BETTER CONNECTIONS, INC. DEBORAH GORHAM-KEYS

RE: POC FoR MIDLAND COURT, SIGNATURE PAGE AND
TRAINING FOR QUICKMAR, PROTOCOL FOR DIABETES FOR
PERSON NOTED IN POC, TRAINING CERTIFICATES FOR MAR
AND GOALS FROM TX PLAN TO ADDRESS DIABETIC ISSUES.
ORIGINALS TO BE PUT IN MAIL.

NOTES/ COMMENTS:

THIS E-MAIL TRANSMISSION AND ANY ATTACHMENTS TO IT ARE MAY
CONTAIN CONFIDENTIAL INFORMATION AND IS INTENDED SOLELY FOR
THE USE OF THE INDIVIDUAL OR ENTITY TO WHICH IT IS ADDRESSED. IF
YOU ARE NOT THE ADDRESSED RECIPIENT, BE NOTIFIED THAT YOUR USE,
FORWARDING, PRINTING, STORING DISSEMINATION, DISTRIBUTION OR
COPYING OF THIS COMMUNICATION IS PROHIBITED. IF YOU RECEIVED THIS
COMMUNICATION IN ERROR, PLEASE NOTIFY

BETTER CONNECTIONS, INC. IMMEDIATELY BY RETURN E-MAIL AND
DELETE DOCUMENT CONTENTS FROM YOUR COMPUTER.

inspection_type: MHLCS Follow-up