facility_name: A Place of My Own  LLC

raw_content:
PRINTED: 03/28/2025

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL013-209 TT 03/27/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
315 LOWER POND ROAD
A PLACE OF MY OWN, LLC
KANNAPOLIS, NC 28083
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

V 000} INITIAL COMMENTS Vv 000

An annual and follow up survey was completed
on 3/27/25. Deficiencies were cited.

This facility is licensed for the following service
category: 10A NCAC 27G .5600B Supervised
Living for Minors with Developmental Disability.

This facility is licensed for 3 and has a current
census of 2. The survey sample consisted of
audits of 2 current clients.

V 112| 27G .0205 (C-D) v112
Assessment/Treatment/Habilitation Plan

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

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

(d) The plan shall include:

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

(2) strategies;

(3) staff responsible;

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

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

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

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

Administrative Director
QURo8\ 4/10/2025

STATE FORM 6609 KFW411 If continuation sheet 1 of 4

Division of Health Service Re

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHLO013-209

PRINTED: 03/28/2025

FORM APPROVED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

STREET ADDRESS, CITY, STATE, ZIP CODE

315 LOWER POND ROAD
KANNAPOLIS, NC 28083

A PLACE OF MY OWN, LLC

(X3) DATE SURVEY
COMPLETED

03/27/2025

This Rule is not met as evidenced by:

Based on record review and interview the facility
failed to review the treatment plan annually with
written consent or agreement by the client's legal
guardian or responsible party affecting 2 of 2
audited clients (#1 and #2). The findings are:

Review on 3/26/25 of client #1's record revealed:
-Admission date of 8/7/23.

-Diagnoses of Intellectual Developmental
Disability, Attention-Deficit Hyperactivity Disorder,
and Autism.

-Short term goals were last updated 8/7/23.
-There was not a signature or written consent
from the guardian or responsible party on client
#1's short term goals.

Review on 3/26/25 of client #2's record revealed:
-Admission date of 11/7/23.

-Diagnoses of Autism Spectrum Disorder,
intellectual Impairment and Language
Impairment, Moderate Intellectual Disability.
-Short term goals were last updated 11/7/23.
-There was not a signature or written consent
from the guardian or responsible party on client
#2's short term goals.

Interview on 3/26/25 with the Owner/Qualified
Professional revealed:

-At the annual "ISP (Individual Support Plan)

meeting the care manager develops the long

term goals, then we develop the short term

Division of Health Service Regulation

STATE FORM

As discussed with the surveyor, goals are
developed annually and reviewed monthly with
the team to assess progress. While we
discuss and agree upon the goals in meeting,
we have not obtained in the past. Going
forward, at a minimum of annual, we will
obtain a physical or electronic signature from
the guardian at the implementation of a new
goal period.

Water temperatures are set and checked on a
quarterly basis in the home. In addition, they
are reviewed when Sanitation comes to
conduct an annual review. In 2023 we
received higher temperature readings that was
resolved by purchasing a new water heater.
We have currently adjusted the thermostat to
reduce the water temperature level. We will
continue to monitor and adjust weekly until we
can maintain temperature levels that are
between 100-116 degrees.

ene KFW411

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

If continuation sheet 2 of 4

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHLO013-209

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

315 LOWER POND ROAD
KANNAPOLIS, NC 28083

A PLACE OF MY OWN, LLC

PRINTED: 03/28/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R
03/27/2025

(x4) ID
PREFIX
TAG

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

ID
PREFIX
TAG

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

(xs)
COMPLETE
DATE

Vv 112

V 752|

Continued From page 2

goals."

-Did not update short term goals until the goals
were achieved at 90%.

-Clients #1 and #2 had not achieved their goals at
90% and therefore they had not been updated.
-"We do not get a physical signature (from the
guardian) because we are all part of the
planning."

Interview on 3/26/25 with the Owner #2 revealed:
-"Guardians don't sign the short term goals."
-"They (guardians) sign the ISP."

-"There has never been a signature required for
the short term goals."

27G .0304(b)(4) Hot Water Temperatures

10A NCAC 27G .0304 FACILITY DESIGN AND
EQUIPMENT

(b) Safety: Each facility shall be designed,
constructed and equipped in a manner that
ensures the physical safety of clients, staff and
visitors.

(4) In areas of the facility where clients are
exposed to hot water, the temperature of the
water shall be maintained between 100-116
degrees Fahrenheit.

This Rule is not met as evidenced by:

Based on observation and interview, the facility
failed to maintain water temperature between
100-116 degrees Fahrenheit where clients are
exposed to hot water. The findings are:

Observation on 3/26/25 of the facility at
approximately 3:30pm revealed:

-Water temperature in the kitchen sink and
upstairs bathroom sink and shower was 118

Division of Health Service Regulation
STATE FORM

Vv 112

V 752

6809

KFW411

If continuation sheet 3 of 4

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

A PLACE OF MY OWN, LLC

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

MHLO013-209

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

315 LOWER POND ROAD

KANNAPOLIS, NC 28083

PRINTED: 03/28/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

R
03/27/2025

degrees Fahrenheit.
-Water temperature in the downstairs bathroom
sink was 120 degrees Fahrenheit.

Attempted interview with client #1 on 3/26/25 was
unsuccessful since he was nonverbal.

Attempted interview with client #2 on 3/26/25 was
unsuccessful because he answered yes to all
questions.

Interview on 3/26/25 with staff #1 revealed:
-Adjusted the water for clients #1 and #2.

-There had not been any injuries due to hot water.
-"When the fire department came out they told us
(facility staff) it was high and we lowered it.

-"We (facility staff) will lower it again."

Interview on 3/26/25 with the Program
Manager/Qualified Professional (QP) revealed:
-Was not aware the water was too hot.

-The water heater had recently been replaced.
-Staff adjusted the water for the clients.

-There had not been any injuries due to hot water.
-Would lower the water temperature.

Division of Health Service Regulation
STATE FORM

6809

KFW411

(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 752] Continued From page 3 V 752

If continuation sheet 4 of 4


state: NC

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

raw_content:
PRINTED: 03/28/2025

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL013-209 03/27/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
315 LOWER POND ROAD
A PLACE OF MY OWN, LLC
KANNAPOLIS, NC 28083
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000} INITIAL COMMENTS V 000

An annual and follow up survey was completed

on 3/27/25. Deficiencies were cited.

This facility is licensed for the following service

category: 10A NCAC 27G .5600B Supervised

Living for Minors with Developmental Disability.

This facility is licensed for 3 and has a current

census of 2. The survey sample consisted of

audits of 2 current clients.

V 112| 27G .0205 (C-D) v112

Assessment/Treatment/Habilitation Plan

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

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

(d) The plan shall include:

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

(2) strategies;

(3) staff responsible;

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

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

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

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

STATE FORM

6899

TITLE

(X6) DATE

If continuation sheet 1 of 4

KFW411

Division of Health Service Regulation

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

MHLO013-209

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
315 LOWER POND ROAD
KANNAPOLIS, NC 28083

A PLACE OF MY OWN, LLC

PRINTED: 03/28/2025

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R
03/27/2025

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

This Rule is not met as evidenced by:

Based on record review and interview the facility
failed to review the treatment plan annually with
written consent or agreement by the client's legal
guardian or responsible party affecting 2 of 2
audited clients (#1 and #2). The findings are:

Review on 3/26/25 of client #1's record revealed:
-Admission date of 8/7/23.

-Diagnoses of Intellectual Developmental
Disability, Attention-Deficit Hyperactivity Disorder,
and Autism.

-Short term goals were last updated 8/7/23.
-There was not a signature or written consent
from the guardian or responsible party on client
#1's short term goals.

Review on 3/26/25 of client #2's record revealed:
-Admission date of 11/7/23.

-Diagnoses of Autism Spectrum Disorder,
intellectual Impairment and Language
Impairment, Moderate Intellectual Disability.
-Short term goals were last updated 11/7/23.
-There was not a signature or written consent
from the guardian or responsible party on client
#2's short term goals.

Interview on 3/26/25 with the Owner/Qualified
Professional revealed:

-At the annual "ISP (Individual Support Plan)

meeting the care manager develops the long

term goals, then we develop the short term

Division of Health Service Regulation
STATE FORM

ene KFW411

If continuation sheet 2 of 4

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHLO013-209

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

315 LOWER POND ROAD
KANNAPOLIS, NC 28083

A PLACE OF MY OWN, LLC

PRINTED: 03/28/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R
03/27/2025

(x4) ID
PREFIX
TAG

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

ID
PREFIX
TAG

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

(xs)
COMPLETE
DATE

Vv 112

V 752|

Continued From page 2

goals."

-Did not update short term goals until the goals
were achieved at 90%.

-Clients #1 and #2 had not achieved their goals at
90% and therefore they had not been updated.
-"We do not get a physical signature (from the
guardian) because we are all part of the
planning."

Interview on 3/26/25 with the Owner #2 revealed:
-"Guardians don't sign the short term goals."
-"They (guardians) sign the ISP."

-"There has never been a signature required for
the short term goals."

27G .0304(b)(4) Hot Water Temperatures

10A NCAC 27G .0304 FACILITY DESIGN AND
EQUIPMENT

(b) Safety: Each facility shall be designed,
constructed and equipped in a manner that
ensures the physical safety of clients, staff and
visitors.

(4) In areas of the facility where clients are
exposed to hot water, the temperature of the
water shall be maintained between 100-116
degrees Fahrenheit.

This Rule is not met as evidenced by:

Based on observation and interview, the facility
failed to maintain water temperature between
100-116 degrees Fahrenheit where clients are
exposed to hot water. The findings are:

Observation on 3/26/25 of the facility at
approximately 3:30pm revealed:

-Water temperature in the kitchen sink and
upstairs bathroom sink and shower was 118

Division of Health Service Regulation
STATE FORM

Vv 112

V 752

6809

KFW411

If continuation sheet 3 of 4

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

A PLACE OF MY OWN, LLC

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

MHLO013-209

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

315 LOWER POND ROAD

KANNAPOLIS, NC 28083

PRINTED: 03/28/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

R
03/27/2025

degrees Fahrenheit.
-Water temperature in the downstairs bathroom
sink was 120 degrees Fahrenheit.

Attempted interview with client #1 on 3/26/25 was
unsuccessful since he was nonverbal.

Attempted interview with client #2 on 3/26/25 was
unsuccessful because he answered yes to all
questions.

Interview on 3/26/25 with staff #1 revealed:
-Adjusted the water for clients #1 and #2.

-There had not been any injuries due to hot water.
-"When the fire department came out they told us
(facility staff) it was high and we lowered it.

-"We (facility staff) will lower it again."

Interview on 3/26/25 with the Program
Manager/Qualified Professional (QP) revealed:
-Was not aware the water was too hot.

-The water heater had recently been replaced.
-Staff adjusted the water for the clients.

-There had not been any injuries due to hot water.
-Would lower the water temperature.

Division of Health Service Regulation
STATE FORM

6809

KFW411

(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 752] Continued From page 3 V 752

If continuation sheet 4 of 4

inspection_type: MHLCS Annual and Follow-up

document_type: Statement of Deficiency


summary: Plan of Correction - MHLCS Annual and Complaint

raw_content:
PRINTED: 03/20/2024
FORM APPROVED.
Division of Health Service Requlation

STATEMENT OF DEFICIENCIES (x1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED

MHL013-209 ———___ 03/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
315 LOWER POND ROAD
KANNAPOLIS, NC 28083

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

DEFICIENCY)

A PLACE OF MY OWN, LLC

V 000 INITIAL COMMENTS.

An annual and complaint survey was completed
| on 3-14-24. The complaint was unsubstantiated
(4NC00213629). Deficiencies were cited.

This facility is licensed for the following service
category: 10A NCAC 27G 5600B Supervised
Living for Minors with a Developmental Disability

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

27G .0207 Emergency Plans and Supplies

VED
10A NCAC 27G .0207 EMERGENCY PLANS RECE

| AND SUPPLIES MAY 09 2024
(a) Awritten fire plan for each facility and
area-wide disaster plan shall be developed and ‘

shall be approved by the appropriate local DHSR-MH Licensure Sect
authority.

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

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

The facility has adjusted the policy regarding
our fire drill and update the form to reflect
fire drill to be conducted quarterly on each
shift. This has been implemented and will

A F be monitored by Executive Staff and or the
This Rule is not met as evidenced by: OP by 4st of Re month of the quarter

Based on record review and interviews, the ending month to ensure drills are completed
facility failed to ensure that disaster drills were timely. This will also allow sufficient time
completed on each shift at least quarterly. The before quarter end to ensure compliance.
findings are:

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

STATE FORM “- 6QPU11 If continuation sheet 1 of 4

PRINTED: 03/20/2024
FORM APPROVED
Division of Health Service Regulation

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

(X2) MULTIPLE CONSTRUCTION
A, BUILDING:

(X3) DATE SURVEY
COMPLETED

B. WING __

MHLO013-209 03/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
315 LOWER POND ROAD
KANNAPOLIS, NC 28083

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

DEFICIENCY)

A PLACE OF MY OWN, LLC

(x4) 1D
PREFIX
TAG

V 114! Continued From page 1

Review on 3-14-24 of facility's disaster drill
schedule for the second quarter of 2023 through
the 1st quarter of 2024 revealed

-The 2nd quarter of 2023 had no ‘st or 3rd
shift disaster drill documented.

-The 4th quarter of 2023 had no third shift
disaster drill documented.

Interview on 3-14-24 with the Executive Director
revealed:

-They would ensure that going forward,
disaster drills would be completed on each shift,
at least quarterly.

27G .0209 (C) Medication Requirements

410A NCAC 27G .0209 MEDICATION

REQUIREMENTS

(c) Medication administration:

(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;

Division of Health Service Regulation
STATE FORM oe 6QPU11 If continuation sheet 2 of 4

NAME OF PROVIDER OR SUPPLIER

A PLACE OF MY OWN, LLC

(x4) 1D
PREFIX
TAG

Division of Health Service Requlation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER;

MHL013-209

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 03/20/2024
FORM APPROVED

(X3) DATE SURVEY

COMPLETED

03/14/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

315 LOWER POND ROAD

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

Continued From page 2

| (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, observation and

| interviews, the facility failed to ensure that all

medications were dispensed only by a registered
pharmacists, physicians, or other health care
practitioners authorized by law and registered
with the North Carolina Board of Pharmacy and
that medication was only administered with a
written order signed by a physician, effecting
three of three clients (Clients #1, #2, and #3). The

| findings are:

Observation on 3-14-24 at approximately 2:00 pm
revealed

-Pill dispenser with Client #1's name on it had
been filled for one week. AM had two pills, pm a
had three pills.

-Pill dispenser with Client #2's name on it had
been filled for the week. AM had 9 pills, pm had 4
pills.

-Pill dispenser with Client #3's name on it had
been filled for the week. AM had 3 pills, pm had 3
pills.

Review on 3-14-24 of Client #2's March 2024

Division of Health Service Regulation

STATE FORM

5800

ID
PREFIX
TAG

KANNAPOLIS, NC 28083

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

| (x)
| comPLeTe
| DATE

Pill dispensers have been removed from
use as of 3.15.24. Outreach was made to
all PCP, Medication Management
Providers and the pharmacy to obtain all
doctors orders for prescriptions. Doctors
Order have been obtained for all current
prescriptions and are maintained in a
binder separated by resident in the
medication closet. Client #2 does not
have a current order for Polyethylene.
This items has been updated and
removed from the MAR to reflect current
prescriptions. Client # 3 does not have a
current order for Polyethylene. This items
has been updated and removed from the
MAR to reflect current prescriptions.
Client #3 does not have current order for
Multivitamin gummies. Those items were
provided by his social worker at intake.
Since a doctors order is not current, they
have been removed from the MAR and
discontinued for use. If an updated order
is provided by his PCP, it will be
maintained and updated in the MAR.

The QP will review the MAR and doctors
orders at a minimum monthly or at
prescription refill to ensure the information
is correct.

6QPU11

If continuation sheet 3 of 4

Division of Health Service Regulation

PRINTED: 03/20/2024
FORM APPROVED

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

MHLO013-209

NAME OF PROVIDER OR SUPPLIER

(X2) MULTIPLE CONSTRUCTION

A BUILDING

B. WING

315 LOWER POND ROAD
KANNAPOLIS, NC 28083

A PLACE OF MY OWN, LLC

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

ID
PREFIX
TAG

(X3) DATE SURVEY
COMPLETED

03/14/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

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

Vv 118) Continued From page 3

MAR revealed:
- Polyethylene glycol 17 grams with juice or
water prn (as needed) (for constipation)

Review on 3-14-24 of Client #2's physician's
orders revealed

-No signed order for 17 grams of
polyethylene glycol 17 grams with juice or water
prn (as needed).

| Review on 3-14-24 of Client #3's March 2024
MAR revealed:
-2 multivitamin gummy each morning.
-Polyethylene glycol 17 grams with juice or
water daily. (for constipation)

| Review on 3-14-24 of Client #3's physician's
orders revealed:

-No signed physician's order for 2
multivitamin gummy each morning.

-No signed physicians order for Polyethylene
| glycol 17 grams with juice or water daily.

| Interview on 3-14-24 with the Qualified
| Professional revealed:

-Putting the pills in a pill dispenser made
giving the clients their medications easier.

-She understood why that should not happen
and would correct it immediately.

-She would make sure that all medications
had the correct orders signed by the physician

Division of Health Service Regulation
STATE FORM

be faioro , vin Du

Toi Jackson, Admin Director (May 9, 2024 09:04 EDT)

Vv 118

S00, 6QPU11

May 9, 2024

If continuation sheet 4 of 4

Survey Response - 3.23.24 - Lower Pond

Final Audit Report 2024-05-09

Created: 2024-05-09
By: HE in. dream.manifest@gmail.com)
Status: Signed

Transaction ID: CBJCHBCAABAAESs_0_HrTo7bja5CuAbwktjvGsqRpwiP-

"Survey Response - 3.23.24 - Lower Pond" History

Document created by HD (tin. dream.manitest@gmail.com)
2024-05-09 - 1:01:19 PM GMT- IP address: 65.184.76.48

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2024-05-09 - 1:02:31 PM GMT

© Email viewed by (iE @ thinkdreammanifest.org
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Signer Othinkdreammanifest.org entered name at signing as | | Admin Director

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% Document e-signed by cease Director
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(3 Adobe Acrobat Sign

inspection_type: MHLCS Annual and Complaint

document_type: Plan of Correction


summary: MHLCS Annual and Complaint


summary: Statement of Deficiency - MHLCS Annual and Complaint

raw_content:
PRINTED: 03/20/2024

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
MHL013-209 03/14/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
315 LOWER POND ROAD
A PLACE OF MY OWN, LLC
KANNAPOLIS, NC 28083
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000} INITIAL COMMENTS V 000

An annual and complaint survey was completed

on 3-14-24. The complaint was unsubstantiated

(#NC00213629). Deficiencies were cited.

This facility is licensed for the following service

category: 10A NCAC 27G 5600B Supervised

Living for Minors with a Developmental Disability.

This facility is licensed for three and currently has

a census of three. The survey sample consisted

of audits of three current clients.

V 114| 27G .0207 Emergency Plans and Supplies Vv 114

10A NCAC 27G .0207 EMERGENCY PLANS
AND SUPPLIES

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

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

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

This Rule is not met as evidenced by:

Based on record review and interviews, the
facility failed to ensure that disaster drills were
completed on each shift at least quarterly. The
findings are:

Division of Health Service Regulation

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

STATE FORM

TITLE

809 6QPU11

(X6) DATE

If continuation sheet 1 of 4

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHLO013-209

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

315 LOWER POND ROAD
KANNAPOLIS, NC 28083

A PLACE OF MY OWN, LLC

PRINTED: 03/20/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

03/14/2024

(x4) ID
PREFIX
TAG

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

ID
PREFIX
TAG

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

(xs)
COMPLETE
DATE

V114

V 118)

Continued From page 1

Review on 3-14-24 of facility's disaster drill
schedule for the second quarter of 2023 through
the 1st quarter of 2024 revealed:

-The 2nd quarter of 2023 had no ‘st or 3rd
shift disaster drill documented.

-The 4th quarter of 2023 had no third shift
disaster drill documented.

Interview on 3-14-24 with the Executive Director
revealed:

-They would ensure that going forward,
disaster drills would be completed on each shift,
at least quarterly.

27G .0209 (C) Medication Requirements

10A NCAC 27G .0209 MEDICATION
REQUIREMENTS

(c) Medication administration:

(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;

Division of Health Service Regulation
STATE FORM

Vv 114

V 118

6809

6QPU11

If continuation sheet 2 of 4

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHLO013-209

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

315 LOWER POND ROAD
KANNAPOLIS, NC 28083

A PLACE OF MY OWN, LLC

PRINTED: 03/20/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

03/14/2024

(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, observation and
interviews, the facility failed to ensure that all
medications were dispensed only by a registered
pharmacists, physicians, or other health care
practitioners authorized by law and registered
with the North Carolina Board of Pharmacy and
that medication was only administered with a
written order signed by a physician, effecting
three of three clients (Clients #1, #2, and #3). The
findings are:

Observation on 3-14-24 at approximately 2:00 pm
revealed:

-Pill dispenser with Client #1's name on it had
been filled for one week. AM had two pills, pm a
had three pills.

-Pill dispenser with Client #2's name on it had
been filled for the week. AM had 9 pills, pm had 4
pills.

-Pill dispenser with Client #3's name on it had
been filled for the week. AM had 3 pills, pm had 3
pills.

Review on 3-14-24 of Client #2's March 2024

Division of Health Service Regulation
STATE FORM

6809

6QPU11

(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 118] Continued From page 2 Vv 118

If continuation sheet 3 of 4

Division of Health Service Regulation

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

MHLO013-209

NAME OF PROVIDER OR SUPPLIER

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

315 LOWER POND ROAD
KANNAPOLIS, NC 28083

A PLACE OF MY OWN, LLC

PRINTED: 03/20/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

03/14/2024

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118] Continued From page 3 Vv 118

MAR revealed:
- Polyethylene glycol 17 grams with juice or
water prn (as needed) (for constipation)

Review on 3-14-24 of Client #2's physician's
orders revealed:

-No signed order for 17 grams of
polyethylene glycol 17 grams with juice or water
prn (as needed).

Review on 3-14-24 of Client #3's March 2024
MAR revealed:
-2 multivitamin gummy each morning.
-Polyethylene glycol 17 grams with juice or
water daily. (for constipation)

Review on 3-14-24 of Client #3's physician's
orders revealed:

-No signed physician's order for 2
multivitamin gummy each morning.

-No signed physicians order for Polyethylene
glycol 17 grams with juice or water daily.

Interview on 3-14-24 with the Qualified
Professional revealed:

-Putting the pills in a pill dispenser made
giving the clients their medications easier.

-She understood why that should not happen
and would correct it immediately.

-She would make sure that all medications
had the correct orders signed by the physician.

Division of Health Service Regulation
STATE FORM

6809

6QPU11

If continuation sheet 4 of 4


facility_name: Adrienne's House

summary: Statement of Deficiency - MHLCS Follow-up

raw_content:
PRINTED: 05/04/2026
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA. (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
R
MHL013-212 B. WING _____ 04/30/2026
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

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

DEFICIENCY)
{V 000}| INITIAL COMMENTS {V 000}

A follow-up survey was completed on 04/30/2026.
Deficiencies were cited.

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

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

{V 295}| 27G .1703 Residential Tx. Child/Adol - Req. forA | {V 295}
P

10A NCAC 27G .1703 REQUIREMENTS FOR
ASSOCIATE PROFESSIONALS

(a) In addition to the qualified professional
specified in Rule .1702 of this Section, each
facility shall have at least one full-time direct care
staff who meets or exceeds the requirements of
an associate professional as set forth in 10A
NCAC 27G .0104(1).

(b) The governing body responsible for each
facility shall develop and implement written
policies that specify the responsibilities of its
associate professional(s). Ata minimum these
policies shall address the following:

(1) management of the day to day
day-to-day operations of the facility;
(2) supervision of paraprofessionals

regarding responsibilities related to the
implementation of each child or adolescent's
treatment plan; and

(3) participation in service planning
meetings.

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

STATE FORM 6899 1QK512 If continuation sheet 1 of 15

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-212 B. WING

NAME OF PROVIDER OR SUPPLIER

120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 05/04/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
04/30/2026

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

(X4) ID
PREFIX
TAG

ID
PREFIX
TAG

CROSS-REFERENCED TO THE APPROPRIATE

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

(x5)
COMPLETE
DATE

DEFICIENCY)

{V 295}] Continued From page 1 {V 295}

This Rule is not met as evidenced by:

Based on record review and interviews, the
facility failed to employ an Associate Professional
(AP) who provided services to the facility on a
full-time basis. The findings are:

Review on 04/24/2026 of the AP's personnel
record revealed:

-Date of Hire: 12/09/2025.

-There was an AP Job description signed and
dated 12/09/2025.

Interview on 04/24/2026 with the AP revealed:
-She started as the AP in February or March
2026.

-"| work 24 hours per week on the weekends; 12
hours on Saturday and Sunday."

-She worked part-time and did not work
throughout the weekday at the facility due to other
full-time employment obligations.

Interview on 04/27/2026 with the Qualified
Professional/Licensee revealed:

-"She (AP) only works part-time, and we have not
been able to find another person who meets the
requirements of an AP."

Interview on 04/30/2026 with the Executive
Director revealed:
-"We will look for a full time AP (to hire)."

This deficiency constitutes a recited deficiency.

{V 296}| 27G .1704 Residential Tx. Child/Adol - Min.

Staffing

{V 296}

10A NCAC 27G .1704. MINIMUM STAFFING

Division of Health Service Regulation

STATE FORM 6899

1QK512

If continuation sheet 2 of 15

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-212 B. WING

NAME OF PROVIDER OR SUPPLIER
120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 05/04/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
04/30/2026

REQUIREMENTS

(a) A qualified professional shall be available by
telephone or page. A direct care staff shall be
able to reach the facility within 30 minutes at all
times.

(b) The minimum number of direct care staff
required when children or adolescents are
present and awake is as follows:

(1) wo direct care staff shall be present for
one, two, three or four children or adolescents;
(2) hree direct care staff shall be present
for five, six, seven or eight children or
adolescents; and

(3) ‘our direct care staff shall be present for
nine, ten, eleven or twelve children or
adolescents.

(c) The minimum number of direct care staff
during child or adolescent sleep hours is as
follows:
(1) wo direct care staff shall be present
and one shall be awake for one through four
children or adolescents;

(2) wo direct care staff shall be present
and both shall be awake for five through eight
children or adolescents; and

(3) hree direct care staff shall be present
of which two shall be awake and the third may be
asleep for nine, ten, eleven or twelve children or
adolescents.

(d) In addition to the minimum number of direct
care staff set forth in Paragraphs (a)-(c) of this
Rule, more direct care staff shall be required in
the facility based on the child or adolescent's
individual needs as specified in the treatment
plan.

(e) Each facility shall be responsible for ensuring
supervision of children or adolescents when they
are away from the facility in accordance with the
child or adolescent's individual strengths and

Division of Health Service Regulation

STATE FORM 6899

1QK512

(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 296}| Continued From page 2 {V 296}

If continuation sheet 3 of 15

PRINTED: 05/04/2026
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
MHL013-212 B. WING _____ 04/30/2026

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

. 120 TODD DRIVE NW
ADRIENNE'S HOUSE CONCORD, NC 28025

(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 296}| Continued From page 3 {V 296}

needs as specified in the treatment plan.

This Rule is not met as evidenced by:

Based on record reviews and interviews the
acility failed to ensure the minimum staffing ratio
of 2 staff for up to 4 adolescents while they were
awake. The findings are:

Review 04/24/2026 of the facility's incident
reports from 03/01/2026 - 04/23/2026 revealed:
-03/29/2026; Client #1's self-harm (shoelace
around neck) and hospitalization incident.

terview on 04/29/2026 with Client #1 revealed:
here were always two or more facility staff on
duty.

45

5

terview on 04/29/2026 with Client #2 revealed:
-There were two facility staff on duty at each shift.

5

lerview on 04/29/2026 with Client #3 revealed:

-"Staff have left to go on break and only one staff
remain here."
-She did not know when or what facility staff left
he facility.

5

terview on 04/29/2026 with Client #4 revealed:
- "There have been times when staff would leave.
They would step out to go outside or to get some
ood."

5

erview on 04/29/2026 with Staff #1 revealed:
Division of Health Service Regulation
STATE FORM 6899

1QK512 If continuation sheet 4 of 15

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-212 B. WING

NAME OF PROVIDER OR SUPPLIER
120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 05/04/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
04/30/2026

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

(X4) ID
PREFIX
TAG

ID
PREFIX
TAG

CROSS-REFERENCED TO THE APPROPRIATE

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

(x5)
COMPLETE
DATE

DEFICIENCY)

{V 296} Continued From page 4 {V 296}

-She left Staff #2 at facility alone with four clients
on 03/29/2026.

- "My break was an hour because | was working a
24-hour shift. But most of the time nobody (facility
staff) takes a break."

Interview on 04/30/2026 with Staff #2 revealed:
-Staff #1 left her alone with four clients on
03/29/2026 for one hour.

-"When | got [Client #1] out of the bathtub, she
(Staff #1) came back. She was gone between 5
and 6 pm (on 03/29/2026)."

-"Staff will take 2 kids and leave 2 kids with the
other staff (if facility staff need to leave the
facility."

Interview on 04/30/2026 with the Qualified
Professional/Licensee revealed:

-"| didn't know she (Staff #1) left (the facility on
03/29/2026) and [Staff #2] did not mention it.

-"| will send communication out staff letting them
know that management must be notified before
they leave (the facility)."

Interview on 04/30/2026 with the Executive
Director revealed:

-"We are going to maintain ratio. We will
communicate with staff that they are not to leave
the premises without notifying anyone
(management)."

This deficiency constitutes a recited deficiency.

{V 366}| 27G .0603 Incident Response Requirements {V 366}
10A NCAC 27G .0603 INCIDENT

RESPONSE REQUIREMENTS FOR

CATEGORY AAND B PROVIDERS

(a) Category A and B providers shall develop and

Division of Health Service Regulation

STATE FORM 6899

1QK512

If continuation sheet 5 of 15,

PRINTED: 05/04/2026
FORM APPROVED

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA. (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
R
MHL013-212 B. WING _____ 04/30/2026
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

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

DEFICIENCY)
{V 366}| Continued From page 5 {V 366}

implement written policies governing their
response to level I, Il or Ill incidents. The policies
shall require the provider to respond by:

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

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

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

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

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

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

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

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

by:

(1) immediately securing the client record
by:

(A) obtaining the client record;

(B) making a photocopy;

(C) certifying the copy's completeness; and

Division of Health Service Regulation
STATE FORM 6899 1QK512 If continuation sheet 6 of 15

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-212 B. WING

NAME OF PROVIDER OR SUPPLIER
120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 05/04/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
04/30/2026

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

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

(B) gather other information needed;

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

(D) issue a final written report signed by the
owner within three months of the incident. The
final report shall be sent to the LME in whose
catchment area the provider is located and to the
LME where the client resides, if different. The
final written report shall address the issues
identified by the internal review team, shall
include all public documents pertinent to the
incident, and shall make recommendations for
minimizing the occurrence of future incidents. If
all documents needed for the report are not
available within three months of the incident, the
LME may give the provider an extension of up to
three months to submit the final report; and

(3) immediately notifying the following:

(A) the LME responsible for the catchment
area where the services are provided pursuant to

Division of Health Service Regulation

STATE FORM 6899

1QK512

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

DEFICIENCY)
{V 366}| Continued From page 6 {V 366}
(D) transferring the copy to an internal
review team;
(2) convening a meeting of an internal

If continuation sheet 7 of 15

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-212 B. WING

NAME OF PROVIDER OR SUPPLIER
120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 05/04/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
04/30/2026

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

(D) the Department;

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

(F) any other authorities required by law.

This Rule is not met as evidenced by:
Based on record reviews and interviews, the
facility failed to implement written policies
governing their response to Level | and II
incidents. The findings are:

Review 04/24/2026 of the facility's incident
reports from 03/01/2026 - 04/23/2026 revealed:
-03/24/2026; Client #2's medication unavailable
for administration incident.

-03/28/2026; Client #1's self-harm (cutting)
incident.

-03/29/2026; Client #1's self-harm (shoelace
around neck) and hospitalization incident.
-04/20/2026; Client #3's Absent without leave
(AWOL), Police, and Emergency Medical
Services (EMS) involvement incident.

Review on 04/24/2026 of the facility's records
revealed:

There was no Risk Cause Analysis (RCA)
documentation for the above incidents from
Division of Health Service Regulation

STATE FORM

6899 1QK512

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

DEFICIENCY)
{V 366}| Continued From page 7 {V 366}
Rule .0604;
(B) the LME where the client resides, if
different;
(C) the provider agency with responsibility

If continuation sheet 8 of 15

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-212 B. WING

NAME OF PROVIDER OR SUPPLIER
120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 05/04/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
04/30/2026

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

(X4) ID
PREFIX
TAG

ID
PREFIX
TAG

CROSS-REFERENCED TO THE APPROPRIATE

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

(x5)
COMPLETE
DATE

DEFICIENCY)

{V 366}| Continued From page 8

03/01/2026 - 04/23/2026 to demonstrate how the
facility:

-Attended to the health and safety needs of the
individuals involved in the incident.

-Determined the cause of the incident.

-Maintained documentation regarding
Subparagraphs (a)(1) through (a)(2) of this Rule.

{V 366}

nterview on 04/24/2026 with the Qualified
Professional/Licensee revealed:

-"| will update our form to ensure that all
components (of the RCA) are met."

nterview on 04/30/2026 wi
Director revealed:

-"We will revise the incident report (form) to add
how we are going to correct and prevent incidents
rom happening."

h the Executive

This deficiency constitutes a recited deficiency.

{V 367}| 27G .0604 Incident Reporting Requirements {V 367}
10A NCAC 27G .0604 INCIDENT
REPORTING REQUIREMENTS FOR
CATEGORY AAND B PROVIDERS

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

Division of Health Service Regulation

STATE FORM 6899

1QK512

If continuation sheet 9 of 15

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-212 B. WING

NAME OF PROVIDER OR SUPPLIER
120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 05/04/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
04/30/2026

means. The report shall include the following
information:

(1) reporting provider contact and
identification information;

(2) client identification information;

(3) type of incident;

(4) description of incident;

(5) status of the effort to determine the

cause of the incident; and

(6) other individuals or authorities notified
or responding.

(b) Category A and B providers shall explain any
missing or incomplete information. The provider
shall submit an updated report to all required
report recipients by the end of the next business
day whenever:

(1) he provider has reason to believe that
information provided in the report may be
erroneous, misleading or otherwise unreliable; or
(2) he provider obtains information
required on the incident form that was previously
unavailable.

(c) Category A and B providers shall submit,
upon request by the LME, other information
obtained regarding the incident, including:

(1) hospital records including confidential
information;
(2) reports by other authorities; and

(3) he provider's response to the incident.
(d) Category A and B providers shall send a copy
of all level III incident reports to the Division of
Mental Health, Developmental Disabilities and
Substance Abuse Services within 72 hours of
becoming aware of the incident. Category A
providers shall send a copy of all level III
incidents involving a client death to the Division of
Health Service Regulation within 72 hours of
becoming aware of the incident. In cases of
client death within seven days of use of seclusion

Division of Health Service Regulation

STATE FORM 6899

1QK512

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

DEFICIENCY)
{V 367}| Continued From page 9 {V 367}

If continuation sheet 10 of 15

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-212 B. WING

NAME OF PROVIDER OR SUPPLIER
120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 05/04/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
04/30/2026

or restraint, the provider shall report the death
immediately, as required by 10A NCAC 26C
.0300 and 10A NCAC 27E .0104(e)(18).

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

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

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

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

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

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

This Rule is not met as evidenced by:

Based on record reviews and interviews, the
facility failed to report all level II incidents in the
Incident Response Improvement System (IRIS),
failed to notify the Local Management Entity
(LME)/Managed Care Organization (MCO)
responsible for the catchment area where
services were provided as required, and failed to
Division of Health Service Regulation

STATE FORM

6899 1QK512

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

DEFICIENCY)
{V 367}] Continued From page 10 {V 367}

If continuation sheet 11 of 15

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-212 B. WING

NAME OF PROVIDER OR SUPPLIER
120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 05/04/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
04/30/2026

submit to the LME/MCO upon request other
information regarding the incident. The findings
are:

Review 04/24/2026 of the facility's incident
reports from 03/01/2026 - 04/23/2026 revealed:
-03/28/2026; Client #1's self-harm (cutting)
incident.

-04/20/2026; Client #3's Absent without leave
(AWOL) Police, and Emergency Medical Services
(EMS) incident.

Review on 04/24/2026 of IRIS revealed:
-There was no report submitted in the IRIS
system for Client #1's self-harm incident dated
03/28/2026 or Client #3's incident dated
04/20/2026.

Review on 04/24/2026 an IRIS Report dated
03/29/2026 for Client #1 revealed:

-The incident occurred on 03/29/2026.

-The provider learned of the incident on
03/29/2026.

-The report was submitted 04/01/2026.
-LME/MCO Comments dated 04/07/2026: "Due to
confidentiality and HIPAA (Health Insurance
Portability and Accountability Act) requirements,
incident reports CANNOT contain content or
attachments with the full names of other
consumers. Uploading an attachment containing
the information of another consumer is a HIPPA
violation. Please a) Notify your Quality
Management (QM) Director and b) provide us
with their contact information. Thank you!
Emailed provider. "

-There was no response to the LME/MCO
request.

Interviews on 04/24/2026 and 04/30/2026 with the
Qualified Professional/Licensee revealed:

Division of Health Service Regulation
STATE FORM

6899 1QK512

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

DEFICIENCY)
{V 367}] Continued From page 11 {V 367}

If continuation sheet 12 of 15

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-212 B. WING

NAME OF PROVIDER OR SUPPLIER
120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 05/04/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
04/30/2026

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

(X4) ID
PREFIX
TAG

ID
PREFIX
TAG

CROSS-REFERENCED TO THE APPROPRIATE

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

(x5)
COMPLETE
DATE

DEFICIENCY)

{V 367}] Continued From page 12 {V 367}

-"| did not complete an IRIS report (for Client #3's
incident dated 04/20/2026)."

-"| submit IRIS reports within 72 hours."

-"When | submit IRIS reports, | will go back to
check emails for updates as needed."

Interview on 04/30/2026 with the Executive
Director revealed:

-"We will file IRIS reports for all incidents as
required. It's going to be part of our routine to
check for updates after the IRIS report is
submitted."

This deficiency constitutes a recited deficiency.

V 513) 27E .0101 Client Rights - Least Restrictive V 513

Alternative

10A NCAC 27E .0101
ALTERNATIVE

(a) Each facility shall provide services/supports
that promote a safe and respectful environment.
These include:

(1) using the least restrictive and most
appropriate settings and methods;

(2) promoting coping and engagement
skills that are alternatives to injurious behavior to
self or others;

(3) providing choices of activities
meaningful to the clients served/supported; and
(4) sharing of control over decisions with
the client/legally responsible person and staff.
(b) The use of a restrictive intervention
procedure designed to reduce a behavior shall
always be accompanied by actions designed to
insure dignity and respect during and after the
intervention. These include:

(1) using the intervention as a last resort;
and

LEAST RESTRICTIVE

Division of Health Service Regulation

STATE FORM 6899

1QK512

If continuation sheet 13 of 15

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-212 B. WING

NAME OF PROVIDER OR SUPPLIER
120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 05/04/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
04/30/2026

(2) employing the intervention by people
trained in its use.

This Rule is not met as evidenced by:

Based on record review, observation, and
interview, the facility failed to use the least
restrictive environment for 2 of 4 Clients (#1 and
#2). The findings are:

Observation on 04/24/2026 at 12:15 pm of the
acility revealed:

-The bathroom door in Clients' #1 and 2 bedroom
was locked.

nterview on 04/30/2026 with Client #1 revealed:
-"They (facility staff) locked the door (bathroom)
completely because | had suicide attempts."

nterview on 04/30/2026 with Client #2 revealed.
-"They told me it (the bathroom door) would be
ike that (locked) when | got here (on 12/18/2025).
They told me it would be unlocked at shower
ime."

nterview on 04/30/2026 with Client #3 revealed:
-"The other bathroom (in Clients' #1 and 2
bedroom) was locked."

-She did not remember how long the bathroom
door had been locked.

Interview on 04/30/2026 with Client #4 revealed:
-"The bathroom door in the other room was
locked. A couple of days ago, they (facility staff)
told clients (#1 and #2) that it (bathroom door)
could be unlocked."

Division of Health Service Regulation

STATE FORM 6899

1QK512

(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 513] Continued From page 13 V 513

If continuation sheet 14 of 15

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

MHL013-212

(X2) MULTIPLE CONSTRUCTION

A.

B.

BUILDING:

WING

STREET ADDRESS, CITY, STATE, ZIP CODE
120 TODD DRIVE NW

PRINTED: 05/04/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
04/30/2026

Interview on 04/30/2026 with the Qualified
Professional/Licensee revealed:

-"We communicated to staff that the door
(bathroom) is to be unlocked at all times. We also
communicated that it is their (Clients #1 and #2)
right to have access (to the bathroom in their
bedroom)."

Interview on 04/30/2026 with the Executive
Director revealed:
-"We will keep the door (bathroom) unlocked."

Division of Health Service Regulation

STATE FORM

6899

ADRIENNE'S HOUSE
CONCORD, NC 28025
(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 513] Continued From page 14 V 513

1QK512

If continuation sheet 15 of 15

inspection_type: MHLCS Follow-up