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

raw_content:
PRINTED: 10/27/2025
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-C
MHL002-028 B.WING 10/10/2025

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

243 LILEDOUN ROAD
LUCA’S HOPE Il
TAYLORSVILLE, NC 28681

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

INITIAL COMMENTS

Accomplaint and follow up survey was
completed on October 10, 2025. The
complaint was

unsubstantiated (intake #NC00233424).
Deficiencies were cited.

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

This facility is licensed for 6 and has a
current census of 1. The survey sample
consisted of audits of 1 current client and
1 former client.

A sister facility is identified in this report. The
sister facility will be identified as sister facility
A.

All staff at the facility are related. The Chief

Executive Officer/Director/Licensee (CEO/D/L)

is the Vice President/Licensee/Qualified

Professional (VP/L/QP)'s and Staff #1's

Mother. The VP/L/QP and Staff #1 are Sister

and

Brother. The CEO/DIL is Staff #2's Aunt. Staff

#2 and the VP/L/QP and Staff #1 are cousins =
and Staff #3 is Staff #2's Aunt. RECEIVED

27G .0201 (A) (1-7) Governing Body Policies

DHSR-MH Licensure Sect

10A NCAC 27G .0201 GOVERNING
BODY POLICIES

(a) The governing body responsible for
each facility or service shall develop and
implement written policies for the following:
(1) delegation of management authority for
the operation of the facility and services;
(2) criteria for admission;

Villu. XAowhe. / Ditectow I] Z/as

(3) criteria for discharge;
(4) admission assessments, including:

(A) who will perform the assessment; and
(B) time frames for completing assessment.

Division of Health Service Regulation

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (x6) DATE STATE FORM © 7MO411 continuation sheet 1 of 64

PRINTED: 10/27/2025
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
MHL002-028 B. WING 10/10/2025

NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
243 LILEDOUN ROAD
LUCA’S HOPE Ill

TAYLORSVILLE, NC 28681

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

Continued From page 1

(5) client record management, including:

(A) persons authorized to document;

(B) transporting records;

(C) safeguard of records against loss,
tampering, defacement or use by
unauthorized persons; (D) assurance of
record accessibility to

authorized users at all times; and

(E) assurance of confidentiality of records.
(8) screenings, which shall include:

(A) an assessment of the individual's
presenting problem or need;

(B) an assessment of whether or not the
facility can provide services to address the
individual's needs; and

(C) the disposition, including referrals and
recommendations;

(7) quality assurance and quality
improvement activities, including:

(A) composition and activities of a quality
assurance and quality improvement
committee; (B) written quality assurance
and quality

improvement plan;

(C) methods for monitoring and evaluating
the quality and appropriateness of client
care,

including delineation of client outcomes

and utilization of services;

(D) professional or clinical supervision,
including a requirement that staff who are not
qualified professionals and provide direct
client services shall be supervised by a
qualified professional in that area of service;
(E) strategies for improving client care;

(F) review of staff qualifications and a
determination made to grant
treatment/habilitation privileges:

(G) review of all fatalities of active clients who
were being served in area-operated or
contracted residential programs at the time of
death;

(H) adoption of standards that assure operational

Division of Health Service Regulation
STATE FORM °7M0411 If continuation sheet 2 of 64
PRINTED: 10/27/2025
FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (Xt) PROVIDERSUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED

R-C
MHL002-028 B. WING 10/10/2025

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

243 LILEDOUN ROAD
LUCA'S HOPE Ill
TAYLORSVILLE, NC 28681

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

Continued From page 2

and programmatic performance meeting
applicable standards of practice. For this
purpose, “applicable standards of practice"
means a level of competence established
with reference to the prevailing and
accepted

methods, and the degree of knowledge, skill
and care exercised by other practitioners in
the field;

V105

Moving Forward Luca’s Hope III will utilize its

admissions and intake criteria to screen and

determine if a potential client meets our

inclusionary criteria for the overall program. This
This Rule is not met as evidenced by: process will determine whether the program can
Based on record review and interview, the meet the clients needs. All applicants or potential

facilty failed to ensure admission screenings new admissions will be required to go through
the facility screening process. The screening
for

ee . process includes; submitting an application,
potential clients were conducted to include updated Comprehensive clinical assessment for
the clients presenting problems and review, a signed service order, including a

whether or not the facility can provide the current PCPincluding Physicians orders in
services the clients need. The findings are: regards to medications that would be
administered to the client. These documents will
Review on 9/26/25 of Former Client (FC) be reviewed by the Director and the QMHP to
#5's record revealed: determine if the potential client can be accepted
-A total of 9 pages. into the program. Upon determining whether a
-2 pages of July 2025 Medication client can be admitted, the facility must receive
Administration Record (MARs), 2 pages of the following documents; Birth Certificate, social

security card, copy of insurance or medicaid
eae dos eee pages of September card. All documents mentioned above must be

, received by the facility before the intake process
regarding placement of school and 1 page of takes place and the client is admitted. Adhering

the Department of Social Services (DSS) to our intake process will ensure that the facility
legal custody letter. can provide adequate services while also
-MARs for July, August and September 2025 ensuring that staff are made knowledgeable of
had age 11 years old and diagnoses of clients’ diagnosis, history and potential behaviors
Disruptive Mood Disorder and Attention Deficit in order for clients to receive appropriate care.
Hyperactivity Disorder. The facility will ensure that client information is
-No admission screening to include an documented and maintained including adhering

Fong" ‘ to our policies for intakes regardless of the
assessment of the client's presenting problems or situation. The facility will include performing meet
and greet sessions for all potential clients as part
of the assessment to determine if the facility can
meet clients needs. The assessment will be
completed by the QMHP before the decision
about a client's admission can be made.

a a GG

Division of Health Service Regulation
STATE FORM 970411 If continuation sheet 3 of 64
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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

RC
MHL002-028 BAWING 10/10/2025

NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28684

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

Continued From page 3

needs.

Interview on 10/7/25 with FC #5's local DSS
legal guardian and DSS Supervisor revealed:
-FC #5 was admitted to the facility on 7/15/25
and he was discharged on 9/5/25.

Interview on 10/8/25 with Staff #1 revealed:
-Was notified verbally by the Chief Executive
Officer/Director/Licensee (CEO/D/L) a "few
hours before" FC #5 was admitted to the
facility.

Interview on 10/8/25 with Staff #2 revealed:
-Was "told" by the CEO/D/L "[FC #5] was going
to be arespite...he wasn't going to be there
(facility) that long..."

Interview on 10/6/25 with the Vice
President/Licensee/Qualified Professional
(VP/L/QP) revealed:

-"...work with [CEO/D/L] in tandem to see if
the kids (clients) are a good fit...A lot of
information comes from [CEO/DIL] first since
she's been doing it longer...We have video
conferences with the prospective client and
the guardian and the social worker...It's a
group effort of DSS,

[CEO/D/L], but in the wheel house
(responsibilities) that will be me...That's
dropping the ball on my end and there are
things we need to start looking out for..."
-"We do have conversations (about clients).
The staff doesn't go in green (uninformed).
We make staff familiar with each of the kid's
and each of their diagnosis. It can be from
the CCA

(Comprehensive Clinical Assessment) or the
PCP (Person Centered Plan/Treatment Plan)
and staff are aware of what is going on with
these kids and there are conversations going
on at our meetings

of what has been happening and going on at
the house (facility). Staff are made very
aware of

Division of Health Service Regulation
STATE FORM ° 7411 If continuation sheet 4 of 64
PRINTED: 10/27/2025
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
MHL002-028 B. WING 10/10/2025

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

243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681

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

Continued From page 4

each kid's diagnosis and how to approach
them..."

~Documentation of client information was
not maintained.

Interviews on 9/26/25 and 10/6/25 with the
CEO/DIL revealed:

-The 9 documents she provided were the
only records she had for FC #5.

-"| take emergency placements for the county
and it might be for 1 night...He (FC #5) was
admitted as a DSS emergency situation...DSS
said for a day or night...when | take them
(clients) this is all | have (papers
presented)...this is late at

night...he (FC #5) ended up staying longer
because the placement they had for him
didn't work out...we don't just take them
without

information about them...with [FC #5] they
(DSS) just called and said ‘Just for one
night...just one night’..."

-"...Biggest thing (need) for him (FC #5) was
his bed wetting, incontinence."

-Policy prior to admissions was to “ask
them (referral agency) to send us
something...an updated CCA
(Comprehensive Clinical

Assessment)...a PCP...some type of
evaluation...if we think it's (client) something
we can handle...depends on the group of
kids

currently have too...If we want to move
forward, will contact them (for admission)..."
-"We (CEO/D/L and VP/L/QP) would tell
them (staff) about the clients. Things are
told but we are not documenting it."
-"Usually" the VP/L/QP was responsible to
conduct the admission screenings.

"We (CEO/DIL and VP/L/QP) usually do a
meet and greet and get an idea if he
(prospective client) would fit with the group
(clients)...think | should be involved too and
talk to them

(clients)..."

Division of Health Service Regulation
STATE FORM &°7M0411 {f continuation sheet 5 of 64

PRINTED: 10/27/2025
FORM APPROVED
Division of Health Service Reg

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
‘AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED

R-C
MHL002-028 B. WING 10/10/2025

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

243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) aes TER FICIENCY) APPROPRIATE

Continued From page 5

-"Didn't do it (admission screening) because
thought (DHSR and DSS) were under the
same umbrella..."

This deficiency is cross referenced into 10A
NCAC 27G.1301 Scope (V179) for a Type A1
rule violation and must be corrected within 23
days.

27G .0202 (F-I) Personne! Requirements

10A NCAC 27G .0202 PERSONNEL
REQUIREMENTS

(f) Continuing education shall be
documented. (g) Employee training
programs shall be

provided and, at a minimum, shall consist of
the following:

(1) general organizational orientation;

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

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

(4) training in infectious diseases and
bloodborne pathogens.

{h) Except as permitted under 10a NCAC
27G_ .5602(b) of this Subchapter, at least
one staff member shall be available in the
facility at all times when a client is present.
That staff

member shall be trained in basic first aid
including seizure management, currently
trained to provide cardiopulmonary
resuscitation and trained in the Heimlich
maneuver or other first aid techniques such as
those provided by Red Cross, the American
Heart Association or their

equivalence for relieving airway

obstruction. (i) The governing body shall

develop and
implement policies and procedures for

identifying, reporting, investigating and
controlling infectious

Division of Health Service Regulation
STATE FORM ©°7M0411 If continuation sheet 6 of 64

PRINTED: 10/27/2025
FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

A. BUILOING: COMPLETED

R-C
MHL002-028 Be WIR 10/10/2025

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

243 LILEDOUN ROAD
LUCA'S HOPE II!

TAYLORSVILLE, NC 28684

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

Continued From page 6

and communicable diseases of personnel
and clients.

This Rule is not met as evidenced by:

Based on record review and interview, the
facility failed to provide training to meet the
mh/dd/sa needs of the clients affecting 2 of 3
audited paraprofessional staff (Staff #1 and
#2). The findings are:

Review on 9/26/25 of Staff #1's record
revealed: -Date of hire 9/6/23.

-Job title of Residential Counselor.
-No documentation of client specific
mbh/dd/sa_ needs training.

Review on 9/26/25 of Staff #2's record
revealed: -Date of hire 12/13/23.

-Job title of Residential Counselor.
-No documentation of client specific
mh/dd/sa_ needs training.

Review on 9/26/25 of Former Client (FC)
#5's record revealed:

-A total of 9 pages.

-2 pages of July 2025 Medication
Administration Record (MARs), 2 pages of
August 2025 MARs, 2 pages of September
2025 MARs, 2 pages

regarding placement of school and 1 page of
the Department of Social Services (DSS)
legal custody letter.

-MARs for July, August and September 2025
had age 11 years old and diagnoses of

Disruptive Mood Disorder and Attention Deficit

Hyperactivity Disorder.

Division of Health Service Regulation

STATE FORM °° 7M0414

Division of Health Service Reg

STATEMENT OF DEFICIENCIES (1) PROVIDER/SUPPLIER/CLIA.

AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

MHL002-028

NAME OF PROVIDER OR SUPPLIER

v108

The facility will ensure that all staff will receive
upon hiring and maintain annually training for
CPR, First Aide training,Bloodborne Pathogens
training, Emergency Action Procedures, Safety
classes, clients rights, confidentiality,
EBPI,Abuse &mNeglect, Medication
Administration(Medication administration
training will include demonstrating a
medication pass being observed by a nurse),
seizure management, Client specific,
Documentation, and goal planning. There will
also be a minimum of 12 in-service training hours
required per year. This also includes continuing
education that may be necessary in areas that
will benefit the care of clients and quality of the
facility. This will be monitored by the Director and
the QMHP. Quarterly Record reviews will be
completed on all staff training records ensuring
that all required classes and training are kept
current. Luca’s Hope III will utilize training
services from outside resources and in-house
resources from the QMHP.

If continuation sheet 7 of 64

PRINTED: 10/27/2025
FORM APPROVED

{X2) MULTIPLE CONSTRUCTION (%3) DATE SURVEY

COMPLETED

R-C
10/10/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

243 LILEDOUN ROAD

LUCA'S HOPE III

TAYLORSVILLE, NC 28681

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

Continued From page 7

-No documentation which identified the
specific mh/dd/sa needs.

Interview on 10/8/25 with Staff #1 revealed:
-Was notified verbally by the Chief Executive
Officer/Director/Licensee (CEO/D/L) a "few
hours before" FC #5 arrived to the facility.
-Was aware FC #5 had "Autism...talked
about he's very quiet...reserved...wets the
bed

sometimes..."

-"...Been assigned so much, don't
remember (client specifics)..."

Interview on 10/8/25 with Staff #2 revealed:
-Was "told" by the CEO/D/L "[FC #5] was going
to be a respite...he wasn't going to be there
(facility) that long...he has some
disabilities...know he had some form of
Autism...1 did learn that he was a bed wetter,
that he had to wear pull ups..."

-She would normally read the clients
Comprehensive Clinical Assessment (CCA)
to learn about the client needs.

-She would also ask the Vice
President/Licensee/Qualified Professional
(VP/L/QP) and the CEO/D/L "as many
questions as | can, like his behavior, his
dislikes and likes..."

Interview on 10/6/25 with the VP/L/QP
revealed: -"We do have conversations (client
needs). The staff doesn't go in green
(uninformed). We make

staff familiar with each of the kids and each of
their diagnosis. It can be from the CCA or the
PCP (Person Centered Plan) and staff are
aware of what is going on with these kids
(clients) and there are conversations going on
at our meetings of what has been happening
and going on at the house (facility). Staff are
made very aware of each kids diagnosis and
how to approach them. | make them very
aware of what's going on and what has been
brought up to me like during 1:1s

Division of Health Service Regulation
STATE FORM &°7M0411 If continuation sheet 8 of 64
PRINTED: 10/27/2025.
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

RC
MHL002-028 B WING 10/10/2025

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

243 LILEDOUN ROAD
LUCA'S HOPE Ill
TAYLORSVILLE, NC 28681

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

Continued From page 8

(one-on-ones)...It's just something we
have shared (verbally)...| think we are
covered

because new staff never start alone..."

Interview on 10/6/25 with the CEO/D/L
revealed: -The VP/L/QP was responsible to
ensure staff were trained.

-"We do talk about the clients when we do
our staffing like what is going on with this
client and that client...We do talk about the
kiddos

(clients)... We would tell them (new staff)
about the clients. Things are told but we
are not

documenting it..."

This deficiency is cross referenced into 10A
NCAC 27G.1301 Scope (V179) for a Type A1
tule violation and must be corrected within 23
days.

27G .0203 Privileging/Training Professionals

10A NCAC 27G .0203 COMPETENCIES

OF QUALIFIED PROFESSIONALS AND
ASSOCIATE PROFESSIONALS

(a) There shall be no privileging requirements
for qualified professionals or associate
professionals. (b) Qualified professionals and
associate

professionals shall demonstrate knowledge,
skills and abilities required by the population
served. (c) At such time as a
competency-based

employment system is established by
rulemaking, then qualified professionals and
associate

professionals shall demonstrate

competence. (d) Competence shall be
demonstrated by exhibiting core skills
including:

(1) technical knowledge;

(2) cultural awareness;

(3) analytical skills;

(4) decision-making;
(5) interpersonal skills;

Division of Health Service Regulation

STATE FORM © 7MO411 Continuation sheet 9 of 64

PRINTED: 10/27/2025

FORM APPROVED

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (1) PROVIDERISUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A.BUILDING: ‘COMPLETED

R-C
MHL002-028 8. WING ____ 10/10/2025

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

243 LILEDOUN ROAD

LUCA'S HOPE Ill
TAYLORSVILLE, NC 28681

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

Continued From page 9

(6) communication skills; and

(7) clinical skills.

(e) Qualified professionals as specified in
410A NCAC 27G .0104 (18)(a) are deemed
to have met the requirements of the
competency-based employment system in
the State Plan for

MH/DD/SAS.

(f) The governing body for each facility shall
develop and implement policies and
procedures for the initiation of an
individualized supervision plan upon hiring
each associate professional. (g) The
associate professional shall be

supervised by a qualified professional with
the population served for the period of time
as specified in Rule .0104 of this
Subchapter.

This Rule is not met as evidenced by:

Based on record review and interview, 1

of 1 Qualified Professional (Vice
President/Licensee/Qualified Professional
(VP/L/QP)) failed to demonstrate the
knowledge, skills and abilities required by the
population served. The findings are:

Review on 9/26/25 of the VP/L/QP record
revealed:

-Date of hire: 8/7/23.

-Job title: QP

-Job description signed and dated 8/7/23: "1.
Overall responsibility for the interdisciplinary
Team process with each individual
served...Work in conjunction with these
individuals, other

professionals, consultants and staff in
developing, implementing, documenting,
monitoring and

v109

The hired consultant will ensure that the
Qualified Professional will meet the requirements
and demonstrate knowledge and competence by
exhibiting the following skills: technical
knowledge, cultural awareness, analytical
skills,decision-making, interpersonal skills,
communication skills, and clinical skills.

The consultant will monitor and supervise the
Qualified Menta! Health Professional and the
director. Ensuring all responsibilities are being
accurately completed within the required
timeframe. This will be done by weekly
administrative meetings and monthly staff
meetings that are mandatory. Working with a
hired consultant will ensure that the QMHP
gains knowledge needed to ensure admission
and discharge procedures are followed
according to policy. Can Coordinate admissions
and discharges with the appropriate staff. Can
ensure, through regular audits, that accurate
and timely documentation is occurring and that
client records are maintained according to policy.
Can prepare and submit required or requested
reports, documents, assessments, evaluations
and paperwork. Review and sign off on clinical
documentation as

Required. Can continuously use
person-centered approaches and positive
approach strategies when interacting with
consumers. Can Integrate strategies into
program plans. Can provide direction and
supervision to staff, monitor performance

and implementation of the responsibilities

by being present when day-to-day

activities; routines and rhythms are taking
place, on all shifts and by unannounced

visits. Can ensure staff are appropriately
trained regarding plans and demonstrate

an understanding of specific plan

components. Utilizing a hired consultant

will improve the QMHP knowledge and
Competence in the required skills

a

Division of Health Service Regulation

STATE FORM 9 7M04411 If continuation sheet 10 of 64

PRINTED: 10/27/2025
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
MHL002-028 8. WING ______ 10/10/2025

NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
243 LILEDOUN ROAD
LUCA'S HOPE II

TAYLORSVILLE, NC 28681

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

Continued From page 10

adjusting the plan of care and related
programs...2. Ensure admission and
discharge procedures are followed according
to policy. Coordinates admissions and
discharges with the appropriate staff. 3.
Ensure, through regular audits, that accurate
and timely documentation is occurring and
that client records are maintained according
to policy. Prepare and submit required or
requested reports, documents, assessments,
evaluations and paperwork. Review and sign
off on clinical documentation as
required...Continuously use person-centered
approaches and positive approach strategies
when interacting with consumers. Integrate
strategies into program plans. 5. Provide
direction and supervision to staff...Monitor
performance and implementation of the
responsibilities by being present when
day-to-day activities; routines and rhythms are
taking place, on all shifts and by unannounced
visits. 6. Ensure staff are

appropriately trained regarding plans and
demonstrate and understanding of specific
plan components..."

Review on 9/26/25 of Former Client (FC)
#5's record revealed:
-A total of 9 pages.

-2 pages of July 2025 Medication
Administration Record (MARs), 2 pages of
August 2025 MARs, 2 pages of September
2025 MARs, 2 pages

regarding placement of school and 1 page of
the Department of Social Services (DSS)
legal custody letter.
-MARs for July, August and September 2025
had age 11 years old and diagnoses of
Disruptive Mood Disorder and Attention Deficit
Hyperactivity Disorder (ADHD).
-There was no pre-admission screening,
assessment, treatment goals and
strategies, client specifics or physician
orders.

Division of Health Service Regulation

STATE FORM “*7MO411 If continuation sheet 11 of 64
PRINTED: 10/27/2025
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-C
MHL002-028 BOWING 10/10/2025

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

243 LILEDOUN ROAD
LUCA'S HOPE Ill
TAYLORSVILLE, NC 28681

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

Continued From page 11

Interview on 10/7/25 with FC #5's local DSS
legal guardian and DSS Supervisor revealed:
-DSS placed FC #5 at the facility on 7/15/25,
and he was discharged on 9/5/25.

-FC #5's needs were that he "bites himself
sometimes when he gets upset...and
incontinence."

Interview on 10/6/25 with the VP/L/QP
revealed: -"| should be responsible (for
admission

assessments) but we have gone through

them together (her and the Chief Executive
Officer/Director/Licensee (CEO/D/L)). We have
video conferences with the prospective client

and the guardian and the social worker..."

-"| will be the one who does the PCP (Person
Centered Plan/Treatment Plan). It's a group
effort of DSS, and [CEO/D/L] but in the wheel
house (responsibilities) that will be me...That's
dropping the ball on my end (no treatment
strategies) and there are things we need to
start looking out for. We make sure of the
focus that the kids (clients) are meeting their
goals."

-"We do have conversations (with staff about
the clients). The staff doesn't go in green
(uninformed). We make staff familiar with each
of the kids and each of their diagnosis...Staff
are made very aware of each kids diagnosis
and how to approach them. | make them very
aware of what's going and what has been
brought up to me like during 1:1s
(one-on-ones) so there's never an eyes closed
situation with staff...It's just

something we have shared...| think we are
covered because new staff never start alone..."

This deficiency is cross referenced into 10A
NCAC 27G.1301 Scope (V179) for a Type A1
rule violation and must be corrected within 23
days.

Division of Health Service Regulation
STATE FORM 9 7M0411 If continuation sheet 12 of 64

PRINTED: 10/27/2025
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
MHL.002-028 B.WING 10/10/2025

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

243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681

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

Continued From page 12

27G .0204 Training/Supervision
Paraprofessionals

10A NCAC 27G .0204 COMPETENCIES AND.
SUPERVISION OF PARAPROFESSIONALS
(a) There shall be no privileging requirements
for paraprofessionals.

(b) Paraprofessionals shall be supervised by
an associate professional or by a qualified
professional as specified in Rule .0104 of
this Subchapter.

(c) Paraprofessionals shall demonstrate
knowledge, skills and abilities required by
the population served.

(d) At such time as a competency-based
employment system is established by
rulemaking, then qualified professionals and
associate

professionals shal! demonstrate
competence. (e) Competence shall be
demonstrated by exhibiting core skills
including:

(1) technical knowledge;

(2) cultural awareness;

(3) analytical skills;

(4) decision-making;

(5) interpersonal skills;

(6) communication skills; and

(7) clinical skills.

(f) The governing body for each facility shall
develop and implement policies and
procedures for the initiation of the
individualized supervision plan upon hiring
each paraprofessional.

This Rule is not met as evidenced by:

Division of Health Service Regulation
STATE FORM 89-7041 If continuation sheet 13 of 64
PRINTED: 10/27/2025
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
MHL002-028 B WING 10/10/2025

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

LUCA'S HOPE III
TAYLORSVILLE, NC 28681

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

Continued From page 13

Based on record review and interview, 1
of 3 paraprofessional staff (Chief
Executive

Officer/Director/Licensee (CEO/D/L)) failed
to demonstrate the knowledge, skills and
abilities required by the population served.
The findings are:

Review on 10/6/25 of the CEO/D/L record
revealed:

-Date of hire: 6/2/09.

~Job title: Owner/Executive Director.

-Job description unsigned and undated: "The
duties of the Owner/Executive Director vary
within the facility, but are responsible for the
success of the company...This position is
responsible for ensuring that each consumer
receives supports that are individually tailored
and flexible..."

-Job description for Residential Counselor
(paraprofessional) signed by the CEO/D/L
on 1/15/09: "...primarily responsible for the
direct implementation of _ individual
goals...1. Support

and assist individuals in meeting their
emotional, physical, and medical needs as
well as carrying out day to day activities.
Facilitate effective, positive relationships with
participants that are person-centered utilizing
positive approach and promote
independence throughout all daily activities..."

Review on 10/3/25 of a "Staff and Client
Information" sheet completed by CEO/D/L
on 10/3/25 revealed:

-A list of client names, admission dates,
discharge dates and location for the facility
and sister facility A.

-Former Client (FC) #5 was not listed as
being a client at the facility.

Review on 9/26/25 of FC #5's record
revealed: -A total of 9 pages.

Division of Health Service Regulation

v110

The hired consultant will ensure that the
Qualified Professional will meet the requirements
and demonstrate knowledge and competence by
exhibiting the following skills: technical
knowledge, cultural awareness, analytical
skills,decision-making, interpersonal skills,
communication skills, and clinical skills.

The consultant will monitor and supervise the
Qualified Mental Health Professional and the
director. Ensuring all responsibilities are being
accurately completed within the required
timeframe. This will be done by weekly
administrative meetings and monthly staff
meetings that are mandatory.

Working with a hired consultant will ensure
oversight into work updating all job descriptions
such as the CEO/Director, Qualified Mental
Health Professional and Paraprofessional.The
job descriptions will be signed by the CEO/
Director and QMHP. Luca’s Hope 3 will revise
the Admission packet to make sure that the
admission date, Intake date, Discharge date,
Site/Facility location are clearly listed.

STATE FORM © 7M041 |f continuation sheet 14 0f 64

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (1) PROVIDER/SUPPLIER/CLIA

AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

MHL002-028

PRINTED: 10/27/2025
FORM APPROVED

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

COMPLETED

R-C
10/10/2025

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

243 LILEDOUN ROAD
LUCA’S HOPE Ill
TAYLORSVILLE, NC 28681

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

Continued From page 14

-2 pages of July 2025 Medication
Administration Record (MARs), 2 pages of
August 2025 MARs, 2 pages of September
2025 MARs, 2 pages

regarding placement of school and 1 page of
the Department of Social Services (DSS)
legal custody letter.

-MARs for July, August and September 2025
had age 11 years old and diagnoses of
Disruptive Mood Disorder and Attention Deficit
Hyperactivity Disorder.

-There was no pre-admission screening,
assessment, treatment goals and

strategies, client specifics or physician
orders.

Interview on 10/7/25 with FC #5's local DSS.
legal guardian and DSS Supervisor revealed:
-DSS placed FC #5 at the facility on 7/15/25,
and he was discharged on 9/5/25.

-FC #5 was admitted with both of his
medications, Aripiprazole (antipsychotic) and
Clonidine HCL (hydrochloride) (ADHD).

-FC #5's needs were that he "bites himself
sometimes when he gets upset...and
incontinence."

Interview on 10/6/25 with the CEO/D/L
revealed: -"I let [Vice
President/Licensee/Qualified

Professional (VP/L/QP)] type that (Staff and
Client Information) for me, | should have
worked on it myself.”

-The 9 documents provided were the only
records she had for FC #5.

-"He (FC #5) was admitted as a DSS
emergency situation...DSS said for a day or
night...It's always just 1 or 2 nights (according
to what DSS says)...| just don’t want them
(clients) to be on the

couches at DSS...”

-Was responsible to maintain the client
records. -She and the VP/L/QP were
responsible to complete the admission
screenings,

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER:

LUCA'S HOPE Ill

STATE FORM 9970414 If continuation sheet 15 of 64

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

MHL002-028 8. WING

STREET ADDRESS, CITY, STATE, ZIP CODE
243 LILEDOUN ROAD

TAYLORSVILLE, NC 28681

PRINTED: 10/27/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R-C
10/10/2025

(X4) ID
PREFIX
TAG

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

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

DEFICIENCY)

Vv 110 Continued From page 15

assessments and Person Centered Plans.
~Staff were supervised and trained by the
"[VP/L/QP] and myself. | like to be involved."
-"We (CEO/D/L and VP/L/QP) usually do a
meet and greet and get an idea if he
(prospective client) would fit with the group
(clients)...think | should be involved too and
talk to them

(clients)..."

-"We do talk about the clients when we do
our staffing like what is going on with this
client and that client...That's the only time
we get

together... Things are told but we are not
documenting it...We have a chat of what we
need to do ourselves...It's like a
communication chat." -"| am responsible for
therapy sessions

(appointments). | am aware they need
bi-monthly sessions."

This deficiency is cross referenced into 10A
NCAC 27G.1301 Scope (V179) for a Type A1
tule violation and must be corrected within 23
days.

27G .0205 (A-B)
Assessment/Treatment/Habilitation Plan

410A NCAC 27G .0205 ASSESSMENT AND
TREATMENT/HABILITATION OR SERVICE
PLAN

(a) An assessment shall be completed for a
client, according to governing body policy, prior
to the delivery of services, and shall include,
but not be limited to:

(1) the client's presenting problem;

(2) the client's needs and strengths;

(3) a provisional or admitting diagnosis with
an established diagnosis determined within

30 days of admission, except that a client
admitted to a detoxification or other 24-hour

medical program shall have an established
diagnosis upon

Division of Health Service Regulation
STATE FORM &7¢M041 !fcontinuation sheet 16 of 64
PRINTED: 10/27/2025
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-C
MHL002-028 B. WING 10/10/2025

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

243 LILEDOUN ROAD
LUCA'S HOPE Ill
TAYLORSVILLE, NC 28681

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

Continued From page 16

admission;

(4) a pertinent social, family, and medical
history; and

(5) evaluations or assessments, such as.
psychiatric, substance abuse, medical, and
vocational, as appropriate to the client's
needs. (b) When services are provided prior
to the establishment and implementation of
the

treatment/habilitation or service plan, hereafter
teferred to as the "plan," strategies to address
the client's presenting problem shall be
documented.

This Rule is not met as evidenced by:

Based on record review and interview, the
facilty failed to ensure prior to the
establishment and implementation of the
treatment/habilitation plan strategies were
identified to address the client's presenting
problem for 1 of 1 former client (FC #5). The
findings are:

Review on 9/26/25 of FC #5's record revealed:
-Age 11 years old and diagnoses of Disruptive
Mood Disorder and Attention Deficit
Hyperactivity Disorder per the Medication
Administration Records for July, August and
September 2025. -No documentation of an
admission assessment to address strategies
for the client's presenting problem.

vit

The facility will utilize its admissions and intake
criteria to screen and determine if a potential
client meets our inclusionary criteria for the
overail program. This process will determine
whether the program can meet the clients needs.
All applicants or potential new admissions will be
required to go through the facility screening
process. The screening process includes;
submitting an application, updated
Comprehensive clinical assessment for review, a
signed service order, including a current

PCP. The facility will ensure that all assessments
and treatment plans will be completed within 30
days of admission and will continue being
updated on a monthly basis by the QMHP and
supervised by the Director.

Division of Health Service Regulation
STATE FORM ®7Mo411 lf Continuation sheet 17 of 64

PRINTED: 10/27/2025
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. BUILOING: COMPLETED

RC
MHL002-028 BAWING | —____ 10/10/2025

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

243 LILEDOUN ROAD

LUCA'S HOPE Hil

TAYLORSVILLE, NC 28681

(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE

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

Continued From page 17

Interview on 10/7/25 with FC #5's local
Department of Social Services (DSS)

legal guardian and DSS Supervisor

revealed:

-DSS placed FC #5 at the facility on 7/15/25
and he was discharged on 9/5/25.

-FC #5's Comprehensive Clinical Assessment
(CCA) was reviewed with the CEO/D/L prior to
the client being admitted to the facility and a
copy of the CCA was provided to the CEO/D/L
upon admission.

Attempted review on 9/26/25 of FC #5's CCA
was unsuccessful. No CCA for FC #5 was
provided prior to the exit of the survey.

Interview on 10/8/25 with Staff #1

revealed: -Was notified verbally by the
CEO/D/L a “few hours before" FC #5 was
admitted to the

facility..."a few hours before he came,
[CEO/D/L} called and she gave me a quick
update of him, like he does have autism that |
know of, and that's been said by a doctor,
and | know it was talked about that he's very
quiet, reserved and like he wets the bed
sometimes. It was a quick update like that..."

Interview on 10/8/25 with Staff #2 revealed:
-Was "told" by the CEO/D/L "[FC #5] was going
to be a respite...he wasn't going to be there
(facility) that long...he has some
disabilities...know he had some form of
Autism...! did learn that he was a bed wetter,
that he had to wear pull ups..."

-If a new client was getting admitted to the
facility, "| would get a call from [CEO/D/L] or
(VP/L/QP]...| was told [FC #5] was going to be
a respite, and he wasn't going to be there (at
the facility) that long and he had some
disabilities, and | want to say the DSS worker
didn't know all his diagnoses, but he had some
form of autism. [CEO/D/L] let me know this...
learned he was a bedwetter and |

Division of Health Service Regulation

STATE FORM 70411 If continuation sheet 18 of 64

PRINTED: 10/27/2025
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-C
MHL002-028 B. WING 10/10/2025

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

243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681

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

Continued From page 18

was made aware he had to wear pull ups. |
knew that before | worked with him. | think it
was more of an emergency placement."

Interview on 10/6/25 with the Vice
President/Licensee/Qualified Professional
(VP/LIQP) revealed:

-"..A lot of information comes from [CEO/D/L]
first since she's been doing it longer...| should
be responsible (for admission assessments)
but we have gone through them together, me
and

[CEO/D/L]...It's a group effort of DSS,
[CEO/D/L], but in the wheel house
(responsibilities) that will be me... That's
dropping the ball on my end and there are
things we need to start looking out for..." -"We
do have conversations (about the clients). The
staff doesn't go in green (uninformed). We
make staff familiar with each of the kids’
(clients) and each of their diagnosis...Staff are
made very aware of each kids diagnosis and
how to

approach them..."

Interviews on 9/26/25 and 10/6/25 with the
CEO/D/L revealed:

-The 9 documents she provided were the
only records she had for FC #5.
-VP/L/QP was responsible to conduct the
admission assessments, "...but | want to
be involved...”

-"...1 think | should be involved too and talk
to them (clients)."

This deficiency is cross referenced into 10A
NCAC 27G.1301 Scope (V179) for a Type A1
tule violation and must be corrected within 23
days.

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

Division of Health Service Regulation
STATE FORM 970411 If continuation sheet 19 of 64
PRINTED: 10/27/2025
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
MHL002-028 B.WING 10/10/2025

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

LUCA'S HOPE II
TAYLORSVILLE, NC 28681

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

Continued From page 19

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

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

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

projected date of achievement;

(2) strategies;

(3) staff responsible;

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

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

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

This Rule is not met as evidenced by:

Based on record review and interview, the
facilty failed to develop and implement
treatment

strategies based on client needs within 30 days
of admission for 1 of 1 former client (FC #5).
The findings are:

Division of Health Service Regulation
STATE FORM 70411 continuation sheet 20 of 64
PRINTED: 10/27/2025

FORM APPROVED

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (Xt) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED

R-C
MHL002-028 B. WING 10/10/2025

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

243 LILEDOUN ROAD

LUCA'S HOPE III

TAYLORSVILLE, NC 28681

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

Continued From page 20

Review on 9/26/25 of FC #5's record revealed:
-Age 11 years old and diagnoses of Disruptive
Mood Disorder and Attention Deficit
Hyperactivity Disorder per the Medication
Administration Records from July, August and
September 2025. -No documentation of a
treatment plan with strategies to address
client needs such as

incontinence and biting himself.

Interview on 10/7/25 with FC #5's local
Department of Social Services (DSS)

legal guardian and DSS Supervisor
revealed:

-DSS placed FC #5 at the facility on 7/15/25
and he was discharged on 9/5/25 back to his
family. -A copy of FC #5's Comprehensive
Clinical Assessment (CCA) was given to the
Chief

Executive Officer/Director/Licensee
(CEO/D/L) upon admission.

-FC #5's needs were that he “bites himself
sometimes when he gets upset...and
incontinence."

-"...l sent a long list of things we still needed
for [FC #5] including a PCP (Person
Centered Plan/Treatment Plan) and we
(DSS and

CEO/D/L) had a conversation about this...! had
to send it (another list of things needed)...to
[CEO/D/L]...had a hard time keeping up.
She never produced a PCP..."

Interview on 10/8/25 with Staff #1
revealed: -Was aware FC #5 had
"...wets the bed

sometimes..."

-Not aware of any treatment goals and
strategies for FC #5.

Interview on 10/8/25 with Staff #2 revealed:
-Was "told" by the CEO/D/L "...he (FC #5)
..Was a bed wetter, that he had to wear pull
ups..." -Not aware of any treatment goals and
strategies for FC #5.

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

V112

The facility will utilize its admissions and intake
criteria to screen and determine if a potential
client meets our inclusionary criteria for the
overall program. This process will determine
whether the program can meet the clients needs.
All applicants or potential new admissions will be
required to go through the facility screening
process. The screening process includes;
submitting an application, updated
Comprehensive clinical assessment for review, a
signed service order, including a current

PCP. The facility will ensure that all assessments
and treatment plans will be completed within 30
days of admission and will continue being
updated on a monthly basis by the QMHP and
supervised by the Director.

Division of Health Service Regulation
STATE FORM © 7M0411 If continuation sheet 21 of 64
PRINTED: 10/27/2025
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
MHL002-028 B.WING 10/10/2025

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

243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681

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

Continued From page 21

Interview on 9/23/25 and 10/6/25 with the
Vice President/Licensee/Qualified
Professional

(VP/L/QP) revealed:

-"Both myself and [CEO/D/L] are responsible
for treatment plans. | am responsible for
scheduling treatment team meetings. The
majority of the time it is virtual because most
of the people involved prefer virtual..."

-"... will be the one who does the PCP. It's a
group effort of DSS, [CEO/D/L], but in the
wheel house that will be me... That's (keeping
PCPs current) dropping the ball on my end
and there are things we need to start looking
out for. We make sure of the focus that the
kids (clients) are meeting their goals..."

Interviews on 9/18/25, 9/26/25 and 10/6/25
with the CEO/D/L revealed:

-The only records she possessed for FC

#5 consisted of a total of 9 documents.

-She and the VP/L/QP were responsible

for completing PCPs.

-"CFTs (Child and Family Team) are initiated by
[VP/L/QP]... will write things down if | am part
of it and (VP/L/QP] does, and now | realize we
should be adding more to it (PCP)..."

-"We have had CFT meetings, and | can show
that, but | haven't updated the PCPs... have
been sick a lot and had to take care of my
sister...We (facility) haven't been required to
submit

documentation like we used to. The meetings
(CFTs) have happened. | am now trying to get
caught up. They (clients) have been getting
good care...but | have got slack on the
paperwork. | have signature pages because
after our CFT, | send it to the guardian, and
they sign it, but itis up to me to update the
plan. A lot of meetings are virtual now and it's
hard for everyone to physically meet together. |
send the signature pages. I've

Division of Health Service Regulation
STATE FORM &° 7104114 |f continuation sheet 22 of 64
PRINTED: 10/27/2025
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
MHL002-028 BANG 10/10/2025

NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST 8E PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

Continued From page 22

never had to do that before..."

-"He (FC #5) was admitted as a DSS
emergency situation...DSS said for a day or
night...|t's always just 1 or 2 nights (according
to what DSS says)... just don't want them
(clients) to be on the

couches at DSS...”

This deficiency is cross referenced into 10A
NCAC 27G.1301 Scope (V179) for a Type A1
tule violation and must be corrected within 23
days.

27G .0206 Client Records

10A NCAC 27G .0206 CLIENT RECORDS
(a) A client record shall be maintained for
each individual admitted to the facility,
which shall contain, but need not be limited
to:

(1) an identification face sheet which
includes: (A) name (last, first, middle,

maiden);

(B) client record number;

(C) date of birth;

(D) race, gender and marital status;

(E) admission date;

(F) discharge date;

(2) documentation of mental illness,
developmental disabilities or substance
abuse diagnosis coded according to DSM
N;

(3) documentation of the screening and
assessment,

(4) treatment/habilitation or service plan;

(5) emergency information for each client
which shall include the name, address and
telephone number of the person to be
contacted in case of sudden illness or accident
and the name, address and telephone number
of the client's preferred physician;

(6) a signed statement from the client or
legally responsible person granting
permission to seek emergency care from a
hospital or physician;

Division of Health Service Regulation
STATE FORM & 7041 f Continuation sheet 23 of 64
PRINTED: 10/27/2025
FORM APPROVED

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERYCLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED

R-C
MHL002-028 BAWING 10/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

243 LILEDOUN ROAD

LUCA'S HOPE lil

(X4) 1D
PREFIX
TAG

TAYLORSVILLE, NC 28681

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

Continued From page 23

(7) documentation of services provided;
(8) documentation of progress toward
outcomes; (9) if applicable:

(A) documentation of physical disorders
diagnosis according to International
Classification of Diseases (ICD-9-CM);
(B) medication orders;

(C) orders and copies of lab tests; and

(D) documentation of medication and
administration errors and adverse drug
reactions. (b) Each facility shall ensure that
information relative to AIDS or related
conditions is disclosed only in accordance
with the communicable disease laws as
specified in G.S. 130A-143.

This Rule is not met as evidenced by:

Based on record review and interview, the
facilty failed to maintain complete client
records for 1 of 1 former client (FC #5). The
findings are:

Review on 9/26/25 of FC #5's record
revealed: -A total of 9 pages.

-2 pages of July 2025 Medication
Administration Record (MARs), 2 pages of
August 2025 MARs, 2 pages of September
2025 MARs, 2 pages

regarding placement of school and 1 page of
the Department of Social Services (DSS)
legal custody letter.

-MARs for July, August and September 2025
had age 11 years old and diagnoses of
Disruptive Mood Disorder and Attention Deficit
Hyperactivity Disorder.

-There was no identification face sheet to
include a client record number, date of birth,
race,

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

V113

The facility will ensure that all records and
documentation for any client in need of services
must provide all required documentation that is
required to be in their file. This includes a copy of
a physician’s order for medication,copy of birth
certificate, Copy of Insurance or medicaid card,
Emergency contact and a completed application.
Luca's Hope II! will revise and update Client
intake packet to ensure the following client
information which will have an identification face
sheet which includes: Name (last, first,
middle, maiden); client record number; date
of birth; race, gender and marital status;
admission date; discharge date;
documentation of mental illness,
developmental disabilities or

substance abuse diagnosis coded

according to DSM IV; documentation

of the screening and assessment;
treatment/habilitation or service plan;
emergency information for each

client which shall include the name,

address and telephone number of

the person to be contacted in case of

sudden illness or accident and the

name, address and telephone

number of the client's preferred

physician; a signed statement from

the client or legally responsible

person granting permission to seek
emergency care from a hospital or

physician, documentation of progress

toward outcomes; if applicable:
documentation of physical disorders diagnosis
according to International Classification of
Diseases,medication orders; orders and
copies of lab tests; and documentation of
medication and administration errors and
adverse drug reactions. Each facility shall
ensure that information relative to AIDS or

related conditions is disclosed only in
accordance with the communicable disease
laws as specified in G.S. 130A-143. Luca’s

Hope III will ensure that only qualified
personnel will be documenting on the new
client intake forms and process This will be
monitored by the CEO/Director and QMHP

Division of Health Service Regulation
STATE FORM 9 7M0411 !fcontinuation sheet 24 of 64

PRINTED: 10/27/2025

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
MHL002-028 B. WING 10/10/2025
NAME OF PROVIDER OR SUPPLIER:

STREET ADDRESS, CITY, STATE, ZIP CODE

243 LILEDOUN ROAD
LUCA'S HOPE III

TAYLORSVILLE, NC 28681

(X4) 1D SUMMARY STATEMENT OF DEFICIENCIES: PROVIDER'S PLAN OF CORRECTION

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

Continued From page 24

gender, admission date, or discharge
date. -No documentation of mental
illness,

developmental disabilities, or substance
abuse diagnoses coded according to
Diagnostic and Statistical Manual of Mental
Disorders (DSM) IV. -No documentation an
admission screening, or admission
assessment.

-No treatment/habilitation or service plan.
-No documentation of services that were
provided.

-No documentation of client progress
toward outcomes.

-No physician orders.

Interview on 10/7/25 with FC #5's local
Department of Social Services (DSS)

legal guardian and DSS Supervisor
revealed:

-DSS placed FC #65 at the facility on 7/15/25
and he was discharged on 9/5/25.

-A copy of FC #5's Comprehensive Clinical
Assessment (CCA) was provided to the
Chief Executive Officer/Director/Licensee
(CEO/D/L) upon admission.

Interview on 10/6/25 with the Vice
President/Licensee/Qualified Professional
revealed:

-"We do have conversations (with staff

about clients). The staff doesn't go in

green

(uninformed). We make staff familiar with each
of the kid's (clients) and each of their
diagnosis. It can be from the CCA or the PCP.
(Person

Centered Plan/Treatment Plan) and staff are
aware of what is going on with these kids and
there are conversations going on at our
meetings of what has been happening and
going on at the house (facility). Staff are made
very aware of each kids diagnosis and how to
approach them...”

Interviews on 9/26/25 and 10/6/25 with the

Division of Health Service Regulation
STATE FORM ® 70411 If continuation sheet 25 of 64

PRINTED: 10/27/2025

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

MHL002-028 B. WING

NAME OF PROVIDER OR SUPPLIER:

STREET ADDRESS, CITY, STATE, ZIP CODE
243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681

(X4) 1D SUMMARY STATEMENT OF DEFICIENCIES
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL
TAG REGULATORY OR LSC IDENTIFYING INFORMATION)

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

DEFICIENCY)

Continued From page 25

CEO/DIL revealed:

-The 9 documents she provided were the
only records she had for FC #5.

-"...the filing is horrible. | used to do it
(maintain client records) but | got sick...! will
make sure | am maintaining the
records...I've been

updating...Let others help. | let [Staff #2] put
information like names, dates and stuff like
{hat and | found out that allowing her to
complete paperwork, she made mistakes. |
saw paperwork completed and not knowing it
was incorrect. |am going to go back to doing
it myself. It should be my responsibility...and |
am going to take on those things back
myself."

-"We do talk about the clients when we do
our staffing like what is going on with this
client... Things are told but we are not
documenting it."

This deficiency is cross referenced into 10A
NCAC 27G.1301 Scope (V179) for a Type A1
rule violation and must be corrected within 23
days.

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

Division of Health Service Regulation

STATE FORM ©7M0411 If Continuation sheet 26 of 64
PRINTED: 10/27/2025
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
MHL002-028 B. WING 10/10/2025

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

243 LILEDOUN ROAD
LUCA'S HOPE Il
TAYLORSVILLE, NC 28681

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

V118 Continued From page 26

privileged to prepare and administer

medications. (4) A Medication Administration

Record (MAR) of all drugs administered to

each client must be kept current. Medications

administered shall be

recorded immediately after administration.

The MAR is to include the following:

(A) client's name;

(B) name, strength, and quantity of the

drug; (C) instructions for administering

the drug;

(D) date and time the drug is administered;

and (E) name or initials of person

administering the drug.

(5) Client requests for medication changes or

checks shall be recorded and kept with the

MAR file followed up by appointment or

consultation with a physician. V118

The facility completed a class on 9/30/2025 that
involved each employee performing a simulated
return demonstration on how to give medication
to clients. The facility staff demonstrated the
return of medication administration while being
monitored by a licensed nurse. The facility will
set in place a checklist that will be utilized
moving forward that will have a list of items that

Py . . must be provided prior to completing an intake
Based on record review and interview, the for ail new clients being enrolled into the

facility failed to ensure medications were program. This new practice will ensure that a
administered on the written order of a physician order is present to indicate accuracy of
physician, failed to keep the MAR current the medication that the new client should be
affecting 1 of 1 former client (FC #5), and taking This checklist will prevent clients from
failed to ensure medications were being enrolled into the facility without physician
administered only by persons trained by a orders for their prescribed medications. Moving
legally qualified person to prepare and forward the facility will ensure that all

administer medications are reviewed on a regular monthly
medications for 2 of 3 paraprofessional basis so that expired medications and med

4 St . q errors are monitored so that this will not be an
stat (Staff #1 and Staff #2). The findings issue moving forward. The facility will review /

check all medications to ensure that they are not
out of date. The reviews will be completed by the
QP or the Director. The facility will also ensure

This Rule is not met as evidenced by:

Finding #1:

that medications are reviewed and checked to
ensure that the prescription and mars are
accurate and match the doctor's order. These
reviews will be completed by the QP and the
Director. The reviews and checks will be done
monthly/weekly including the Mars in order to
prevent any possible medication errors. The
facility has already set in place a checklist that
will include The QP or Director reviewing client
medications, both psychotropic and regular
medications, showing that they are being tracked
and updated on a 6 month basis to ensure that
mediation is being given appropriately as
prescribed. The QP will assist the Director with
oversight regarding the checklist and monitoring
The Mar will also reflect if a client refuses to take
their prescribed medication or if the staff fails to
give medication within the window timeframe.
Staff will call the pharmacy or the doctor and
inform them of the client not getting their
medication and get instructions on possible side
effects, what to look for because of client taking
their medication as prescribed whether it's from
them refusing or staff forgetting to give the
medication. The facility has already created
forms to include the QP & Director whom will
monitor and document that these practices
mentioned above are being met on a regular
basis as stated. There will be more new forms
created that will be signed on a weekly/monthly
basis effective immediately To ensure that the
above areas that are out of compliance are being
met and moving forward will no longer be an
issue. This will be completed on a
weekly/monthly basis to show that the facility is
back in compliance

Review on 9/26/25 of FC #5's record revealed:
-Age 11 years old and diagnoses of Disruptive
Mood Disorder and Attention Deficit
Hyperactivity Disorder per the MARs from
July, August and September 2025.

Division of Health Service Regulation
STATE FORM © 70411 Hf continuation sheet 27 of 64

PRINTED: 10/27/2025

FORM APPROVED

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIOER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED

R-C
MHL002-028 BWING 10/10/2025

NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
243 LILEDOUN ROAD
LUCA'S HOPE Ill

TAYLORSVILLE, NC 28681

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

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

Division of Health Service Regulation

Continued From page 27

Interview on 10/7/25 with FC #5's local
Department of Social Services (DSS)

legal guardian and DSS Supervisor
revealed:

-DSS placed FC #5 at the facility on 7/15/25
and he was discharged on 9/5/25.

Review on 10/1/25 of FC #5's physician's
orders requested on 9/26/25 and received
from the Chief Executive
Officer/Director/Licensee (CEO/D/L) on
10/1/25 revealed:

-Atipiprazole 5 mg 1 tablet daily written 8/8/25.
-Clonidine HCL 0.1 mg 1 tablet twice daily
written 8/13/25.

-No physician's order to change the
administration directions of clonidine HCL
from twice daily to 1 tablet every night.

-No documentation of a physician's order

to administer "Allergy relief."

Review on 9/26/25 of FC #5's MARs dated
July 2025 through September 2025
revealed:

-Aripiprazole (Autistic Disorder) 5 milligrams
(mg) 1 tablet daily was initialed as
administered

7/16/25-9/5/25 (24 doses prior to order
dated 8/8/25.

Clonidine HCL (hydrochloride) (ADHD) 0.1
mg twice daily was initialed as administered
7/16/25-8/31/25 (57 doses prior to order
dated 8/13/25).

-Clonidine HCL 0.1 mg had instructions to
administer "1 tablet every night" instead of
twice daily on the September 2025 MAR, but
was initialed as administered at 8am and
8pm

9/1/25-9/4/25 and at 8am on 9/5/25.
~"Allergy relief 5 mg" was documented as
"NON-PRESCRIPTION MEDICATION(S)
GIVEN" and initialed as administered once
each day on 9/2/25, 9/3/25 and 9/4/25 with no
instructions of the frequency, route, or reason
for administering

STATE FORM &7M0411 If continuation sheet 28 of 64

PRINTED: 10/27/2025
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

RC

MHL002-028 8. WING

10/10/2025

NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE.
243 LILEDOUN ROAD
LUCA'S HOPE Ill
TAYLORSVILLE, NC 28681

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

Continued From page 28

the medication.
Finding #2:

Review on 9/26/25 of Staff #1's record
revealed: -Date of Hire: 9/6/23.

-Medication administration training dated
4/30/25 signed by the Registered Nurse (RN)
Medication Training Consultant.

Review on 9/26/25 of Staff #2's record
revealed: -Date of Hire: 12/13/23.

-Medication administration training dated
4/30/25 signed by the RN Medication Training
Consultant.

Interview on 9/29/25 with Staff #1 revealed:
-Was trained in medication administration

"it was earlier this year (4/30/25)...She

(RN

Medication Training Consultant) came in (to
the facility) and we talked about it
(medication

administration) and everything...and then after
we talked about it, we would take the test, and
she would go over any questions we had.”
Could not recall the individual who observed
his return demonstration in medication
administration.

Interview on 9/25/25 and 10/8/25 with Staff
#2 revealed:

-Received training in medication
administration on 4/30/25 from the RN
Medication Training Consultant.

-The 4/30/25 training did not include a
return demonstration by staff.

Interview on 9/22/25 with the RN

Medication Training Consultant revealed:
-Conducted medication administration training
for Luca's Hope III and Sister Facility A.

-"l rely some on [CEO/D/L]. She ensures me she

Division of Health Service Regulation

STATE FORM 70411 !f continuation sheet 29 of 64
PRINTED: 10/27/2025
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

R-C
10/10/2025

MHL002-028 8. WING

NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
243 LILEDOUN ROAD
LUCA'S HOPE Itt
TAYLORSVILLE, NC 28681

(x4) ID
PREFIX
TAG

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

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

Continued From page 29

works with them (facility staff) individually
before they can give medications...| didn't
realize they (facility staff) needed observed
when trained." -"I haven't ever actually
observed a med
(medication pass)..."

Interview on 9/23/25 and 10/6/25 with the
Vice President/Licensee/Qualified
Professional

(VP/L/QP) revealed:

-"No new staff are on by themselves, we don't
just throw them in...A senior staff will make sure
they can do it (medication administration). Most
of the time it is [CEO/D/L]. Staff are watched
passing (administering) medications on shift
for about 5 days, or however many days they
are on that week..."

-".. The PRNs are not listed (pre-typed) on
the MARs...If the client doesn't have any
allergies they are allowed over the counter
(OTC)

medications. If an over the counter is given
toa client it should be charted on the back

of the MAR..."

-"| do review and look at MARs...but that's not
my wheelhouse or ownership, but I've done it.
That (reviewing MARs) could be me or
[CEO/D/L]. Usually it's her (CEO/DIL)..."

Interview on 10/6/25 with the CEO/D/L
revealed: -"I had it (medication administration
training) years ago, and normally the nurse
(Registered Nurse) would come and go over
things and test us, but | never knew we had

to demonstrate (medication administration),
do the pass as part of the training.”
-Responsible for completing the MARs monthly
and ensuring they were accurately updated in
accordance with physician's orders. "Normally

it's me, but it was one of the duties | gave to
[Staff #2], but | am going to go back to doing

it. She (Staff #2) was actually printing them
(MARs) and

Division of Health Service Regulation
STATE FORM &7M0411 If continuation sheet 30 of 64
PRINTED: 10/27/2025
FORM APPROVED
Division of Health Service Regulation
‘STATEMENT OF DEFICIENCIES (<1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED

R-C
MHL002-028 B. WING 10/10/2025

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

243 LILEDOUN ROAD

LUCA’S HOPE Ill
TAYLORSVILLE, NC 28681

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

Continued From page 30

using the previous one...she would just update
it, pull it up and print them out. ! will ensure
they are accurate."

-Facility staff were supposed to obtain a copy
of the physician's order whenever a client's
medication was changed. "I am going to tell
them (staff) to make sure we get a copy...We
(facility staff) have gotten slack at it..."

-OTC medications were administered to

clients as needed (PRN) based on known
allergies documented in their record.

-Moving forward, an authorization form would
be completed for all PRN OTC medications.
The form would be signed by both the
prescribing physician and the client's legal
guardian.

Due to the failure to accurately document
medication administration, it could not be
determined if clients received their

medications as ordered by the physician.

Review on 10/6/25 of the Plan of Protection
dated 10/6/25 written by the CEO/D/L
revealed:

-"What immediate action will the facility take to
ensure the safety of the consumers in your
care? (V118) The facility has already
completed a new class with the nurse on
9/30/2025. The class was Medication
Administration that included staff performing a
pass demonstration of the

medication to be given to clients. The
medication class was preformed in front of a
licensed

(Registered) Nurse. The facility will set in place
a checklist that will be utilized moving forward
that will have a list of items that must be
provided prior to completing an intake for a
new client. This new practice will ensure that a
physician order is present to indicate accuracy
of the medication that the new client should be
taking. This

checklist will prevent clients being enrolled

into the facility without physician orders.
Moving

Division of Health Service Regulation

STATE FORM °7M0411 If continuation sheet 31 of 64

PRINTED: 10/27/2025
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDERISUPPLIERICLIA (K2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED

R-C
MHL002-028 8. WING _____ 10/10/2025

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

243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681

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

Continued From page 31

forward we will ensure that all medications are
reviewed on a regular monthly basis so that
expired medications and med (medication)
errors are monitored so that this will not be an
issue moving forward. The facility will
review/check all medications to ensure that
they are not out of date. The facility will also
ensure that medications are reviewed and
checked to ensure that the prescription and
mars are accurate and match the doctor's
order. The reviews and checks will be done
monthly, including the mars prevention any
medication errors. The facility has already set
in place a checklist that will include someone
reviewing and monitoring the medications, both
psychotropic and regular medications being
tracked and updated on a 6-month basis to
ensure that mediation is being given
appropriately as prescribed. The QP
({VP/L/QP) will assist the Director (CEO/D/L)
with oversight of this being set in place and
implemented including followed through. The
medication errors will include when a client
refuses to take the medication or if the staff
fails to give medication within the window
timeframe, staff will call the pharmacy or the
doctor and inform them of the client not getting
their medication and get instructions on
possible side effects, what to look for because
of client not getting their medication as
prescribed whether it's from them refusing or
staff forgetting to give the medication.

Describe your plans to make sure the

above happens.

The facility has already created forms to
include the QP & Director who will monitor
and document that these practices mentioned
above are being met on a regular basis. There
will be more new forms created that will be
signed ona

weekly/monthly basis effective immediately

to ensure that the above areas that are out

of

Division of Health Service Regulation

STATE FORM 70411 lf continuation sheet 32 of 64

PRINTED: 10/27/2025

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
MHL002-028 B.WING 10/10/2025

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

243 LILEDOUN ROAD
LUCA'S HOPE Ill
TAYLORSVILLE, NC 28681

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

V118 Continued From page 32

compliance are being met and moving forward
will not be an issue. This will be completed on
a weekly/monthly basis to show that we are
back in compliance."

Review on 10/7/25 of the addendum to the
Plan of Protection dated 10/7/25 written by
the

CEO/D/L revealed:

~"What immediate action will the facility take to
ensure the safety of the consumers in your
care? ...The facility completed a class on
9/30/2025 that involved each employee
performing a simulated return demonstration
on how to give medication to clients. The
facility staff demonstrated the return of
medication administration while being
monitored by a licensed nurse...a list of items
that must be provided prior to completing an
intake for all new clients being enrolled into the
program...enrolled into the facility without
physician orders for their prescribe
medications...Moving forward the facility will
ensure that all medications are
teviewed...The reviews will be completed by
the QP or the Director...including the Mars

in order to prevent any possible medication
errors... The QP or Director reviewing client
medications...showing that they are being
tracked and updated on a 6-month
basis...The QP will assist the Director with
oversight regarding the checklist and
monitoring. The Mar will also reflect if a
client refuses to take their prescribed
medication...

Describe your plans to make sure the
above happens.

...created forms to include the QP & Director
whom will monitor and document...as stated.
There will be more new forms
created...effective immediately. To

ensure...moving forward will no longer be an

issue..."

Division of Health Service Regulation

STATE FORM ©7041 !f continuation sheet 33 of 64

PRINTED: 10/27/2025
FORM APPROVED

Division of Health Service Regulation
‘STATEMENT OF DEFICIENCIES (<1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A, BUILDING: COMPLETED

R-C
MHL002-028 B. WING ____ 40/10/2025

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

243 LILEDOUN ROAD
LUCA'S HOPE III

TAYLORSVILLE, NC 28681

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

Continued From page 33

FC #5 was 11 years old with diagnoses
which included Disruptive Mood Disorder
and ADHD. While residing at the facility, FC
#5 was

administered aripiprazole daily from
7/16/25-8/8/25 for a total of 24 doses,
clonidine twice daily from 7/16/25-8/13/25 for
a total of 57 doses, and allergy relief
medication from

9/2/25-9/4/25 for a total of 3 doses, without
evidence of a physician's order. A
physician's order for FC #5 dated 8/13/25,
authorized that clonidine be administered
twice daily. FC #5's MAR for the period of
9/1/25-9/5/25 listed

instructions to administer one tablet nightly.
FC #5's MAR was initialed to indicate the
clonidine was administered twice daily,
reflecting a

discrepancy between the prescribed dosage
and the documented administration. Staff #1
and Staff #2 received formal medication
administration training conducted by a
Registered Nurse.

However, they did not complete a return skills
demonstration observed by a Registered
Nurse following the training to validate their
competency in safely and accurately
administering

medications.

This deficiency constitutes a Type B rule
violation which is detrimental to the health,
safety and welfare of the clients and must be
corrected within 45 days.

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

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

(d2) Before hiring health care personnel into a
health care facility or service, every employer
ata health care facility shall access the Health
Care Personnel Registry and shall note each
incident

Division of Health Service Regulation
STATE FORM 70411 lf continuation sheet 34 of 64

PRINTED: 10/27/2025

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

B. WING

10/10/2025
MHL002-028

STREET ADDRESS, CITY, STATE, ZIP CODE
243 LILEDOUN ROAD

NAME OF PROVIDER OR SUPPLIER

LUCA'S HOPE Il
TAYLORSVILLE, NC 28681

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

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

Continued From page 34

of access in the appropriate business files.

V131
Luca's Hope III will ensure that before hiring any
employee/staff, their information shall be entered
into the Health Care Personnel Registry
verifying whether they are eligible to provide
services within the healthcare facility. This will be
monitored theby CEO/Director and the QMHP.

This Rule is not met as evidenced by:
Based on record review and interview, the
facility failed to access the Health Care
Personnel Registry (HCPR) prior to an offer of
employment for 3 of 6 audited staff (Staff #1,
Staff #2, and the Vice
President/Licensee/Qualified Professional
(VP/LIQP)). The findings are:

Review on 9/26/25 of Staff #1's record
revealed: -Date of Hire: 9/6/23.
-HCPR accessed on 10/5/23.

Review on 9/26/25 of Staff #2's record
revealed: -Date of Hire: 12/13/23.
~HCPR accessed on 12/14/23.

Review on 9/26/25 of the VP/L/QP's
record revealed:

-Date of Hire: 8/7/23.
-HCPR accessed on 9/8/24.

Interview on 9/23/25 with the VP/L/QP
revealed: -"[Chief Executive
Officer/Director/Licensee (CEO/D/L)] is
responsible for HCPR...| have helped in the
past but it is [CEO/D/L] who is accountable.“

Interview on 10/6/25 with the CEO/D/L
revealed: -"| am responsible for...HCPR
(checks)...1 go in and request the
information...it was a mistake on my part,
that's my fault...1 was responsible for that...
know it should be done prior to being

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

LUCA'S HOPE III

STATE FORM © 7M041 Continuation sheet 35 of 64

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

(X%2) MULTIPLE CONSTRUCTION
A. BUILDING:

MHL002-028 B. WING

STREET ADDRESS, CITY, STATE, ZIP CODE
243 LILEDOUN ROAD

TAYLORSVILLE, NC 28681

PRINTED: 10/27/2025
FORM APPROVED

{X3) DATE SURVEY
COMPLETED

R-C
10/10/2025

(x4) ID
PREFIX
TAG

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

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

DEFICIENCY)

Vv 131 Continued From page 35

hired. It just happened. | was responsible
for that...| don't know what happened...”

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

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

(g) Health care facilities shall ensure that

the Department is notified of all allegations
against health care personnel, including
injuries of

unknown source, which appear to be related
fo any act listed in subdivision (a)(1) of this
section. (which includes:

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

c. Misappropriation of the property of a
healthcare facility.

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

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

Facilities must have evidence that all alleged
acts are investigated and must make every
effort to protect residents from harm while the
investigation is in progress. The results of

all investigations must be reported to the
Department within five working days of the
initial notification to the Department.

Division of Health Service Regulation
STATE FORM &° 7M0411 !f continuation sheet 36 of 64
PRINTED: 10/27/2025
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
MHL002-028 B.WING 10/10/2025

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

243 LILEDOUN ROAD

LUCA'S HOPE III
TAYLORSVILLE, NC 28681

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

Continued From page 36

This Rule is not met as evidenced by:
Based on record review and interview, the
facility failed to protect clients from harm
during an investigation and failed to report,
within 5 working days, the results of the
investigation to the

Department. The findings are:

Reviews on 9/25/25 and 10/8/25 of the North
Carolina Incident Response and Reporting
(IRIS) revealed:

~Former Client (FC) #2's allegation of

abuse against Staff #1 on 8/27/25 had a
submission date of 8/30/25. No internal
investigation was attached.

-FC #3 allegation of abuse against Staff #1 on
8/28/25 had a submission date of 9/1/25.
Internal investigation was submitted on
10/8/25.

Interview on 9/29/25 with the local Department
of Social Services (DSS) !nvestigator
revealed: -8/27/25 - FC #2 alleged "...[Staff
#1)...slapped him (FC #2) across the face...he
had pretty significant bruising on his ear.
-8/28/25 - FC #3 alleged "[Staff #1] slammed
his head on the ground...he (FC #3) did have a
bump on his head..."

-On the evening of 8/27/25 FC #2 was
removed from the facility by DSS due to the
abuse

allegation.

-Staff #1 continued to work on shift when she
left the evening of 8/27/25 (after the first
allegation). -On 8/28/25 FC #3 was removed
from the facility by DSS due to the abuse
allegation.

-On 8/28/25 the Chief Executive
Officer/Director/Licensee (CEO/D/L) "...made
the decision to remove [Staff #1] and said ‘He
(Staff #1) would no longer be employed at the
home (facility).

Interview on 9/26/25 with the Vice

V132

Luca’s Hope Iil will ensure that the Health
Care Personnel registry is notified within 5
working days of any allegations against staff/
personnel or the facility. This will include
injuries of unknown source, Neglect or abuse,
Misappropriation of the property of a resident,
Diversion of drugs belonging to a health care
facility or to a patient or client.

Fraud against a health care facility or
against or a client for whom the

employee is providing services.

Luca’s Hope III will report evidence that

all alleged acts are investigated and

will ensure to protect residents from

harm while the investigation is in

progress. The results of all

investigations will be reported to the
Department within five working days of

the initial notification to the

Department. Luca’s Hope III will ensure

that the results of the internal

investigation are attached to the report.
Luca’sHope !II will ensure that all IRIS
incidents are reported and submitted

within the IRIS system. All Level 2

incidents will be reported within 72

hours of the incident. All Level 3

incidents will be reported within 24

hours of the incidents. Luca's Hope III

will ensure that any staff involved in an
allegation will not be allowed to work
effective immediately until the

investigation is cleared and deemed
unsubstantiated. This will be monitored

and executed by the CEO/Director

Division of Health Service Regulation
STATE FORM &°7M0411 If continuation sheet 37 of 64
PRINTED: 10/27/2025

FORM APPROVED

STATEMENT OF DEFICIENCIES.
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

R-C
10/10/2025

MHL002-028 B.WING

NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681

(x4) ID
PREFIX
TAG

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

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

Continued From page 37

President/Licensee/Qualified Professionai
(VP/L/QP) revealed:

-On the evening of 8/27/25 the CEO/DIL called
to inform her FC #2 made an allegation of
abuse against Staff #1.

-On 8/28/25 she was notified FC #3 made

an allegation of abuse against Staff #1.

-Staff #1 continued to work throughout the
night shift on 8/27/25 into the morning of
8/28/25. -"After the 28th (8/28/25) we (she
and the

CEO/D/L) went ahead and suspended

(Staff #1)..."

-The abuse investigations for FC #2 and FC
#3 =were completed on 9/1/25.

Interviews on 9/26/25, 9/29/25 and 10/7/25
with the CEO/DI/L revealed:

-On 8/27/25 at 7:00 p.m. she received a call
from Staff #2 that DSS was there and FC #2
made an abuse allegation against Staff #1.
-On the evening of 8/28/25, DSS returned due
to FC #3 allegation of abuse against Staff #1.
-Staff #1 was working on 8/27/25 (after the
first allegation) and continued to work into
the

morning of 8/28/25. He walked the clients

to school that morning.

-The IRIS reports were not submitted, "!
started it (IRIS), but | didn't save it..."

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

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

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

Division of Health Service Regulation

STATE FORM & 7MO411 "Teontinuation sheet 38 of 64
PRINTED: 10/27/2025

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

R-C
MHL002-028 B. WING 10/10/2025

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

243 LILEDOUN ROAD
LUCA'S HOPE Ill
TAYLORSVILLE, NC 28681

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

Continued From page 38

Chapter.

(b) Requirement. - An offer of employment

by a provider licensed under this Chapter to
an

applicant to fill a position that does not require
the applicant to have an occupational license
is conditioned on consent to a State and
national criminal history record check of the
applicant. If the applicant has been a resident
of this State for less than five years, then the
offer of employment is conditioned on consent
to a State and national criminal history record
check of the applicant. The national criminal
history record check shall

include a check of the applicant's fingerprints.
If the applicant has been a resident of this
State for five years or more, then the offer is
conditioned on consent to a State criminal
history record check of the applicant. A
provider shall not employ an applicant who
refuses to consent to a criminal history record
check required by this section. Except as
otherwise provided in this subsection, within
five business days of making the conditional
offer of employment, a provider shall submit a
request to the Department of Justice under
G.S. 114-19.10 to conduct a

criminal history record check required by this
section or shall submit a request to a private
entity to conduct a State criminal history
record check required by this section.
Notwithstanding G.S. 114-19.10, the
Department of Justice shall return the

results of national criminal history record
checks for employment positions not

covered by Public Law 105-277 to the
Department of Health and Human

Services, Criminal Records Check Unit.
Within five

business days of receipt of the national
criminal history of the person, the Department
of Health and Human Services, Criminal
Records Check Unit, shail notify the provider

as to whether the information received may

affect the employability

Division of Health Service Regulation
STATE FORM © 7M0411 continuation sheet 39 of 64

PRINTED: 10/27/2025
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
MHL002-028 8. WING 40/10/2025

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

243 LILEDOUN ROAD

LUCA'S HOPE III
TAYLORSVILLE, NC 28681

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

Continued From page 39

of the applicant. In no case shall the results of
the national criminal history record check be
shared with the provider. Providers shall make
available upon request verification that a
criminal history check has been completed on
any staff covered by this section. A county that
has adopted an appropriate local ordinance
and has access to the Division of Criminal
Information data bank may conduct on behalf
of a provider a State criminal history record
check required by this section without the
provider having to submit a request to the
Department of Justice. In such a case, the
county shall commence with the State criminal
history record check required by this section
within five business days of the

conditional offer of employment by the
provider. All criminal history information
received by the provider is confidential and
may not be disclosed, except to the applicant
as provided in subsection (c) of this section.
For purposes of this

subsection, the term "private entity"

means a business regularly engaged in
conducting

criminal history record checks utilizing

public records obtained from a State

agency.

(c) Action. - If an applicant's criminal history
record check reveals one or more convictions
of a relevant offense, the provider shall
consider all of the following factors in
determining whether to hire the applicant:

(1) The ievel and seriousness of the crime.

(2) The date of the crime.

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

the conviction.

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

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

(6) The prison, jail, probation, parole,

Division of Health Service Regulation

STATE FORM © 7M0411 if continuation sheet 40 of 64
PRINTED: 10/27/2025
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

MHL002-028 B. WING 10/10/2025

NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681

(x4) ID
PREFIX
TAG

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

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

DEFICIENCY)

Continued From page 40

rehabilitation, and employment records of the
person since the date the crime was
committed. (7) The subsequent commission

by the person of a relevant offense.

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

(d) Limited Immunity. - A provider and an
officer or employee of a provider that, in

good faith, complies with this section shall

be immune from civil liability for:

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

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

Endangering Executive and Legislative
Officers; Article 6, Homicide; Article 7A,

Rape and Other

Division of Health Service Regulation

STATE FORM %7M0411 'f continuation sheet 41 of 64
PRINTED: 10/27/2025
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

R-C
10/10/2025

B. WING

MHL002-028

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE
243 LILEDOUN ROAD
LUCA'S HOPE Il
TAYLORSVILLE, NC 28681

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

DEFICIENCY)

Continued From page 41

Sex Offenses; Article 8, Assaults; Article 10,
Kidnapping and Abduction; Article 13,
Malicious Injury or Damage by Use of
Explosive or

Incendiary Device or Material; Article 14,
Burglary and Other Housebreakings; Article
45, Arson and Other Burnings; Article 16,
Larceny; Article 17, Robbery; Article 18,
Embezzlement; Article 19, False Pretenses
and Cheats; Article 19A,

Obtaining Property or Services by False or
Fraudulent Use of Credit Device or Other
Means; Article 19B, Financial Transaction
Card Crime Act; Article 20, Frauds; Article 21,
Forgery; Article 26, Offenses Against Public
Morality and

Decency; Article 26A, Adult Establishments;
Article 27, Prostitution; Article 28, Perjury;
Article 29, Bribery; Article 31, Misconduct in
Public Office; Article 35, Offenses Against the
Public Peace; Article 36A, Riots and Civil
Disorders; Article 39, Protection of Minors;
Article 40,

Protection of the Family; Article 59, Public
Intoxication; and Article 60,
Computer-Related Crime. These crimes also
include possession or sale of drugs in
violation of the North Carolina Controlled
Substances Act, Article 5 of Chapter 90 of
the General Statutes, and alcohol-related
offenses such as sale to underage persons in
violation of G.S. 18B-302 or driving while
impaired in violation of G.S. 20-138.1

through G.S. 20-138.5.

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

(g) Conditional Employment. - A provider
may employ an applicant conditionally

prior to

obtaining the results of a criminal history

record check regarding the applicant if both
of the

Division of Health Service Regulation
STATE FORM © 70411 If continuation sheet 42 of 64

PRINTED: 10/27/2025
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A, BUILDING:

(X3) DATE SURVEY
COMPLETED

R-C
MHL002-028 8. WING 10/10/2025

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

243 LILEDOUN ROAD

LUCA'S HOPE Ill
TAYLORSVILLE, NC 28681

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE

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

Continued From page 42

following requirements are met:

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

conditional employment. (2000-154, s. 4;
2001-155, s. 1; 2004-124, ss. 10.19D(c),
(h); 2005-4, ss. 1, 2, 3, 4, 5(a); 2007-444,
s. 3.)

V133

Luca’s Hope III will ensure that before an offer of
This Rule is not met as evidenced by: employment is made to a potential

Based on record review and interview, the stafffemployee a criminal history record check of

facility failed to request a criminal history the applicant will be performed to determine

record check within 5 days of making the whether they are eligible for hire 5 days before

conditional offer of employment for 1 of 6 making a conditional offer of employment. All

audited staff (Staff #1). The findings are: criminal background requests will be performed
and monitored by the Director/CEO

Review on 9/26/25 of Staff #1's record

revealed: -Date of Hire: 9/6/23.

-Criminal history record check requested

10/12/23.

Interview on 9/23/25 with the Vice
President/Licensee/Qualified Professional
revealed:

-"(Chief Executive
Officer/Director/Licensee (CEO/D/L)] is
responsible for...background checks. |
have helped in the past but it is
[CEO/D/L] who is accountable.”

Interview on 10/6/25 with the CEO/D/L
revealed: -"! am responsible for background
checks...I go in

Division of Health Service Regulation
STATE FORM &° 710411 !f continuation sheet 43 of 64
PRINTED: 10/27/2025

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-C
MHL002-028 B, WING 10/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE
243 LILEDOUN ROAD

LUCA'S HOPE I!

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

Continued From page 43

and request the information. It takes a day or
two...it was a mistake on my part, that's my
fault...| know it should be done prior to being
hired. It just happened. | was responsible for
that. [Staff #1] was hired before (in 201 9)...He
left and got rehired...He came back in 2023...
don't know what happened...”

27G .1301 Residential Tx - Scope

410A NCAC 27G .1301 SCOPE
(a) The rules of this Section apply only to

a residential treatment facility that

provides

residential treatment, level II, program

type service.

(b) A residential treatment facility providing
residential treatment, level III service, shall be
licensed as set forth in 10A NCAC 27G .1700.
(c) A residential treatment facility for children
and adolescents is a free-standing residential
facility which provides a structured living
environment within a system of care approach
for children or adolescents who have a
primary diagnosis of mental iliness or
emotional disturbance and who may also have
other disabilities.

(d) Services shall be designed to address

the functioning level of the child or
adolescent and include training in
self-control, communication skills, social
skills, and recreational skills.

Children or adolescents may receive services
ina day treatment facility, have a job
placement, or attend school.

(e) Services shall be designed to support the
child or adolescent in gaining the skills
necessary to return to the natural, or
therapeutic home setting.

(f) The residential treatment facility shall
coordinate with other individuals and
agencies within the client's system of care.

Division of Health Service Regulation
STATE FORM © 7M0411

Division of Health Service Regulation

TAYLORSVILLE, NC 28681

If continuation sheet 44 of 64

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

PRINTED: 10/27/2025
FORM APPROVED

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(x1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

R-C
10/10/2025

B. WING —

MHL002-028

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE
243 LILEDOUN ROAD

LUCA'S HOPE Ill
TAYLORSVILLE, NC 28681

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

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

Continued From page 44

V1i79
The facility will utilize its admissions and intake
criteria to screen and determine if a potential
client meets our inclusionary criteria for the
overall program. This process will determine
whether the program can meet the clients needs.
All applicants or potential new admissions will be
required to go through the facility screening
process. The screening process includes;
submitting an application, updated
Comprehensive Clinical assessment for review,
signed service order, including a current PCP.
These documents will be reviewed by the
Director and the QMHP to determine if the
potential client can be accepted into the
program. Upon determining whether a client can
be admitted, the facility must receive the
following documents; Birth Certificate, social
security card, copy of insurance or medicaid
card. All documents mentioned above must be
received by the facility before the intake process
takes place and the client is admitted.

This Rule is not met as evidenced by:

Based on record review and interview, the
facility failed to provide a structured living
environment within a system of care approach
for children or adolescents who have a
primary diagnoses of mental illness,
emotional disturbance and who may have
other disabilities, affecting 1 of 1 current client
(Client #1) and 1 of 1 former client (FC #5).
The findings are:

Cross reference: 10A NCAC 276.0201
Governing Body Policies (V105). Based on
record review and interview, the facilty failed to
ensure

admission screenings for potential clients

were conducted to include the clients
presenting problems and whether or not the
facility can provide the services the clients
need.

The facility has begun to utilize an outside
professional consultant as of October 17th 2025.
The facility is working with the consultant to
monitor our progress with meeting the
requirements in the plan of protection. The hired
consultant will ensure that the qualified professional
will meet the requirements and demonstrate
knowledge and competence. The consultant will
monitor and supervise the qualified mental health
professional and the director. The facility will
ensure that the clients will receive clinical
services 2 times monthly from a licensed
therapist. The facility will ensure that all
records and documentation for all potential
clients will provide all required documentation
before being accepted into the program

All of this will be monitored by the QMHP and
the director supervised by the hired
consultant.

Cross reference: 10A NCAC 27G.0202
Personnel Requirements (V108). Based on
record review and interview, the facility failed
to provide training to meet the mh/dd/sa needs
of the clients

affecting 2 of 3 audited paraprofessional

staff (Staff #1 and #2).

Cross reference: 10A NCAC 276.0203
Competencies of Qualified Professionals &
Associate Professionals (V1 09). Based on
record review and interview, 1 of 1 Qualified
Professional (Vice
President/Licensee/Qualified Professional

(VP/L/QP)) failed to demonstrate the

knowledge,

Division of Health Service Regulation
STATE FORM &°7M0411 "continuation sheet 45 of 64
PRINTED: 10/27/2025
FORM APPROVED

Division of Health Service R
(X3) DATE SURVEY

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

R-C
MHL002-028 8. WING __________ 10/10/2025

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

243 LILEDOUN ROAD
LUCA'S HOPE III

TAYLORSVILLE, NC 28681

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

Continued From page 45

skills and abilities required by the
population served.

Cross reference: 10A NCAC 27G.0204
Competencies and Supervision of
Paraprofessionals (V110). Based on record
review and interview, 1 of 3 paraprofessional
staff (Chief Executive
Officer/Director/Licensee

(CEO/D/L)) failed to demonstrate the
knowledge, skills and abilities required by the
population served.

Cross reference: 10A NCAC 27G.0205
Assessment and Treatment/Habilitation or
Service Plan (V111). Based on record review
and interview, the facilty failed to ensure prior
to the establishment and implementation of
the

treatment/habilitation plan strategies were
identified to address the client's

presenting problem for 1 of 1 former

client (FC #6).

Cross reference: 10A NCAC 27G.0205
Assessment and Treatment/Habilitation or
Service Plan (V112). Based on record review
and interview, the facilty failed to develop and
implement treatment strategies based on
client needs within 30 days of admission for

4 of 1 former client (FC #5).

Cross reference: 10A NCAC 27G.0206
Client Records (V113). Based on record
review and interview, the facilty failed to
maintain complete client records for 1 of 1
former client (FC #5).

Cross reference: 10A NCAC 27G.1302
Staff (V180). Based on record review and
interview, the facility failed to ensure that
clinical

consultation was provided by a qualified
mental health professional (QMHP) at least
twice a month and failed to ensure at least
one direct

Division of Health Service Regulation

STATE FORM 70411 continuation sheet 46 of 64

PRINTED: 10/27/2025
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

RC
MHL002-028 B. WING ________

NAME OF PROVIDER OR SUPPLIER

LUCA'S HOPE Ill

STREET ADDRESS, CITY, STATE, ZIP CODE
243 LILEDOUN ROAD

TAYLORSVILLE, NC 28681

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

Continued From page 46

care staff was present and providing
supervision at all times affecting 1 of 1
current client (Client #1) and 1 of 1 former
client (FC #8).

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

Review on 10/10/25 of the plan of protection
date 10/10/25 written by the CEO/D/L
tevealed:

-"What immediate action will the facility take to
ensure the safety of the consumers in your
care? (V179/V105) The facility will utilize its
admissions and intake criteria to screen and
determine if a potential client meets our
inclusionary criteria for the overall program.
This process will determine whether the
program can meet the clients needs. All
applicants or potential new admissions will be
required to go through the facility screening
process. The screening process includes,
submitting an application, updated
Comprehensive clinical assessment for review,
a signed service order, including a current PCP
(Person Centered Plan). These documents will
be reviewed by the Director (CEO/DIL) and the
QMHP (Qualified Mental Health Professional
(VP/LIQP)) to determine if the potential client
can be accepted into the program. Upon
determining whether a client can be admitted,
the facility must receive the following
documents; Birth Certificate, social security
card, copy of insurance or

medicaid card. All documents mentioned
above must be received by the facility before
the intake process takes place and the client
is admitted. (V108) The facility will ensure that
all staff will receive upon and maintain
annually training for CPR (cardiopulmonary
resuscitation), First Aide training, Bloodborne
Pathogens training,

Emergency Action Procedures, Safety
classes, clients rights, confidentiality, EBPI
(Evidence Based Protective Interventions),
Medication Administration, seizure
management, Client specific,

Documentation, and goal planning. There

will also be a minimum of 12 in-service

Division of Health Service Regulation
STATE FORM 7MO411 If Continuation sheet 47 of 64
PRINTED: 10/27/2025

FORM APPROVED

Division of Health Service R

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

(X3) DATE SURVEY
COMPLETED

RC
MHL002-028 8. WING __________— 10/10/2025

NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE.
243 LILEDOUN ROAD

LUCA'S HOPE Il!
TAYLORSVILLE, NC 28681

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

Continued From page 47

training hours required per year. This also
includes continuing education that may be
necessary in areas that will benefit the care
of clients and quality of the facility. This will
be monitored by the Director and the

QMHP.

Quarterly Record reviews will be completed on
all staff training records ensuring that all
required classes and training are kept current.
(V109/V110) The facility will ensure that the
the Qualified Professional will meet the
requirements and demonstrate knowledge
and competence by exhibiting the following
skills: technical

knowledge, cultural awareness, analytical
skills, decision-making, interpersonal skills,
communication skills, and clinical skills. The
director will monitor and supervise the
Qualified Mental Health Professional.
Ensuring all

responsibilities are being accurately
completed within the required timeframe.
This will be done by weekly administrative
meetings and monthly staff meetings that
are mandatory.

(V111/112) The facility will ensure that all
assessments and treatment plans will be
completed within 30 days of admission and will
continue being updated on a monthly basis by
the QMHP and supervised by the Director.
(V113) The facility will ensure that all records
and documentation for any client in need of
respite and emergency services must provide
all required documentation that is required to
be in their file. This includes a copy of a
physician's order for medication, copy of birth
certificate, Copy of Insurance or medicaid
card, Emergency contact and a completed
application.

(V180) The facility will ensure that all clients
receiving services will be enrolled with mental
health provider for clinical consultation within
30 days of admission. The QMHP will initiate
this process. The director will supervise.
Describe you plans to make sure the above

Division of Health Service Regulation

STATE FORM *7M0411 If continuation sheet 48 of 64
PRINTED: 10/27/2025
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-C
MHL002-028 B. WING 40/0/2025

NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681

(%4) ID
PREFIX
TAG

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

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

DEFICIENCY)

Continued From page 48

happens.
The facility will contact and begin utilizing an
outside professional consultant by October
17th, 2025. The facility will work with the
consultant to monitor our progress with
meeting the

requirements in the plan of protection. The
facility will also schedule a staff training as a
refresher on Safety, clients rights,
confidentiality, Client specific, and
Documentation focusing on incident reports
and writing incident reports within the required
time frame by October 17th."

Review on 10/10/25 of the addendum to the
plan of protection dated 10/10/25 written by
the

CEO/DIL revealed:

-"What immediate action will the facility take
to ensure the safety of the consumers in your
care? ...(V109/V110) The hired consultant will
ensure that the Qualified Professional
(VP/L/QP) will meet the requirements and
demonstrate

knowledge and competence... The consultant
will monitor and supervise the Qualified
Mental Health Professional and the director.
(V113)...The facility will ensure that all records
and documentation for any client in need of
services must provide all required
documentation (V180)...The clients will
receive services from a licensed clinical
therapist. The clients will receive clinical
services 2 times monthly...All clients receiving
services

Describe you plans to make sure the

above happens.

... The Professional consultant must be a
licensed professional for example certified in
MS (Master of Science), LCAS (Licensed
Clinical Addiction Specialist), LC MHC
(Licensed Clinical Mental Health
Counselor)-QS (Qualified Supervisor), TFCBT
(Trauma Focused Cognitive Behavioral
Therapy), CCSI (Clinical Supervisor Intern),
C-DBT (Child Dialectical Behavior Therapy).
The

Division of Health Service Regulation
STATE FORM &7MO411 | continuation sheet 49 of 64
PRINTED: 10/27/2025
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

R-C
10/10/2025

MHL002-028 B. WING ____

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE
243 LILEDOUN ROAD
LUCA'S HOPE Ill
TAYLORSVILLE, NC 28681

(%4) ID
PREFIX
TAG

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

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

DEFICIENCY)

Continued From page 49

professional consultant will monitor the
facility 2. times a month."

Clients served by the facility were children
and adolescents who had mental health
diagnoses including but not limited to
Disruptive Mood Disorder, Attention Deficit
Hyperactivity Disorder and Reactive
Attachment Disorder of Childhood. The
CEO/D/L and the VP/L/QP did not complete
and maintain accurate client records and did
not complete screening assessments for
potential clients. This impaired the staffs
ability to

effectively support the population served,
affecting the quality of care and client safety.
FC #5 was admitted without an initial
evaluation, which resulted in services being
provided without a comprehensive
understanding of the FC #5's specific needs
or appropriate care planning. The CEO/D/L
and VP/L/QP failed to develop

individualized treatment plans for FC #5 and
did not establish therapeutic goals or
interventions essential for client progress.
Staff were not trained to address
client-specific needs, which further limited
the effectiveness of care. FC #5 had no
treatment strategies to address his
incontinence.

Client #1 and FC #5 did not receive the
required clinical consultation at least twice
monthly by a qualified mental health
professional, which resulted in limited
professional oversight.

The CEO/D/L and VP/L/QP did not ensure
clients were always under direct supervision
and

neglected client safety, as staff were permitted
to sleep during their shifts. The facility

demonstrated systemic deficiencies that
Teflected a collective failure to deliver quality
client treatment.

This deficiency constitutes a Type A1 rule
violation for serious neglect and must be
corrected within 23 days.

Division of Health Service Regulation
STATE FORM 9 7M0444 f ontiuation sheet 50 of 64
PRINTED: 10/27/2025
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-C
MHL002-028 B. WING 10/10/2025

NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
243 LILEDOUN ROAD
LUCA'S HOPE Ill

TAYLORSVILLE, NC 28681

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

27G .1302 Residential Tx - Staff

410A NCAC 27G .1302 STAFF
(a) Each facility shall have a director who has
a minimum of two years experience in child or
adolescent services and who has educational
preparation in administration, education,
social work, nursing, psychology or a related
field. (b) At all times, at least one direct care
staff member shall be present with every four
children or adolescents. If children or
adolescents are cared for in separate
buildings, the ratios shall apply to each
building.

(c) When two or more clients are in the
facility, an emergency on-call staff shall be
readily

available by telephone or page and able to
reach the facility within 30 minutes.

(d) Psychiatric consultation shall be available
as needed for each client.

(e) Clinical consultation shall be provided by
a qualified mental health professional to
each facility at least twice a month.

vi80
The facility will ensure that all clients receiving
services will be enrolled with a mental! health
provider for clinical consultation within 30 days of
admission. The QMHP will initiate this process.
The director will supervise. The QMHP will also
supervise and monitor clients and staff by
conducting clinical meetings 2 times per month.
The facility will ensure that all staff are present
and awake on all shifts. The facility will ensure
that the clients will receive therapy sessions by a
licensed therapist.

This Rule is not met as evidenced by:
Based on record review and interview, the
facility failed to ensure that clinical consultation
was provided by a qualified mental health
professional (QMHP) at least twice a month
and failed to ensure at least one direct care
staff was present and providing supervision at
all times affecting 1 of 1 current client (Client
#1) and 1 of 1 former client (FC #5). The
findings are:

Review on 9/26/25 of Client #1's record
revealed: -Date of Admission: 7/10/23.
-Age: 13 years old.

-Diagnoses: Reactive Attachment Disorder of

Division of Health Service Regulation

STATE FORM © 7M0411 If continuation sheet 51 of 64

PRINTED: 10/27/2025
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-C
MHL002-028 B.WING 10/10/2025

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

243 LILEDOUN ROAD

LUCA'S HOPE III

TAYLORSVILLE, NC 28681

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

DEFICIENCY)

Continued From page 51

Childhood.
-No documentation of clinical consultation
by a QMHP.

Review on 9/26/25 of FC #5's record revealed:
-Age 11 years old and diagnoses of Disruptive
Mood Disorder and Attention Deficit
Hyperactivity Disorder.

-There was no client record to include an
identification face sheet, a client record
number, date of birth, race, gender,
admission and

discharge dates, diagnoses, screening,
assessment, and treatment plan.

-No evidence of clinical consultation by a
QMHP.

Attempted review on 9/23/25 of documentation
of clinical consultation by a QMHP was
unsuccessful. No documentation was
provided prior to the exit of the survey on
10/10/25.

Interview on 10/7/25 with FC #5's Department
of Social Services (DSS) legal guardian and
DSS Supervisor revealed:

-DSS and the Local Management
Entity/Managed Care Organization
(LME/MCO) visited the facility on 8/8/25. "...It
took a long time for [Staff #1] to come to the
door. | think he was asleep in the back (of the
facility)...”

Interview on 9/29/25 with Staff #1 revealed:
-The facility, "...It's a sleep program. Of
course you can sleep..."

-Sometimes he worked the “whole weekend,
like a Friday through Monday morning."

-He "wouldn't stay awake the entire time. !
would doze off in the middle of the night and
set my alarm for every 30 minutes to wake
back up and check on the boys (clients) and
make sure they were good.”

Division of Health Service Regulation

STATE FORM © 7M041 !f continuation sheet 52 of 64

PRINTED: 10/27/2025
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X%1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

RC
10/10/2025

MHL002-028 B. WING

NAME OF PROVIDER OR SUPPLIER:

STREET ADDRESS, CITY, STATE, ZIP CODE
243 LILEDOUN ROAD
LUCA'S HOPE Il!
TAYLORSVILLE, NC 28681

(X4) ID
PREFIX
TAG

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

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

Continued From page 52

Interview on 9/23/25 and 10/6/25 with the
Vice President/Licensee/Qualified
Professional

(VP/L/QP) revealed:

-Clients were on a waiting list for therapy.
-DSS and the Local Management
Entity/Managed Care Organization
(LME/MCO) Case Manager “has been really
helping us, trying to find a therapist."

~"This is an asleep program...from my
understanding, staff can have their bedroom
and sleep as long as they are checking
(making rounds on clients)..."

-There was no documentation of staff
making rounds on clients.

Interview on 10/6/25 with the Chief
Executive Officer/Director/Licensee
(CEO/D/L) revealed: -Clients "should be
monitored at all times..." -Staff worked as a
“live-in for the whole

weekend..."

-"We are a level Ill which is an asleep
program, but they (staff) have to get up
multiple times per night, especially during 12
hours (shifts)."

-Staff “can't just sleep all night. they are to get
up and monitor (clients) at least 4 times
(overnight)..."

-Staff "used to have to fill out the times
(document making rounds)" but

maintaining records became challenging
when she

experienced health issues.

-Clients “didn't have therapy because of being
on a waiting list. It's not just us (Luca's Hope
Ill and sister facility A). It's just hard to get..."
-"| set appointments... am responsible for
therapy sessions. | am aware they (clients)
need bi-monthly sessions..."

This deficiency is cross referenced into 10A
NCAC 27G.1301 Scope (V179) for a Type A1
tule violation and must be corrected within 23

27G .0603 Incident Response Requirements

410A NCAC 27G .0603 INCIDENT
RESPONSE REQUIREMENTS FOR
CATEGORY A AND B PROVIDERS

(a) Category A and B providers shall develop
and implement written policies governing their
response to level I, II or I{l 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:

Division of Health Service Regulation
STATE FORM 9 7M0411 If continuation sheet 54 of 64

PRINTED: 10/27/2025

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-C
MHL002-028 B.WANG 10/10/2025

NAME OF PROVIDER OR SUPPLIER,
STREET ADDRESS, CITY, STATE, ZIP CODE
243 LILEDOUN ROAD
LUCA'S HOPE lil

TAYLORSVILLE, NC 28681

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

Continued From page 54

(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
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 shail 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

Division of Health Service Regulation
STATE FORM 970411 If Continuation sheet 55 of 64
PRINTED: 10/27/2025
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

RC
MHL002-028 B. WING _____ 10/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

243 LILEDOUN ROAD

LUCA'S HOPE tll

(4) ID
PREFIX
TAG

TAYLORSVILLE, NC 28681

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

Continued From page 55

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 review and interview, the
facility failed to implement written policies
governing their response to Level I! and Level
Illincidents. The findings are:

Review on 9/26/25 of internal level |

facility incident reports from 6/8/25

through 9/26/25 revealed:

-8/26/25 - Former Client (FC) #2 - was banging
on walls, pulling down blinds, breaking and
throwing items, and fighting with a peer (Client
#1) "...his peer ended up slamming client (FC
#2) on the floor while they were both fighting
causing client to hit his head on the
floor...Client was removed from the facility on
8/26/2025

by...guardian (Department of Social Services)

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

V366

Luca's Hope shall ensure that the staff and
facility shall adhere to our written policies
governing our

response to level I, Il or Ill incidents.
Luca's Hope III will report evidence that
all alleged acts are investigated and will
ensure to protect residents from harm
while the investigation is in progress.
The results of all investigations will be
reported to the Department within five
working days of the initial notification to
the Department. Luca's Hope III will
ensure that the results of the internal
investigation are attached to the report.
Luca’sHope III will ensure that all IRIS
incidents are reported and submitted
within the IRIS system. All Level 2
incidents will be reported within 72 hours
of the incident. All Level 3 incidents will
be reported within 24 hours of the
incidents. Luca’s Hope II! will ensure
that any staff involved in an allegation
will not be allowed to work effective
immediately until the investigation is
cleared and deemed unsubstantiated.
This shall be monitored by the
CEO/Director and QMHP and
supervised by the hired Consultant

Division of Health Service Regulation
STATE FORM &7Mo411 If continuation sheet 56 of 64
PRINTED: 10/27/2025
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
MHL002.028 B. WING 10/10/2025

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

243 LILEDOUN ROAD
LUCA'S HOPE Ill

TAYLORSVILLE, NC 28681

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

Continued From page 56

and placed in another location...[Local
Management Entity/Managed Care
Organization (LME/MCO)] was notified and
they did speak to the facility regarding the
incident asked if the incident was entered into
the IRIS (Incident Response and Reporting
System) system..." -8/27/25 - FC #3 - "...Staff
(Staff #1) instructed client to go to his room
and put on

underwear...Client started laughing and playing
because he thought that it was funny that he
didn't have on underwear. Client jumped on his
bed while laughing and got into a fetal position
laughing and then he rolled over on his back
and hit his head on the wall...Client was taken
out of the facility on the 8/27/2025 the same
day that the client made the report...[Local
County

Department of Social Services transported
client to another location...[LME/MCO] was

notified and did speak to the facility regarding
the incident and if the incident was entered
into the IRIS system (North Carolina Incident
Response Improvement System)..."

Review on 10/7/25 of the local police
Computer-Aided Dispatch (CAD) list from
6/1/25 through 10/7/25 revealed:

-All the following law enforcement calls
involved FC #6:

-7/1/25 - police responded to a missing
person - Absent Without Official Leave
(AWOL) for 15 minutes prior to the call.
-7/2/25 - civil dispute - property damage

has occurred.

-7/3/25 - civil dispute - asking another

client where he could buy a gun.

-7/4125 - AWOL - "...grabbed his things and he
stated he is going to get a gun and come back
and shoot up the group home. He was also
trying to attack some of the other boys
(clients)."

Division of Health Service Regulation
STATE FORM 7Moa11 lf continuation sheet 57 of 64
PRINTED: 10/27/2025
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
MHL002-028 B WING 10/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE
243 LILEDOUN ROAD

LUCA'S HOPE It
TAYLORSVILLE, NC 28681

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

Continued From page 57

Reviews on 9/25/25 and 10/8/25 of IRIS
revealed: -Level III incident for FC #2 was
originally

submitted 8/30/25 (72 hours after allegation
of abuse).

-On 9/29/25 FC #2's incident was
re-submitted, the "internal investigation"
attached was the internal incident report and
the Department of Health and Human
Services (DHHS) Criteria for determining
incident levels.

-Level III incident report for FC #3

originally submitted 9/1/25 (4 days after
allegation of abuse).

-On 10/8/25 FC #3's incident was
re-submitted with the internal investigation
attached.

-No level Il incident reports for FC #6 had
been submitted regarding law enforcement

visits to the facility on 7/1/25, 7/2/25, 7/3/25
and 7/4/25.

Review on 9/26/25 of the facility's
documented response to incidents
revealed:

-No documentation the facility attended to the
health and safety needs of clients involved in
the incidents above.

-No documentation the facility determined
the cause of the incident.

-No documentation the facility developed
and implemented corrective measures.

-No documentation of person(s) responsible
for implementation of corrections and
preventive measures.

Interview on 9/29/25 with the local DSS
Investigator revealed:

-8/27/25 - FC #2 alleged "...[Staff

#1]...slapped him (FC #2) across the

face...he had pretty significant bruising on

his ear..."

-8/28/25 - FC #3 alleged [Staff #1] slammed
his head on the ground...he (FC #3) did have a
bump on his head..."

-On the evening of 8/27/25 FC #2 was removed

Division of Health Service Regulation

STATE FORM °7M0411 | Continuation sheet 68 of 64

PRINTED: 10/27/2025

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
MHL.002-028 8. WING 10/10/2025

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

243 LILEDOUN ROAD
LUCA'S HOPE til
TAYLORSVILLE, NC 28681

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

DEFICIENCY)

Continued From page 58

from the facility due to the abuse allegation.
-Staff #1 was still working on shift when she
left the evening of 8/27/25 (after the first
allegation). -On 8/28/25 FC #3 was removed
from the facility due to the abuse allegation.
~On 8/28/25 the Chief Executive
Officer/Director/Licensee (CEO/DI/L) "...made
the decision to remove [Staff #1] and said 'He
(Staff #1) would no longer be employed at the
home (facility)."

Interview on 9/26/25 with the Vice
President/Licensee/Qualified Professional
(VP/L/QP) revealed:

-She provided oversight for the facility at the
time of the incident.

-She was responsible to conduct the
investigation of abuse for both FC #2 and FC
#3 which was done on 9/1/25.

-The CEO/D/L was responsible to enter

level Il and level I!I incidents into IRIS.

-On the evening of 8/27/25 the CEO/D/L called
to inform her FC #2 made an allegation of
abuse against Staff #1.

-On 8/28/25 she was notified FC #3 made

an allegation of abuse against Staff #1.
-Staff #1 continued to work throughout the
night shift on 8/27/25 into the morning of
8/28/25. -"After the 28th (8/28/25) we (she
and the

CEO/D/L) went ahead and suspended

(Staff #1)..."

-On 9/1/25 she did an internal investigation
by interviewing Staff #1.

-No other staff and no clients were
interviewed. -"...Knowing the staff (Staff #1)
and the kids (clients), | determined it (abuse)
didn't happen..."

Interviews on 9/26/25, 9/29/25 and 10/7/25
with the CEO/D/L revealed:
-On 8/27/25 at 7:00 p.m. she received a call from

Division of Health Service Regulation
STATE FORM ®°7M041 |f continuation sheet 59 of 64
PRINTED: 10/27/2025

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
MHL002-028 BOWING 10/10/2025

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

243 LILEDOUN ROAD

LUCA'S HOPE Ill
TAYLORSVILLE, NC 28681

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

Continued From page 59

Staff #2 that DSS was there and FC #2 made
an allegation of abuse against Staff #1.

-On the evening of 8/28/25, DSS returned due
to FC #3 alleging abuse against Staff #1.
-The VP/L/QP was responsible to investigate
both abuse allegations.

-There was no internal review team who did
not provide oversight to the clients involved
in the investigation.

-A written preliminary findings of fact was

not submitted to the LME/MCO within five
working days.

-Staff #1 was working on 8/27/25 (after the
first allegation) and continued to work into
the

morning of 8/28/25; He walked the clients

to school that morning.

-She called the police for FC #6 "...just to pick
him up and bring him back (to the
facility)...each time he would be at the end of
the road..."

27G .0604 Incident Reporting Requirements

410A NCAC 27G .0604 INCIDENT
REPORTING REQUIREMENTS FOR
CATEGORY A AND B PROVIDERS

(a) Category A and B providers shall report all
level II 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 Il
deaths involving the clients to whom the
provider rendered any service within 90 days
prior to the incident to the LME

responsible for the catchment area where
services are provided within 72 hours of
becoming aware of the incident. The report
shall be submitted on a form provided by the
Secretary. The report may be submitted via
mail, in person, facsimile or encrypted
electronic means. The report shall include the
following

Division of Health Service Regulation
STATE FORM &° 7M0411 If continuation sheet 60 of 64

PRINTED: 10/27/2025

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
MHL002-028 B. WING 10/10/2025

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

243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681

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

Continued From page 60

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:

(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 Ill 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 Ill
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

Division of Health Service Regulation
STATE FORM & 7M0411 lf Continuation sheet 61 of 64
PRINTED: 10/27/2025
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-C
MHL002-028 B WING 10/10/2025

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

243 LILEDOUN ROAD
LUCA'S HOPE Ill
TAYLORSVILLE, NC 28681

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

Continued From page 61

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 !I or level Il! incident;

(2) restrictive interventions that do not meet
the definition of a level I! or level Ill incident; (3)
searches of a client or his living area; (4)
seizures of client property or property in the
possession of a client;

(5) the total number of level 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.

V367

Luca’s Hope shall ensure that the staff and
facility shall report all level II and level II!
incidents to the LME/MCO responsible for the
catchment area where services are provided
within 72 hours of becoming aware of the
Level 2 incident and within 24 hours for a

This Rule is not met as evidenced by: level 3 incident.

Based on record review and interview, the
facility failed to notify the LME/MCO (Local
Management Entity/Managed Care
Organization) of level Il and level I!I incident
reports. The findings are:

Review on 10/7/25 of the local police
Computer-Aided Dispatch (CAD) list from
6/1/25 through 10/7/25 revealed:

Division of Health Service Regulation
STATE FORM 8710411 If Continuation sheet 62 of 64
PRINTED: 10/27/2025
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

RC
MHL002-028 BAWING 10/10/2025

NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
243 LILEDOUN ROAD
LUCA'S HOPE Il
TAYLORSVILLE, NC 28684

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

Continued From page 62

-All the following law enforcement calls
involved Former Client (FC) #6:

-7/1/25 - police responded to a missing
person - Absent Without Official Leave
(AWOL) for 15 minutes prior to the call.
-7/2/25 - civil dispute - property damage

has occurred.

-7/3/25 - civil dispute - asking another

client where he could buy a gun.

-7/4125 - AWOL - "...grabbed his things and he
stated he is going to get a gun and come back
and shoot up the group home. He was also
trying to attack some of the other boys
(clients)."

Reviews on 9/25/25 and 10/8/25 of the North
Carolina Incident Response Improvement
System (IRIS) revealed:

-Level II! incident for FC #2 was originally
submitted 8/30/25 (72 hours after allegation
of abuse).

-On 9/29/25 FC #2's incident was
re-submitted, the "internal investigation”
attached was the internal incident report
and the Department of Health and Human
Services Criteria for

determining incident levels.

-Level Ill incident report for FC #3

originally submitted 9/1/25 (4 days after
allegation of abuse).

-On 10/8/25 FC #3's incident was
re-submitted with the internal investigation
attached.

-No level II incident reports for FC #6 had
been submitted regarding law enforcement
officer's visits to the facility on 7/1/25, 7/2/25,
7/3/25 and 7/4/25.

Interview on 9/29/25 with the local Department
of Social Services (DSS) social worker
revealed: -8/27/25 - FC #2 was removed from
the facility due to an abuse allegation against
Staff #1. -8/28/25 - FC #3 was removed from
the facility

Division of Health Service Regulation
STATE FORM °° 7M0411 if continuation sheet 63 of 64

PRINTED: 10/27/2025

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

MHL002-028 8. WING ___ 10/10/2025

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

243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681

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

V367 | Continued From page 63

due to an abuse allegation against Staff #1.

Interview on 9/26/25 with the Vice
President/Licensee/Qualified Professional
(VP/L/QP) revealed:

-She was the QP who provided oversight for
the facility at the time of the incident.

-The Chief Executive
Officer/Director/Licensee (CEO/D/L) was
responsible to enter level | and level II!
incidents into IRIS.

Interview on 9/29/25 with the CEO/D/L
tevealed: -She was responsible to submit
IRIS reports. -FC #2 and FC #3's IRIS
reports were not

submitted timely, "| started it (IRIS), but |
didn't save it..."

-She did not complete IRIS reports when

the police were called for FC #6.

-On 8/27/25 at 7:00 p.m. she received a call
from Staff #2 that DSS was there and FC #2
made an allegation of abuse against Staff #1.
-On the evening of 8/28/25, DSS returned due
to FC #3 alleging abuse against Staff #1.
-The VP/Licensee/QP was responsible to
investigate both abuse allegations.

-There was not an internal review team who
did not provide oversight to the clients
involved in the investigation.

-A written preliminary findings of fact was

not submitted to the Local Management
Entity/Managed Care Organization within

five working days.

-After the first allegation, Staff #1 was working
on 8/27/25 and continued to work into the
morning of 8/28/25; He walked the clients to
school that morning.

-She called the police for FC #6 “...just to pick
him up and bring him back (to the
facility)...each time he would be at the end of
the road..."

Division of Health Service Regulation
STATE FORM & 7M0411 !f continuation sheet 64 of 64

inspection_type: MHLCS Complaint and Follow-up

document_type: Plan of Correction