raw_content:
Division of Health Service Regulation

PRINTED: 01/30/2025

FORM APPROVED

10A NCAC 27G .0603 INCIDENT
RESPONSE REQUIREMENTS FOR

CATEGORY AAND B PROVIDERS

(a) Category A and B providers shall develop and
implement written policies governing their
response to level |, 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

Division of Health Service Regulation

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

STATE FORM

6808 2wysi1

TITLE

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
Cc
MHL013-240 01/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
550 ARCHDALE DRIVE
TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000} INITIAL COMMENTS V 000
Acomplaint survey was completed on 1/15/25.
The complaint was unsubstantiated (intake
#NC00224971). Deficiencies were cited.
This facility is licensed for the following service
category: 10A NCAC 27G .1700 Residential
Treatment Staff Secure for Children or
Adolescents.
This facility is licensed for 6 and has a current
census of 3. The survey sample consisted of
audits of 1 current client.
V 366} 27G .0603 Incident Response Requirements V 366

(X6) DATE

If continuation sheet 1 of 9

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL013-240

TRANSCENDING HEIGHTS, LLC

CONCORD,

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

NC 28027

PRINTED: 01/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE
550 ARCHDALE DRIVE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

Cc
01/15/2025

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 I.

(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 Ill 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
(D) transferring the copy to an internal
review team;

(2) convening a meeting of an internal

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

Division of Health Service Regulation
STATE FORM

6809

(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 1 V 366

If continuation sheet 2 of 9

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING:

MHL013-240

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

TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027

PRINTED: 01/30/2025

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

Cc
01/15/2025

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
Rule .0604;

(B) the LME where the client resides, if
different;

(C) the provider agency with responsibility

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
Division of Health Service Regulation

STATE FORM 009 2wystt

(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 2 V 366

If continuation sheet 3 of 9

Division of Health Service Regulation

PRINTED: 01/30/2025

FORM APPROVED

governing their response to level II incidents as
required. The findings are:

Review on 12/9/24 of the North Carolina Incident
Response Improvement System (IRIS) for the
dates 10/1/24-12/9/24 revealed:

-No incident report was submitted regarding
former client (FC) #4 having suicidal ideation and
going to the hospital on 11/9/24.

-No incident was submitted regarding FC #4
having suicidal ideation, and going to the hospital
on 11/20/24.

-No incident report was submitted regarding FC
#4 having suicidal ideation and going to the
hospital on 11/23/24.

-12/8/24 incident report completed by staff #3
"Consumer stated she took an abundant amount
of medication, and she was feeling unwell.
Consumer asked to make a phone call to the
facility director who was outside of that facility at
the particular moment. Once consumer was told
to go lay back Consumer fled the facility."

-No risk/cause analysis was submitted to IRIS for
the incidents which occurred on 11/9/24,
11/20/24, 11/23/24, and 12/8/24.

Interview on 1/12/25 with staff #3 revealed:
-Completed the IRIS report for the 12/8/24
incident.

-Did not know the IRIS report was not completed
fully to include the risk cause analysis.

Interview on 1/8/25 and 1/13/25 with the Qualified
Professional (QP) revealed:

-Incident reports were completed by "whoever is
there when it happens. We send the code to
[Director]."

-On 11/9/24 FC #4 "broke a piece of plastic and
scraped her thigh. She was transported by

myself to the hospital. She was admitted."

Division of Health Service Regulation

STATE FORM

6808 2wysi1

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL013-240 01/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
550 ARCHDALE DRIVE
TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027
(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 3 V 366

If continuation sheet 4 of 9

Division of Health Service Regulation

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING:

MHL013-240

550 ARCHDALE DRIVE

TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION

PRINTED: 01/30/2025

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

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

Cc
01/15/2025

-On 11/20/24 FC #4 "took a fake nail and was
trying to cut herself. She said she was not safe. |
contacted [Director]; she said to take her (FC #4)
to the hospital because she needed further
observations."

-On 11/23/24 FC #4 "started destroying property
and saying she wanted to harm herself and
needs further help. | contacted [Director] and
was told to return her to the hospital.
-Completed IRIS reports for 11/9/24, 11/20/24,
and 11/23/24 incidents. Did not know they were
incomplete and were not submitted.

Interviews on 12/19/24 and 1/13/24 with the
Director revealed:

-IRIS reports are typically done by the QP and
occasionally by staff #3.

-Did not know IRIS reports for incidents on
11/9/24, 11/20/24, 11/23/24, and 12/8/24 were
incomplete and the reports for the incidents on
11/9/24, 11/20/24, 11/23/24 were not submitted.
-Had not developed and implemented corrective
measures.

-Had not developed and implemented measures
to prevent similar incidents.

-Had not assigned persons to be responsible for
implementation of the corrections and
preventative measures.

-Had not written and submitted findings to the
local Management Entity/Managed Care
Organization in the required timeframe.

-"We are going to restructure (procedure for
completing IRIS reports) because obviously it
was not getting submitted properly."

V 367] 27G .0604 Incident Reporting Requirements V 367

10A NCAC 27G .0604 INCIDENT
REPORTING REQUIREMENTS FOR

Division of Health Service Regulation
STATE FORM 009 2wystt

(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 4 V 366

If continuation sheet 5 of 9

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL013-240

TRANSCENDING HEIGHTS, LLC

CONCORD,

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

NC 28027

PRINTED: 01/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE
550 ARCHDALE DRIVE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

Cc
01/15/2025

CATEGORY AAND B PROVIDERS

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

(1) reporting provider contact and
identification information;

(2) client identification information;

(3) type of incident;

(4) description of incident;

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

(6) other individuals or authorities notified

or responding.

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

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

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

Division of Health Service Regulation
STATE FORM

6809

(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 5 V 367

If continuation sheet 6 of 9

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL013-240

TRANSCENDING HEIGHTS, LLC

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 01/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE
550 ARCHDALE DRIVE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

Cc
01/15/2025

(1) hospital records including confidential
information;

(2) reports by other authorities; and

(3) the provider's response to the incident.

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

(e) Category A and B providers shall send a
report quarterly to the LME responsible for the
catchment area where services are provided.

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

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

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

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

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

(6) a statement indicating that there have

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

Division of Health Service Regulation
STATE FORM

6809

CONCORD, NC 28027
(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 6 V 367

If continuation sheet 7 of 9

Division of Health Service Regulation

PRINTED: 01/30/2025

FORM APPROVED

This Rule is not met as evidenced by:

Based on record reviews and interviews, the
facility failed to report level II incidents in the
Incident Response Improvement System (IRIS)
within 72 hours of becoming aware of the
incident.

Review on 12/9/24 of IRIS for the dates
10/1/24-12/9/24 revealed:

-No incident report was submitted regarding
former client (FC) #4 having suicidal ideation and
going to the hospital on 11/9/24.

-No incident was submitted regarding FC #4
having suicidal ideation and going to the hospital
on 11/20/24.

-No incident report was submitted regarding FC
#4 having suicidal ideation and going to the
hospital on 11/23/24.

Interview on 1/8/25 and 1/13/25 with the Qualified
Professional (QP) revealed:

-Incident reports were completed by "whoever is
there when it happens. We send the code to
[Director]".

-On 11/9/24 FC #4 "broke a piece of plastic and
scraped her thigh. She was transported by
myself to the hospital. She was admitted."

-On 11/20/24 FC #4 "took a fake nail and was
trying to cut herself. She said she was not safe. |
contacted [Director]; she said to take her (FC #4)
to the hospital because she needed further
observations."

-On 11/23/24 FC #4 "started destroying property

Division of Health Service Regulation

STATE FORM

6808 2wysi1

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL013-240 01/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
550 ARCHDALE DRIVE
TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027
(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 7 V 367

If continuation sheet 8 of 9

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL013-240

TRANSCENDING HEIGHTS, LLC

NC 28027

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 01/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE
550 ARCHDALE DRIVE
CONCORD,

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

Cc
01/15/2025

and saying she wanted to harm herself and
needs further help. | contacted [Director] and
was told to return her to the hospital."
-Completed IRIS reports for 11/9/24, 11/20/24,
and 11/23/24 incidents. Did not know they were
incomplete and were not submitted.

Interviews on 12/19/24 and 1/13/24 with the
Director revealed:

-IRIS reports are typically done by the QP and
occasionally by staff #3.

-Did not know IRIS reports for incidents on
11/9/24, 11/20/24, and 11/23/24 had not been
completed fully or submitted.

-"We are going to restructure (procedure for
completing IRIS reports) because obviously it
was not getting submitted properly."

Division of Health Service Regulation
STATE FORM

6809

2wysi1

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 367 | Continued From page 8 V 367

If continuation sheet 9 of 9


state: NC

facility_name: Harmony House

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

raw_content:
PRINTED: 01/22/2026

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-C
MHL013-243 B. WING 01/08/2026
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
28 STRICKER AVENUE NW
HARMONY HOUSE
CONCORD, NC 28027
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000) INITIAL COMMENTS V 000

Acomplaint and follow up survey was completed
on 1/8/26. The complaint was unsubstantiated
(Intake #NC00234613). No deficiencies were
cited.

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

This facility is licensed for 4 and has a current
census of 3. The survey sample consisted of
audits of 1 current client.

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

STATE FORM 6899 7P7411 If continuation sheet 1 of 1

inspection_type: MHLCS Annual and Follow-up

document_type: Statement of Deficiency


summary: Statement of Deficiency - MHLCS Annual and Complaint

raw_content:
PRINTED: 07/08/2025
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
MHL013-243 B. WING _____ 06/24/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
28 STRICKER AVENUE NW
HARMONY HOUSE
CONCORD, NC 28027
(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 complaint survey was completed
on 06/24/2025. The complaint was
unsubstantiated (Intake #NC00229956).
Deficiencies were cited.

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

This facility is licensed for 4 and has a current
census of 3. The survey sample consisted of
audits of 3 current clients.

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

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

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

This Rule is not met as evidenced by:

Based on interview and record review, the facility
failed to ensure the North Carolina Health Care
Personnel Registry (HCPR) was accessed prior
to making an offer of employment for 1 of 1 Staff
(#1). The findings are:

Review on 06/20/2025 of Staff #1's personnel
record revealed:

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

STATE FORM 6899 893811 If continuation sheet 1 of 24

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-243 B. WING

NAME OF PROVIDER OR SUPPLIER
28 STRICKER AVENUE NW

HARMONY HOUSE CONCORD, NC 28027

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 07/08/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

06/24/2025

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

ID
PREFIX
TAG

(X4) ID
PREFIX
TAG

CROSS-REFERENCED TO THE APPROPRIATE

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

(x5)
COMPLETE
DATE

DEFICIENCY)

V 131] Continued From page 1 V 131

-Date of Hire: 02/18/2025.
-HCPR verification check: 05/06/2025.

nterview 06/24/2025 with the Qualified
Professional revealed:

-"| will double check (that HCPR is accessed prior
(0 hire)."

nterview on 06/24/2025 with the Licensee
revealed:

-"Generally, | pull the background check and
HCPR at the same time. | think the paperwork got
mixed up."

-"Moving forward, | will match the person with the
last 4 digits of the social security number before |
put it (HCPR form) in the file."

V 295

27G .1703 Residential Tx. Child/Adol - Req. forA | V 295
Pp

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

Division of Health Service Regulation

STATE FORM 6899

893811

If continuation sheet 2 of 24

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-243 B. WING

NAME OF PROVIDER OR SUPPLIER
28 STRICKER AVENUE NW

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 07/08/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

06/24/2025

(3)

meetings.

participation in service planning

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 06/24/2025 of the AP's personnel
record revealed:

-Date of Hire: 06/24/2024.

-Job description: Associate Professional.
-Bachelor of Science unofficial transcript.
-There was no resume available to verify
employment history related to the population
served.

Attempted Interview on 06/24/2025 with the AP
was unsuccessful due to no response to phone
call prior to survey exit.

terview on 06/24/2025 with Client #2 revealed:
"| have only seen him (AP) once and | have been
here for like 8 months. That's like [Qualified
Professional (QP)]'s dad.

5

lerview on 06/24/2025 with Staff #1 revealed:
-"No, | don't know him (AP)."

5

5

lerview on 06/24/2025 with the QP revealed:
-"He comes once a month for a shift (12 hours)."

nterview on 06/24/2025 wi
revealed:

-"So, [QP] and | have talked about me taking on
Division of Health Service Regulation

STATE FORM

h the Licensee

6899 893811

HARMONY HOUSE
CONCORD, NC 28027
(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 295} Continued From page 2 V 295

If continuation sheet 3 of 24

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-243 B. WING

NAME OF PROVIDER OR SUPPLIER
28 STRICKER AVENUE NW

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 07/08/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

06/24/2025

10A NCAC 130 .0102 INVESTIGATING AND
REPORTING HEALTH CARE PERSONNEL
The reporting by health care facilities to the
Department of all allegations against health care
personnel as defined in G.S. 131E-256 (a)(1),
including injuries of unknown source, shall be
done within 24 hours of the health care facility
becoming aware of the allegation. The results of
the health care facility's investigation shall be
submitted to the Department in accordance with
G.S. 131E-256(g).

This Rule is not met as evidenced by:

Based on record reviews and interviews, the
‘acility failed to ensure Health Care Personnel
Registry (HCPR) was notified of all allegations of
abuse against personnel within 24 hours as
required affecting 1 of 1 Staff (Chef). The findings
are:

Review on 06/24/2025 of the Chef's personnel
record revealed:

-Hire date 02/05/2025.

-Job title Chef.

Reviews on 06/20/2025 and 06/23/2025 of the

Division of Health Service Regulation

STATE FORM 6899

893811

HARMONY HOUSE CONCORD, NC 28027
(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 295} Continued From page 3 V 295
the AP role due to his (current AP) inability to
commit as AP."
V 318) 130 .0102 HCPR - 24 Hour Reporting V 318

If continuation sheet 4 of 24

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-243 B. WING

NAME OF PROVIDER OR SUPPLIER
28 STRICKER AVENUE NW

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 07/08/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

06/24/2025

facility records revealed:

-There was no HCPR 24 Hour Initial Report for
the allegation that the Chef interacted
inappropriately with Client #2 incident dated
06/06/2025.

-There was a HCPR 5-Day Working Report dated
06/08/2025.

-There was a HCPR Screenout letter for the Chef
dated 06/13/2025.

Review on 06/13/2025 of the North Carolina
Incident Response Improvement System for the
facility's reports from 03/13/2025 - 06/12/2025
revealed:

-There were no level Ill incident report for Client
#2's allegation of against the Chef.

Interview on 06/24/2025 with Client #2 revealed:
-"| remember it very clearly. We (Chef and Client
#2) went outside. He said, 'l love you so much, |
want to adopt you, and | said | am already
adopted, and he asked for a hug' and | gave him
a hug. He touched my face. He asked for another
hug, and | gave him another hug. | came back
inside, and | said we had a weird conversation."
-Reported the incident to the facility staff on duty
the day of the incident.

-Reported the incident to the Qualified
Professional (QP) the next day.

Interview on 06/24/2025 with the QP revealed:

-"| thought IRIS would inform HCPR."

-She was not aware that the IRIS report for Client
#2's allegation against the Chef dated 06/06/2025
was not successfully submitted in IRIS.

-She did not complete the HCPR 24 Hour Initial
Report for the allegation that the Chef interacted
inappropriately with Client #2.

Division of Health Service Regulation

STATE FORM 6899

893811

HARMONY HOUSE
CONCORD, NC 28027
(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 318] Continued From page 4 V 318

If continuation sheet 5 of 24

PRINTED: 07/08/2025

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
MHL013-243 B. WING 06/24/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
28 STRICKER AVENUE NW
HARMONY HOUSE
CONCORD, NC 28027
(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
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
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

Division of Health Service Regulation
STATE FORM 6899 893811 If continuation sheet 6 of 24

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-243 B. WING

NAME OF PROVIDER OR SUPPLIER
28 STRICKER AVENUE NW

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 07/08/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

06/24/2025

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

Division of Health Service Regulation

STATE FORM 6899

893811

HARMONY HOUSE CONCORD, NC 28027
(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
by:
(1) immediately securing the client record
by:
(A) obtaining the client record;
(B) making a photocopy;
(C) certifying the copy's completeness; and
(D) transferring the copy to an internal
review team;
(2) convening a meeting of an internal

If continuation sheet 7 of 24

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-243 B. WING

NAME OF PROVIDER OR SUPPLIER
28 STRICKER AVENUE NW

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 07/08/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

06/24/2025

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
Rule .0604;

(B) the LME where the client resides, if
different;

(C) the provider agency with responsibility

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 II and III
incidents. The findings are:

Review on 06/13/2025 of the North Carolina
Incident Response Improvement System for the
facility's reports from 03/13/2025 - 06/12/2025
revealed:

Level III:

-There was no IRIS report submitted for Client
#2's physical restraint incident dated 04/24/2025.
-There was no IRIS report submitted for the
allegation that the Chef inappropriately interacted
with Client #2 incident dated 06/06/2025.

Division of Health Service Regulation

STATE FORM

6899 893811

HARMONY HOUSE
CONCORD, NC 28027
(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

If continuation sheet 8 of 24

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-243 B. WING

NAME OF PROVIDER OR SUPPLIER
28 STRICKER AVENUE NW

HARMONY HOUSE CONCORD, NC 28027

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 07/08/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

06/24/2025

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 V 366

-There was no IRIS report submitted for the
allegation that the Chef inappropriately interacted
with Client #3 incident date unknown.

Reviews between 06/13/2025-06/24/2025 of the
facility records revealed:
-There were IRIS reports for the above incidents
that were not successfully submitted in IRIS;
"4/1/0001" code specified on all reports.
-There was no documentation to support that the
above recorded incidents had been evaluated to:
(A) Determine the cause of the incident.
(B) Assign a person to be responsible for
implementation of the corrective and/or
preventive measures.

Interview on 06/24/2025 with the Qualified
Professional revealed:

-"| thought that the supervision section was
enough, but | will create a way to make sure all
sections are for fulfilled for each incident."

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,

Division of Health Service Regulation

STATE FORM 6899

893811

If continuation sheet 9 of 24

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-243 B. WING

NAME OF PROVIDER OR SUPPLIER
28 STRICKER AVENUE NW

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 07/08/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

06/24/2025

in person, facsimile or encrypted electronic
means. The report shall include the following
information:

(1) reporting provider contact and
identification information;

(2) client identification information;

(3) type of incident;

(4) description of incident;

(5) status of the effort to determine the

cause of the incident; and

(6) other individuals or authorities notified
or responding.

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

(1) 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

Division of Health Service Regulation

STATE FORM 6899

893811

HARMONY HOUSE
CONCORD, NC 28027
(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 24

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-243 B. WING

NAME OF PROVIDER OR SUPPLIER
28 STRICKER AVENUE NW

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 07/08/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

06/24/2025

client death within seven days of use of seclusion
or restraint, the provider shall report the death
immediately, as required by 10A NCAC 26C
.0300 and 10A NCAC 27E .0104(e)(18).

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

(1) medication errors that do not meet the
definition of a level II or level 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 Level II and III incidents in
the Incident Response Improvement System
(IRIS) as required once of becoming aware of the
incident. The findings are:

Division of Health Service Regulation

STATE FORM 6899

893811

HARMONY HOUSE
CONCORD, NC 28027
(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 24

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-243 B. WING

NAME OF PROVIDER OR SUPPLIER
28 STRICKER AVENUE NW

HARMONY HOUSE CONCORD, NC 28027

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 07/08/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

06/24/2025

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

ID
PREFIX
TAG

(X4) 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 11 V 367

Review on 06/13/2025 of the North Carolina
Incident Response Improvement System for the
facility's reports from 03/13/2025 - 06/12/2025
revealed:

Level III:

-There was no IRIS report submitted for Client
#2's physical restraint incident dated 04/24/2025.
-There was no IRIS report submitted for the
allegation that the Chef inappropriately interacted
with Client #2 incident dated 06/06/2025.

-There was no IRIS report submitted for the
allegation that the Chef inappropriately interacted
with Client #3 incident date unknown.

Review on 06/23/2025 of an IRIS Report dated
04/24/2025 for Client #2 revealed:

-"Date of Incident: 04/24/2025.

-Date Last submitted: 1/1/0001.

-Restrictive Intervention: Yes."

Review on 06/23/2025 of an IRIS Report dated
06/06/2025 for Client #2 revealed:

-"Date of Incident: 06/06/2025.

-Date Last submitted: 1/1/0001.

-Does this incident include an allegation against
he facility?: Yes."

nterview on 06/24/2025 with the Qualified
Professional revealed:

-Did not complete an IRIS report for Client #3's
allegation against the Chef (date unknown).

-"| thought they were fully submitted, but now |
know how to check to see how. | will get further
raining to ensure they are submitted correctly."

V 500} 27D .0101(a-e) Client Rights - Policy on Rights Vv 500
10A NCAC 27D .0101 POLICY ON RIGHTS

RESTRICTIONS AND INTERVENTIONS

Division of Health Service Regulation

STATE FORM 6899

893811

If continuation sheet 12 of 24

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-243 B. WING

NAME OF PROVIDER OR SUPPLIER
28 STRICKER AVENUE NW

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 07/08/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

06/24/2025

(a) The governing body shall develop policy that
assures the implementation of G.S. 122C-59,
G.S. 122C-65, and G.S. 122C-66.

(b) The governing body shall develop and
implement policy to assure that:

(1) all instances of alleged or suspected
abuse, neglect or exploitation of clients are
reported to the County Department of Social
Services as specified in G.S. 108A, Article 6 or
G.S. 7A, Article 44; and

(2) procedures and safeguards are
instituted in accordance with sound medical
practice when a medication that is known to
present serious risk to the client is prescribed.
Particular attention shall be given to the use of
neuroleptic medications.

(c) In addition to those procedures prohibited in
10A NCAC 27E .0102(1), the governing body of
each facility shall develop and implement policy
that identifies:

(1) any restrictive intervention that is
prohibited from use within the facility; and

(2) in a 24-hour facility, the circumstances
under which staff are prohibited from restricting
the rights of a client.

(d) If the governing body allows the use of
restrictive interventions or if, in a 24-hour facility,
the restrictions of client rights specified in G.S.
122C-62(b) and (d) are allowed, the policy shall
identify:

(1) the permitted restrictive interventions or
allowed restrictions;

(2) the individual responsible for informing
the client; and

(3) the due process procedures for an
involuntary client who refuses the use of
restrictive interventions.

(e) If restrictive interventions are allowed for use
within the facility, the governing body shall

Division of Health Service Regulation

STATE FORM 6899

893811

HARMONY HOUSE
CONCORD, NC 28027
(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 500} Continued From page 12 Vv 500

If continuation sheet 13 of 24

Division of Health Service Regulation

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

MHL013-243 B. WING

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
28 STRICKER AVENUE NW

HARMONY HOUSE CONCORD, NC 28027

PRINTED: 07/08/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

06/24/2025

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

(X4) ID
PREFIX
TAG

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

COMPLETE
DATE

DEFICIENCY)

V 500} Continued From page 13 V 500

develop and implement policy that assures
compliance with Subchapter 27E, Section .0100,
which includes:

(1) the designation of an individual, who
has been trained and who has demonstrated
competence to use restrictive interventions, to
provide written authorization for the use of
restrictive interventions when the original order is
renewed for up to a total of 24 hours in
accordance with the time limits specified in 10A
NCAC 27E .0104(e)(10)(E);

(2) the designation of an individual to be
responsible for reviews of the use of restrictive
interventions; and

(3) the establishment of a process for
appeal for the resolution of any disagreement
over the planned use of a restrictive intervention.

This Rule is not met as evidenced by:

Based on record reviews and interviews, the
acility failed to ensure all incidents of alleged
abuse are reported to the County Department of
Social Services (DSS). The findings are:

Reviews on 06/20/2025 and 06/23/2025 of the
acility records revealed:

-There was no notification to the Local County
DSS for the allegation that the Chef interacted
inappropriately with Client #2 incident dated
06/06/2025.

-There was no notification to the Local County
DSS for the allegation that the Chef interacted
inappropriately with Client #3 incident date
unknown.

nterview on 06/23/2025 with the Qualified
Professional (QP) revealed:

Division of Health Service Regulation

STATE FORM 6299

893811

If continuation sheet 14 of 24

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-243 B. WING

NAME OF PROVIDER OR SUPPLIER
28 STRICKER AVENUE NW

HARMONY HOUSE CONCORD, NC 28027

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 07/08/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

06/24/2025

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 500} Continued From page 14 V 500

-"No, | didn't (notify DSS). | just did not
investigation with HCPR (Health Care Personnel
Registry) and left it at that (pertaining to the
06/06/2025 incident)."

Interview on 06/24/2025 with the QP revealed:
-"| learned about the incident (allegation that the
Chef interacted inappropriately with Client #3)
with [Client #2]'s incident (06/06/2025)."

-"| did not know to inform DSS. Moving forward, |
will notify DSS as well."

V 536] 27E .0107 Client Rights - Training on Alt to Rest. | V 536

Int.

10A NCAC 27E .0107 TRAINING ON
ALTERNATIVES TO RESTRICTIVE
INTERVENTIONS

(a) Facilities shall implement policies and
practices that emphasize the use of alternatives
to restrictive interventions.

(b) Prior to providing services to people with
disabilities, staff including service providers,
employees, students or volunteers, shall
demonstrate competence by successfully
completing training in communication skills and
other strategies for creating an environment in
which the likelihood of imminent danger of abuse
or injury to a person with disabilities or others or
property damage is prevented.

(c) Provider agencies shall establish training
based on state competencies, monitor for internal
compliance and demonstrate they acted on data
gathered.

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

Division of Health Service Regulation

STATE FORM 6899

893811

If continuation sheet 15 of 24

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-243 B. WING

NAME OF PROVIDER OR SUPPLIER
28 STRICKER AVENUE NW

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 07/08/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

06/24/2025

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

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

(g) Staff shall demonstrate competence in the
following core areas:

(1) knowledge and understanding of the
people being served;

(2) recognizing and interpreting human
behavior;

(3) recognizing the effect of internal and
external stressors that may affect people with
disabilities;

(4) strategies for building positive
relationships with persons with disabilities;

(5) recognizing cultural, environmental and
organizational factors that may affect people with
disabilities;

(6) recognizing the importance of and
assisting in the person's involvement in making
decisions about their life;

(7) skills in assessing individual risk for
escalating behavior;

(8) communication strategies for defusing
and de-escalating potentially dangerous behavior;
and

(9) positive behavioral supports (providing

means for people with disabilities to choose
activities which directly oppose or replace
behaviors which are unsafe).

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

(A) who participated in the training and the

Division of Health Service Regulation

STATE FORM 6899

893811

HARMONY HOUSE
CONCORD, NC 28027
(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 536 | Continued From page 15 V 536

If continuation sheet 16 of 24

Division of Health Service Regulation

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

MHL013-243 B. WING

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
28 STRICKER AVENUE NW

HARMONY HOUSE CONCORD, NC 28027

PRINTED: 07/08/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

06/24/2025

(X4) ID
PREFIX
TAG

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

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

COMPLETE
DATE

DEFICIENCY)

V 536 | Continued From page 16 V 536

outcomes (pass/fail);

(B) when and where they attended; and

(C) instructor's name;

(2) The Division of MH/DD/SAS may
review/request this documentation at any time.

(i) Instructor Qualifications and Training
Requirements:

(1) Trainers shall demonstrate competence
by scoring 100% on testing in a training program
aimed at preventing, reducing and eliminating the
need for restrictive interventions.

(2) Trainers shall demonstrate competence
by scoring a passing grade on testing in an
instructor training program.

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

(4) The content of the instructor training the
service provider plans to employ shall be
approved by the Division of MH/DD/SAS pursuant
to Subparagraph (i)(5) of this Rule.

(5) Acceptable instructor training programs
shall include but are not limited to presentation of:
(A) understanding the adult learner;

(B) methods for teaching content of the
course;

(C) methods for evaluating
performance; and

(D) documentation procedures.

(6) Trainers shall have coached experience
teaching a training program aimed at preventing,
reducing and eliminating the need for restrictive
interventions at least one time, with positive
review by the coach.
(7) Trainers shall teach a training program
aimed at preventing, reducing and eliminating the

rainee

Division of Health Service Regulation

STATE FORM 6899 893811

If continuation sheet 17 of 24

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-243 B. WING

NAME OF PROVIDER OR SUPPLIER
28 STRICKER AVENUE NW

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 07/08/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

06/24/2025

need for restrictive interventions at least once
annually.

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

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

(1) Documentation shall include:

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

(B) when and where attended; and
(C) instructor's name.
(2) The Division of MH/DD/SAS may

request and review this documentation any time.
(k) Qualifications of Coaches:

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

(2) Coaches shall teach at least three times
the course which is being coached.

(3) Coaches shall demonstrate
competence by completion of coaching or
train-the-trainer instruction.

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

This Rule is not met as evidenced by:

Based on record reviews and interviews, the
facility failed to ensure 1 of 1 Associate
Professional (AP) completed refresher training in
alternatives to restrictive interventions. The
findings are:

Division of Health Service Regulation

STATE FORM 6899

893811

HARMONY HOUSE
CONCORD, NC 28027
(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 536 | Continued From page 17 V 536

If continuation sheet 18 of 24

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-243 B. WING

NAME OF PROVIDER OR SUPPLIER

28 STRICKER AVENUE NW

HARMONY HOUSE CONCORD, NC 28027

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 07/08/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

06/24/2025

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 536 | Continued From page 18 V 536

Review on 06/24/2025 of the AP's personnel
record revealed:

-Hire date 06/24/2024.

-Initial Nonviolent Crisis Prevention & Intervention
(CPI) Training refresher training in alternatives to
restrictive interventions expired 06/07/2025.
-There was no refresher CPI Training in
alternatives to restrictive interventions.

Attempted interview on 06/24/2025 with the AP
was unsuccessful due to no response to phone
call prior to survey exit.

nterview on 06/24/2025 with the Qualified
Professional revealed:

-She was not responsible for scheduling staff
raining.

-The licensee was responsible for scheduling
staff training.

nterview on 06/24/2025 with the Licensee
revealed:

-"| will set up a tracking system to be on top of
raining expirations."

V 537

27E .0108 Client Rights - Training in Sec Rest & | V 537

TO

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

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

Division of Health Service Regulation

STATE FORM 6899

893811

If continuation sheet 19 of 24

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-243 B. WING

NAME OF PROVIDER OR SUPPLIER
28 STRICKER AVENUE NW

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 07/08/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

06/24/2025

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

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

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

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

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

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

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

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

(3) emphasis on safety and respect for the

rights and dignity of all persons involved (using
concepts of least restrictive interventions and
incremental steps in an intervention);

(4) strategies for the safe implementation
of restrictive interventions;

Division of Health Service Regulation

STATE FORM 6899

893811

HARMONY HOUSE
CONCORD, NC 28027
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 537 | Continued From page 19 V 537

If continuation sheet 20 of 24

PRINTED: 07/08/2025

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
MHL013-243 B. WING 06/24/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
28 STRICKER AVENUE NW
HARMONY HOUSE
CONCORD, NC 28027
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 537 | Continued From page 20 V 537
(5) the use of emergency safety

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

(6) prohibited procedures;

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

(8) documentation methods/procedures.

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

(1) Documentation shall include:

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

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

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

review/request this documentation at any time.

(i) Instructor Qualification and Training
Requirements:

(1) Trainers shall demonstrate competence
by scoring 100% on testing in a training program
aimed at preventing, reducing and eliminating the
need for restrictive interventions.
(2) Trainers shall demonstrate competence
by scoring 100% on testing in a training program
teaching the use of seclusion, physical restraint
and isolation time-out.
(3) Trainers shall demonstrate competence
by scoring a passing grade on testing in an
instructor training program.
(4) The training shall be
competency-based, include measurable learning
objectives, measurable testing (written and by
observation of behavior) on those objectives and
measurable methods to determine passing or
failing the course.

Division of Health Service Regulation
STATE FORM 6899 893811 If continuation sheet 21 of 24

PRINTED: 07/08/2025

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
MHL013-243 B. WING 06/24/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
28 STRICKER AVENUE NW
HARMONY HOUSE
CONCORD, NC 28027
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 537 | Continued From page 21 V 537
(5) The content of the instructor training the

service provider plans to employ shall be
approved by the Division of MH/DD/SAS pursuant
to Subparagraph (j)(6) of this Rule.

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

(A) understanding the adult learner;

(B) methods for teaching content of the
course;

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

(7) Trainers shall be retrained at least

annually and demonstrate competence in the use
of seclusion, physical restraint and isolation
time-out, as specified in Paragraph (a) of this

Rule.

(8) Trainers shall be currently trained in
CPR.

(9) Trainers shall have coached experience

in teaching the use of restrictive interventions at
least two times with a positive review by the
coach.
(10) Trainers shall teach a program on the
use of restrictive interventions at least once
annually.
(11) Trainers shall complete a refresher
instructor training at least every two years.

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

(1) Documentation shall include:

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

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

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

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

Division of Health Service Regulation
STATE FORM 6899 893811 If continuation sheet 22 of 24

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-243 B. WING

NAME OF PROVIDER OR SUPPLIER
28 STRICKER AVENUE NW

HARMONY HOUSE CONCORD, NC 28027

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 07/08/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

06/24/2025

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 537 | Continued From page 22 V 537

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

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

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

This Rule is not met as evidenced by:

Based on record reviews and interviews, the
facility failed to ensure 1 of 1 Associate
Professional (AP) completed refresher training in
seclusion, physical restraint, and isolation time
out. The findings are:

Review on 06/24/2025 of the AP's personnel
record revealed:

-Hire date 06/24/2024.

-Initial Nonviolent Crisis Prevention & Intervention
(CPI) Training in seclusion, physical restraint, and
isolation time out expired 06/07/2025.

-There was no refresher CPI Training in
seclusion, physical restraint, and isolation time
out.

Attempted interview on 06/24/2025 with the AP
was unsuccessful due to no response to phone
call prior to survey exit.

Interview on 06/24/2025 with the Qualified
Professional revealed:

-She was not responsible for scheduling staff
training.

Division of Health Service Regulation

STATE FORM

6899 893811

If continuation sheet 23 of 24

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES

(X1) PROVIDER/SUPPLIER/CLIA

PRINTED: 07/08/2025
FORM APPROVED

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL013-243 B. WING 06/24/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
28 STRICKER AVENUE NW
HARMONY HOUSE
CONCORD, NC 28027
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 537 | Continued From page 23 V 537

-The Licensee was responsible for scheduling
staff training.

Interview on 06/24/2025 with the Licensee
revealed:

-"| will set up a tracking system to be on top of
training expirations."

Division of Health Service Regulation
STATE FORM

6899 893811 If continuation sheet 24 of 24

inspection_type: MHLCS Annual and Complaint


facility_name: Alexander Youth Network - Charlotte Day Treatment

summary: Statement of Deficiency - MHLCS Follow-up

raw_content:
PRINTED: 07/07/2025

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-C
MHL060968 B. WING 06/30/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE CHARLOTTE, NC 28211

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

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

A follow up survey was completed on June 30,
2025. No deficiencies were cited.

This facility is licensed for the following service
category: 10A NCAC 1400 Day Treatment For
Children And Adolescents With Emotional Or
Behavioral Disturbances.

This facility has a current census of 34.

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

STATE FORM 6899 KUZIN2 If continuation sheet 1 of 1

inspection_type: MHLCS Follow-up


summary: Statement of Deficiency - MHLCS Complaint

raw_content:
PRINTED: 06/09/2025

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
Cc
MHL060968 06/03/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1
CHARLOTTE, NC 28211
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000} INITIAL COMMENTS V 000

Acomplaint survey was completed on 6-3-25.
The complaint was unsubstantiated (Intake
#NC00230794). No deficiencies were cited.

This facility is licensed for the following service
category: 10ANCAC 1400 Day Treatment For
Children And Adolescents With Emotional Or
Behavioral Disturbances.

This facility has a current census of 34. The
survey sample consisted of audits of 1 former
client.

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

STATE FORM

6899

YDZ911

TITLE (X6) DATE

If continuation sheet 1 of 1

inspection_type: MHLCS Complaint