summary: Statement of Deficiency - MHLCS Annual and Complaint

raw_content:
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
MHLO001-149
NAME OF PROVIDER OR SUPPLIER
1710 SYKI

JUST IN TIME YOUTH SERVICES

B. WING

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 11/08/2021
FORM APPROVED

11/04/2021

STREET ADDRESS, CITY, STATE, ZIP CODE
ES STREET

BURLINGTON, NC 27215

(X3) DATE SURVEY
COMPLETED

10A NCAC 27D .0101 POLICY ON RIGHTS
RESTRICTIONS AND INTERVENTIONS

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

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

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

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

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

(1) any restrictive intervention that is
prohibited from use within the facility; and
(2) in a 24-hour facility, the circumstances

under which staff are prohibited from restricting
the rights of a client.
(d) If the governing body allows the use of

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

STATE FORM

6899

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000) INITIAL COMMENTS V 000
An annual and complaint survey was completed
on 11/4/21. The complaint was unsubstantiated
(intake #NC00182002). Deficiencies were cited.
This facility is licensed for the following service
category: 10A NCAC 27G .1700 Residential
Treatment Staff Secure for Children or
Adolescents.
V 500} 27D .0101(a-e) Client Rights - Policy on Rights Vv 500

TITLE

(X6) DATE

DTGL11 If continuation sheet 1 of 4

PRINTED: 11/08/2021
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
MHL001-149 B. WING ____ 11/04/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

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

DEFICIENCY)
V 500} Continued From page 1 Vv 500

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

(1) the permitted restrictive interventions or
allowed restrictions;

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

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

(e) If restrictive interventions are allowed for use
within the facility, the governing body shall
develop and implement policy that assures
compliance with Subchapter 27E, Section .0100,
which includes:

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

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

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

This Rule is not met as evidenced by:

Based on observation, record review and
interviews, the facility failed to implement
interventions to address behaviors which did not
restrict the rights for one of three clients (#1). The
findings are:

Division of Health Service Regulation

STATE FORM 6899 DTGL11 If continuation sheet 2 of 4

PRINTED: 11/08/2021

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL001-149 B. WING 11/04/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1710 SYKES STREET
JUST IN TIME YOUTH SERVICES
BURLINGTON, NC 27215
(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

V 500} Continued From page 2 V 500

Observation of facility on 11/3/21 at approximately
2:35 pm revealed:

-Client #1 and client #2's bedroom-There was a
lock on client #1's closet. Client #1's clothing was
in the locked closet.

Review on 11/3/21 of General Statue 122C-62
revealed "A written statement shall be placed in
the client's record that indicates the detailed
reason for the restriction. The restriction shall be
reasonable and related to the client's treatment or
habilitation needs. A restriction is effective for a
period not to exceed 30 days. An evaluation of
each restriction shall be conducted by the
qualified professional (QP) at least every seven
days, at which time the restriction may be
removed. Each evaluation of a restriction shall be
documented in the client's records."

Review on 11/3/21 of client #1's record revealed:
-Admission date 4/29/21.

-Diagnoses of Disruptive Mood Dysregulation
Disorder, Mild Intellectual Disability, Autism,
Attention Deficit Hyperactivity Disorder and Post
Traumatic Stress Disorder.

-Date of birth was 11/30/10.

-There was no evidence of a written statement for
client #1 detailing restrictions of personal
possessions or evidence of an evaluation of each
restriction reviewed at least every seven days by
the Qualified Professional.

Interview on 11/3/21 with the Home Manager
revealed:

-Client #1's closet was locked because he would
smear feces on his clothing.

-She thought client #1 was admitted to the facility
earlier this year.

-They started locking his closet as soon as he
Division of Health Service Regulation

STATE FORM 6899 DTGL11 If continuation sheet 3 of 4

PRINTED: 11/08/2021
FORM APPROVED

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL001-149 B. WING ____ 11/04/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1710 SYKES STREET
JUST IN TIME YOUTH SERVICES
BURLINGTON, NC 27215
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 500} Continued From page 3 V 500

was admitted around March or April 2021.

-She did not realize locking client #1's clothes in
the closet was considered a rights restriction.
-She confirmed client #1's rights were being
restricted.

Interview on 11/4/21 with the Program Director
revealed:

-The agency had been locking up clients personal
items for a while.

-The agency did not meet with the human rights
committee prior to locking up client #1's clothing.
-He confirmed client #1's rights were being
restricted.

Division of Health Service Regulation

STATE FORM 6899 DTGL11 If continuation sheet 4 of 4


state: NC

facility_name: Just In Time Youth Services

summary: Plan of Correction - MHLCS Annual and Complaint

raw_content:
PRINTED: 11/08/2021

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES AND | (X1) PROVIDER/SUPPLIERICLIA} (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
B. WING
MHL001-149 11/04/2021

NAME OF PROVIDER OR SUPPLIER

STREET AD
1710 SYK'

JUST IN TIME YOUTH SERVICES

ES STREET

DRESS, CITY, STATE, ZIP CODE

BURLINGTON, NC 27215

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000) V 000
INITIAL COMMENTS
An annual and complaint survey was completed
on 11/4/21. The complaint was unsubstantiated
(intake #NCO00182002). Deficiencies were cited.
This facility is licensed for the following service
category: 10A NCAC 27G .1700 Residential
Treatment Staff Secure for Children or
Adolescents.
V 500) V 500

27D .0101(a-e) Client Rights - Policy on Rights
10A NCAC 27D .0101 POLICY ON RIGHTS
RESTRICTIONS AND INTERVENTIONS

(a) The governing body shall develop policy
that assures the implementation of G.S. 122C-59,
G.S. 122C-65, and G.S. 122C-66.
(b) The governing body shall develop and
implement policy to assure that:
(1) all instances of alleged or suspected
abuse, neglect or exploitation of clients are
reported to the County Department of Social
Services as specified in G.S. 108A, Article 6 or
G.S. 7A, Article 44; and
(2) procedures and safeguards are instituted
in accordance with sound medical practice when
a medication that is known to present serious risk
to the client is prescribed. Particular attention
shall be given to the use of neuroleptic
medications.

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

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

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

(d) If the governing body allows the use of

The clients rights committee will meet
quarterly to discuss restrictive
interventions related to all clients in the
group home. During the meeting the
committee will discuss all options of
interventions that could vary due to
certain client behaviors, as well as
securing their personal property that locks
on closets are an option, and that client
will have access to a key to their closet, if
locks on the closets are chosen to be
acceptable by the committee.

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

TITLE

(X6) DATE

PRINTED: 11/08/2021
FORM APPROVED

Division of Health Service Regulation

STATE FORM 6899 DTGL11 If continuation sheet 1 of 4

STATEMENT OF DEFICIENCIES AND
PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA|
IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

B. WING

MHL001-149 11/04/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES
BURLINGTON, NC 27215

(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)

(x5)
COMPLETE
DATE

Division of Health Service Regulation
STATE FORM 6899 DTGL11 If continuation sheet 2 of 5

PRINTED: 11/08/2021
FORM APPROVED

Division of Health Service Regulation
V 500) Continued From page 1 V 500

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

(1) the permitted restrictive interventions or
allowed restrictions;

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

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

(e) If restrictive interventions are allowed for use
within the facility, the governing body shal
develop and implement policy that assures
compliance with Subchapter 27E, Section .0100,
which includes:
(1) the designation of an individual, who has
been trained and who has demonstrated
competence to use restrictive interventions, to
provide written authorization for the use o
restrictive interventions when the original order is
renewed for up to a total of 24 hours in
accordance with the time limits specified in 10A
NCAC 27E .0104(e)(10)(E);
(2) the designation of an individual to be
responsible for reviews of the use of restrictive
interventions; and
(3) the establishment of a process for appeal
for the resolution of any disagreement over the
planned use of a restrictive intervention.

This Rule is not met as evidenced by: Based on
observation, record review and interviews, the
facility failed to implement interventions to
address behaviors which did not restrict the
rights for one of three clients (#1). The findings
are:

STATEMENT OF DEFICIENCIES AND | (X1) PROVIDER/SUPPLIER/CLIA] (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
B. WING
MHLO001-149 11/04/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET
JUST IN TIME YOUTH SERVICES
BURLINGTON, NC 27215

(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)

Division of Health Service Regulation
STATE FORM 6899 DTGL11 If continuation sheet 3 of 5

PRINTED: 11/08/2021
FORM APPROVED

Division of Health Service Regulation
V 500) Continued From page 2 V 500

Observation of facility on 11/3/21 at approximatel
2:35 pm revealed:

-Client #1 and client #2's bedroom-There was a
lock on client #1's closet. Client #1's clothing was
in the locked closet.

Review on 11/3/21 of General Statue 122C-62
revealed "A written statement shall be placed in
the client's record that indicates the detailed
reason for the restriction. The restriction shall be
reasonable and related to the client's treatment or
habilitation needs. A restriction is effective for a
period not to exceed 30 days. An evaluation of
each restriction shall be conducted by the
qualified professional (QP) at least every seven
days, at which time the restriction may be
removed. Each evaluation of a restriction shall be
documented in the client's records."

Review on 11/3/21 of client #1's record revealed:
-Admission date 4/29/21.

-Diagnoses of Disruptive Mood Dysregulation
Disorder, Mild Intellectual Disability, Autism,
Attention Deficit Hyperactivity Disorder and Post
Traumatic Stress Disorder.

-Date of birth was 11/30/10.

-There was no evidence of a written statement for
client #1 detailing restrictions of personal
possessions or evidence of an evaluation of each
restriction reviewed at least every seven days by
the Qualified Professional.

Interview on 11/3/21 with the Home Manager
revealed:

-Client #1's closet was locked because he would
smear feces on his clothing.

-She thought client #1 was admitted to the facility
earlier this year.

-They started locking his closet as soon as he

STATEMENT OF DEFICIENCIES AND | (X1) PROVIDER/SUPPLIERI/CLIA} (X2) MULTIPLE CONSTRUCTION, (X3) DATE SURVEY
PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
B. WING
MHLO001-149 11/04/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET
JUST IN TIME YOUTH SERVICES
BURLINGTON, NC 27215

(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)

Division of Health Service Regulation
STATE FORM 6899 DTGL11 If continuation sheet 4 of 5

PRINTED: 11/08/2021
FORM APPROVED

Division of Health Service Regulation

V 500) Continued From page 3 was admitted around V 500
March or April 2021. -She did not realize
locking client #1's clothes in the closet was
considered a rights restriction. -She confirmed
client #1's rights were being restricted.

Interview on 11/4/21 with the Program Director
revealed:

-The agency had been locking up clients personal
items for a while.

-The agency did not meet with the human rights
committee prior to locking up client #1's clothing. -
He confirmed client #1's rights were being
restricted.

Division of Health Service Regulation
STATE FORM 6899 DTGL11 If continuation sheet 5 of 5

inspection_type: MHLCS Annual and Complaint

document_type: Plan of Correction


summary: Statement of Deficiency - MHLCS Complaint

raw_content:
PRINTED: 01/25/2021

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHLO001-149 B. WING 01/25/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1710 SYKES STREET

JUST IN TIME YOUTH SERVICES

BURLINGTON, NC 27215

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000) INITIAL COMMENTS V 000
Acomplaint survey was completed on January
25, 2021. The complaint was unsubstantiated
(Intake #NC00173379). No deficiencies were
cited.
This facility is licensed for the following service:
10A NCAC 27G .1700 Residential Treatment
Staff Secure for Children and Adolescents.
Division of Health Service Regulation
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

STATE FORM

6899

HTJ011 If continuation sheet 1 of 1

inspection_type: MHLCS Complaint

document_type: Statement of Deficiency


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

raw_content:
Division of Health Service Regulation

JUST IN TIME YOUTH SERVICES

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
MHLO001-149
NAME OF PROVIDER OR SUPPLIER
1710 SYKI

A. BUILDING:

B. WING

ES STREET

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/22/2020
FORM APPROVED

10/22/2020

STREET ADDRESS, CITY, STATE, ZIP CODE

BURLINGTON, NC 27215

(X3) DATE SURVEY
COMPLETED

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000) INITIAL COMMENTS V 000
Acomplaint and follow up survey was completed
on 10/22/20. The complaint was unsubstantiated
(intake #NC00170300). No deficiencies were
cited.
This facility is licensed for the following service
10A NCAC 27G.1700 Residential Treatment Staff
Secure for Children and Adolescents.
Division of Health Service Regulation
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
STATE FORM 6899 OHDH11 If continuation sheet 1 of 1

inspection_type: MHLCS Complaint and Follow-up


summary: Statement of Deficiency - MHLCS Follow-up

raw_content:
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

MHL001-149

1710 SYK'

JUST IN TIME YOUTH SERVICES

BURLINGTON, NC 27215

A. BUILDING:

B. WING

STREET ADDRESS, CITY, STATE, ZIP CODE

ES STREET

(X2) MULTIPLE CONSTRUCTION

PRINTED: 06/28/2019
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
06/27/2019

(X4) ID
PREFIX
TAG

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

ID
PREFIX
TAG

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

(x5)
COMPLETE
DATE

{V 000}

{V 536}

NITIAL COMMENTS

A limited follow up survey for the Type A1 and
Type A2 was completed 6/27/19. This was a
imited follow up survey, only 10A NCAC 27G
.0205 Assessment and Treatment or Services
Plan (V112) and 10A NCAC 27G .0209
Medication Requirements (V118) were reviewed
‘or compliance. The following were brought back
into compliance: 10A NCAC 27G .0205
Assessment and Treatment or Services Plan
(V112) and 10A NCAC 27G .0209 Medication
Requirements (V118). No deficiencies were cited.

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

27E .0107 Client Rights - Training on Alt to Rest.
Int.

10A NCAC 27E .0107 TRAINING ON
ALTERNATIVES TO RESTRICTIVE
INTERVENTIONS
(a) Facilities shall implement policies and
practices that emphasize the use of alternatives
to restrictive interventions.
(b) Prior to providing services to people with
disabilities, staff including service providers,
employees, students or volunteers, shall
demonstrate competence by successfully
completing training in communication skills and
other strategies for creating an environment in
which the likelihood of imminent danger of abuse
or injury to a person with disabilities or others or
property damage is prevented.

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

(d) The training shall be competency-based,

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

STATE FORM

{V 000}

{V 536}

6899

Ewsu12

TITLE (X6) DATE

If continuation sheet 1 of 8

PRINTED: 06/28/2019
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
R
MHL001-149 B. WING _____ 06/27/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

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

DEFICIENCY)
{V 536}] Continued From page 1 {V 536}

include measurable learning objectives,
measurable testing (written and by observation of
behavior) on those objectives and measurable
methods to determine passing or failing the
course.

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

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

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

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

(2) recognizing and interpreting human
behavior;

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

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

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

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

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

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

(9) positive behavioral supports (providing

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

(h) Service providers shall maintain

Division of Health Service Regulation
STATE FORM 6899 Ewsu12 If continuation sheet 2 of 8

PRINTED: 06/28/2019
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
R
MHL001-149 B. WING _____ 06/27/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

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

DEFICIENCY)
{V 536}| Continued From page 2 {V 536}

documentation of initial and refresher training for
at least three years.

(1) Documentation shall include:

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

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

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

review/request this documentation at any time.

(i) Instructor Qualifications and Training
Requirements:

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

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

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

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

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

(B) methods for teaching content of the
course;

(C) methods for evaluating trainee
performance; and

(D) documentation procedures.

(6) Trainers shall have coached experience

teaching a training program aimed at preventing,
reducing and eliminating the need for restrictive

Division of Health Service Regulation
STATE FORM 6899 Ewsu12 If continuation sheet 3 of 8

PRINTED: 06/28/2019

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
MHL001-149 B. WING 06/27/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1710 SYKES STREET
JUST IN TIME YOUTH SERVICES
BURLINGTON, NC 27215
(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

{V 536}| Continued From page 3 {V 536}

interventions at least one time, with positive
review by the coach.

(7) Trainers shall teach a training program
aimed at preventing, reducing and eliminating the
need for restrictive interventions at least once
annually.

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

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

(1) Documentation shall include:

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

(B) when and where attended; and

(C) instructor's name.

(2) The Division of MH/DD/SAS may
request and review this documentation any time.
(k) Qualifications of Coaches:

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

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

(3) Coaches shall demonstrate

competence by completion of coaching or
train-the-trainer instruction.

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

This Rule is not met as evidenced by:

Division of Health Service Regulation
STATE FORM 6899 Ewsu12 If continuation sheet 4 of 8

PRINTED: 06/28/2019
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
R
MHL001-149 B. WING _____ 06/27/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

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

DEFICIENCY)
{V 537}| Continued From page 4 {V 537}
{V 537}, 27E .0108 Client Rights - Training in Sec Rest & | {V 537}
ITO

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

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

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

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

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

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

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

Division of Health Service Regulation
STATE FORM 6899 Ewsu12 If continuation sheet 5 of 8

PRINTED: 06/28/2019
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
R
MHL001-149 B. WING _____ 06/27/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

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

DEFICIENCY)
{V 537}| Continued From page 5 {V 537}

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

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

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

(3) emphasis on safety and respect for the

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

(4) strategies for the safe implementation
of restrictive interventions;
(5) the use of emergency safety

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

(6) prohibited procedures;

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

(8) documentation methods/procedures.

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

(1) Documentation shall include:

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

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

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

review/request this documentation at any time.

(i) Instructor Qualification and Training
Requirements:

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

Division of Health Service Regulation
STATE FORM 6899 Ewsu12 If continuation sheet 6 of 8

PRINTED: 06/28/2019

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
MHL001-149 B. WING 06/27/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

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

DEFICIENCY)
{V 537}| Continued From page 6 {V 537}
need for restrictive interventions.
(2) Trainers shall demonstrate competence

by scoring 100% on testing in a training program
teaching the use of seclusion, physical restraint
and isolation time-out.

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

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

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

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

(A) understanding the adult learner;

(B) methods for teaching content of the
course;

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

(7) Trainers shall be retrained at least

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

Rule.

(8) Trainers shall be currently trained in
CPR.

(9) Trainers shall have coached experience

in teaching the use of restrictive interventions at
least two times with a positive review by the
coach.
(10) Trainers shall teach a program on the
use of restrictive interventions at least once

Division of Health Service Regulation
STATE FORM 6899 Ewsu12 If continuation sheet 7 of 8

PRINTED: 06/28/2019

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
MHL001-149 B. WING 06/27/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1710 SYKES STREET
JUST IN TIME YOUTH SERVICES
BURLINGTON, NC 27215
(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
{V 537}| Continued From page 7 {V 537}
annually.
(11) Trainers shall complete a refresher

instructor training at least every two years.

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

(1) Documentation shall include:

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

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

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

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

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

(3) Coaches shall demonstrate

competence by completion of coaching or
train-the-trainer instruction.

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

This Rule is not met as evidenced by:

Division of Health Service Regulation
STATE FORM 6899 Ewsu12 If continuation sheet 8 of 8

inspection_type: MHLCS Follow-up


raw_content:
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
MHL001-149
NAME OF PROVIDER OR SUPPLIER
1710 SYKI

JUST IN TIME YOUTH SERVICES

PRINTED: 05/20/2019

STREET ADDRESS, CITY, STATE, ZIP CODE
ES STREET

BURLINGTON, NC 27215

FORM APPROVED
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

A. BUILDING: COMPLETED
B.WING 05/10/2019

Assessment/Treatment/Habilitation Plan

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

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

(d) The plan shall include:

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

(2) strategies;

(3) staff responsible;

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

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

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

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

STATE FORM

6899

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000) INITIAL COMMENTS V 000
An annual and complaint survey was completed
on 5/10/19. The complaint was unsubstantiated
(intake #NC00151036). Deficiencies were cited.
This facility is licensed for the following service
10A NCAC 27G.1700 Residential Treatment Staff
Secure for Children and Adolescents.
V 112] 27G .0205 (C-D) v112

TITLE

(X6) DATE

Ewsu11 If continuation sheet 1 of 25

PRINTED: 05/20/2019
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
MHL001-149 B. WING ____ 05/10/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

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

DEFICIENCY)
V 112| Continued From page 1 Vv 112

This Rule is not met as evidenced by:

Based on record review and interviews, the
acility failed to implement strategies to address
he needs and behaviors for one of three clients
(#1). The findings are:

Review on 5/9/19 of client #1's record revealed:
-Admission date of 10/31/18.

-Diagnoses of Autism Spectrum Disorder, Major
Depressive Disorder, Conduct Disorder, Attention
Deficit Hyperactivity Disorder and Generalized
Anxiety Disorder.

-17 years old.

-Comprehensive Clinical Assessment dated
3/26/19-Client #1 had a history of walking away
rom placements, sexually aggressive behaviors,
destruction of property and physical aggression.
-Person Centered Plan dated 11/1/18 for client #1
had no strategies to address elopement from the
acility.

Review of facility records on 5/8/19 revealed:
-Incident reports for client #1 had the following
information:

(1). 5/10/19"Staff was reading [client #1]
academic sheet and observed [client #1] made
several inappropriate remarks at school, staff
asked [client #1] what did he say that was
disrespectful and [client #1] stated he made a
comment about porn but he didn't direct the
comment at no one. Staff informed [client #1] he
was going to call teacher and investigate incident.
[Client #1] replied why, you don't believe me , I'm
tired of you f******g people I'm gone, staff
prompted [client #1] not to go out facility and
[client #1] ran out door, staff followed [client #1]
and called non-emergency number to inform of
[client #1] absent and give description of [client
Division of Health Service Regulation

STATE FORM 6899 Ewsu11 If continuation sheet 2 of 25

PRINTED: 05/20/2019

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
MHL001-149 B. WING 05/10/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1710 SYKES STREET
JUST IN TIME YOUTH SERVICES
BURLINGTON, NC 27215
(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

V 112| Continued From page 2 Vv 112

#1] dress. Staff notified [supervisor of client]
unauthorized leave, staff remain on call in case of
[client #1] return."

(2). 4/29/19-"Staff was on shift after previous
unexplained absence from [Client #1], when local
law enforcement return [client #1] to facility. Staff
notified parent and immediate supervisor of
[Client #1] return and was instructed to transport
[client #1] to [Local Hospital] to be evaluated due
to absence and lack of medication being
administered due to client being out of facility.
[Client #1] had been off his medications for 48
hours. Staff transported [client #1] to Hospital for
assessment and [client #1] was admitted for
urther observation. [Client #1] remained in
Hospital until 4-28-19 when [House Manager]
picked him up from hospital and returned [client
#1] to facility with discharge instructions. Staff
ransported [client #1] to [Local behavioral health
agency] on 4-29-19 for follow up appointment with
[License Professional]. [Client #1] was seen and
ransported to school without further incident."

(3). 4/26/19-"Staff monitored [client #1] return
rom being AWOL (away without leave) from
acility and his return by Police. [Client #1] stated
soon as he takes a shower he is leaving and
here is nothing staff can do to stop him. [Local
Police] informed client if he keeps running away
he can be arrested , [client #1] replied | turn 18 in
2 months and you have to release me so do what
you got to do, I'm good. Staff attempted to
de-escalate the situation by encouraging [client
#1] to comply with treatment and medication
management, staff informed him being off his
medications is dangerous. Staff prompted [client
#1] to not exit facility and [client #1] walked out
the door stating catch me if you can, staff called
local law enforcement, [clients guardian], and
Division of Health Service Regulation

STATE FORM 6899 Ewsu11 If continuation sheet 3 of 25

PRINTED: 05/20/2019
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
MHL001-149 B. WING ____ 05/10/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

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

DEFICIENCY)
V 112| Continued From page 3 Vv 112

[supervisor]. Staff feels [client #1] needs to be
assessed to determine mental stability at this time
due to not taking medication while absent from
facility, [client #1] has not returned at this time."

(4). 4/25/19-"Staff informed [client #1] of recent
home visit events that he cannot go home due to
violent outburst with guardian and destruction of
property. Staff prompted [client #1] to decrease
his aggressive behaviors. [Client #1] stated he
has nothing to lose he is leaving facility, staff
attempt to de-escalate situation by speaking in
low non-threatening tone. [Client #1] walked out
back door, staff followed still encouraging [client
#1] to rethink his actions. Staff notified [Director],
[guardian for client #] , and local law enforcement
of [client #1] actions. [Client #1] is still AWOL
(away without leave) from facility at this time,
local law enforcement are still looking for [client
#1] and [client #1] is still listed as missing."

(5). 4/23/19-"Staff prompted [client #1] to clean
out van and [client #1] refused stating he tired of
his place he is leaving. Staff redirected [client #1]
io focus and think situation through more
carefully, before reacting off impulse. [Client #1]
stated he is leaving and there is nothing staff can
do to stop me but call police. [Client #1] ran out
he door and down the street towards park. Staff
called non-emergency number and reported client
(o authorities. [Local Police] called staff at
11:45pm to inform staff [client #1] was at [local
restaurant] in [Name of city], staff went to [local
restaurant] and transported [client #1] back to
acility. [Client #1] came in and went to bed
without further report."

Review of facility records on 5/10/19 revealed:
-There were police reports that responded with all
of the above episodes of elopement for client #1.
Division of Health Service Regulation

STATE FORM 6899 Ewsu11 If continuation sheet 4 of 25

PRINTED: 05/20/2019
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
MHL001-149 B. WING ____ 05/10/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

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

DEFICIENCY)
V 112| Continued From page 4 Vv 112

Interview with client #1 on 5/8/19 revealed:

-He eloped from the home several times in April
2019.

-About a week or two ago towards the end of April
he ran about 3-4 times in one day.

-He would sometimes visit family in the area or
just hang out.
-He just recently ran with a client from another
home.
-They walked to a local restaurant and decided to
call the police after they arrived.

-He did not have a good feeling about being at
that local restaurant.
-The police had located him several times while
he was out in the community.
-Towards the end of April he went to the hospital
after eloping from the home.
-He was not sure how many days he was in the
hospital and/or the reason he was in the hospital.

Interview with the House Manager on 5/10/19
revealed:

-He thought client #1 ran away from the home
about three times.

‘When he had the elopement episode towards
the end of April 2019 he ran several times in one
day.

Client #1 would elope, return to the home and
elope again.

-He thought he stayed out overnight during that
elopement episode.

He did go to the hospital after that incident for
about two days.

He thought he went to the hospital because he
was not taking his medication due to the
elopement.

-Client #1 would normally tell them he was
leaving and just walk out the door.

-Staff were required to call the police each time
Division of Health Service Regulation

STATE FORM 6899 Ewsu11 If continuation sheet 5 of 25

PRINTED: 05/20/2019
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
MHL001-149 B. WING ____ 05/10/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

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

DEFICIENCY)
V 112| Continued From page 5 Vv 112

client #1 elopes from the facility.
-He confirmed client #1 had no strategies to
address his elopement from the facility.

Interview with the Program Director on 5/8/19 and
5/10/19 revealed:

He thought client #1 started running away from
he home in April, 2019.

He thought client #1 eloped from the home about
hree times.

The police department was called each time
client #1 walked away.

During one of client #1's elopement incidents
staff took him to the hospital after he returned.

He thought client #1 possibly went to the hospital
because he was not taking his medication.

-He thought client #1 was gone for a day or two
during that elopement incident.

-Client #1 actually called the police himself during
one of his elopement incidents.

-Client #1 had eloped with another client and they
went to a local restaurant.

-Client #1 called the police and the police
department informed staff of client #1's
whereabouts.

-Staff went to Hooters and returned client #1 to
the group home.

-Client #1 got in trouble at school on 5/9/19.
-Client #1 left the group home on 5/9/19 after
school around 6:00 PM.

-The police department was contacted on 5/9/19
and informed client #1 had eloped from the
facility.

-As of 5/10/19 client #1 remains on the run and
the police officers had not located him.

-Client #1 would normally tell staff he was leaving.
-Client #1 would just walk out the door.

-He confirmed client #1 had no strategies to
address his elopement from the facility.

Division of Health Service Regulation
STATE FORM 6899 Ewsu11 If continuation sheet 6 of 25

PRINTED: 05/20/2019
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
MHL001-149 B. WING ____ 05/10/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 112| Continued From page 6 Vv 112

Interview with the Licensee on 5/9/19 revealed:
-Client #1 was previously at her group home.
-Client #1 left her group home because he
required a higher level of care.

-Client #1 went to a Psychiatric Residential
Treatment Facility (PRTF) due to the incidents of
elopement.

-Client #1 contacted her after he was discharged
from the PRTF and wanted to return to her
facility.

-Client #1 begin to elope again in April 2019.
-She thought client #1 had eloped from the home
about 2-3 times.

-Staff were required to call the police each time
client #1 eloped.

-The police department had an issue with them
calling each time a client eloped.

-The police department felt like they should
"restrain" clients if they try to leave the facility.
-She had told the police department staff can't put
heir hands on a client if they wanted to elope.
-She confirmed client #1 had no strategies to
address his elopement from the facility.

Review on 5/10/19 of a Plan of Protection written
by the Program Director dated 5/10/19 revealed:
What will you immediately do to correct the above
rule violations in order to protect clients from
urther risk or additional harm? "[Program
Director] will contact [Licensed Professional] to
provide a safety plan for [client #1] to address
issues of [client #1] running away from facility."
Describe your plans to make sure the above
happens: "Treatment Team will address additional
strategies and goals to put in treatment plan to
help [client #1] develop positive strategies to
decrease/eliminate running away from facility as
a option when frustrated or upset."

Client #1 had a history of elopement from
Division of Health Service Regulation
STATE FORM 6899 Ewsu11 If continuation sheet 7 of 25

PRINTED: 05/20/2019
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
MHL001-149 B. WING ____ 05/10/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

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

DEFICIENCY)
V 112| Continued From page 7 Vv 112

facilities. There were four documented incidents
of elopement involving client #1 between April
and May 2019. Client #1 ran away from the home
as recently as 5/9/19 and his whereabouts are
still unknown. The police department were
contacted each time client #1 eloped from the
facility. The Licensee indicated client #1 was
discharged from her facility previously due to
consistent episodes of elopement. Although the
Licensee was aware of client #1's elopement
history she failed to have strategies in his
treatment plan to address Client #1's elopements.
This deficiency constitutes a Type A1 rule
violation for serious neglect and must be
corrected within 23 days. An administrative
penalty of $2000.00 is imposed. If the violation is
not corrected within 23 days, an additional
administrative penalty of $500 per day will be
imposed each day the facility is out of compliance
beyond the 23rd day.

V 118] 27G .0209 (C) Medication Requirements Vv 118

10A NCAC 27G .0209 MEDICATION
REQUIREMENTS

(c) Medication administration:

(1) Prescription or non-prescription drugs shall
only be administered to a client on the written
order of a person authorized by law to prescribe
drugs.
(2) Medications shall be self-administered by
clients only when authorized in writing by the
client's physician.

(3) Medications, including injections, shall be
administered only by licensed persons, or by
unlicensed persons trained by a registered nurse,
pharmacist or other legally qualified person and
privileged to prepare and administer medications.
(4) A Medication Administration Record (MAR) of

Division of Health Service Regulation
STATE FORM 6899 Ewsu11 If continuation sheet 8 of 25

PRINTED: 05/20/2019
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
MHL001-149 B. WING ____ 05/10/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

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

DEFICIENCY)
V 118| Continued From page 8 V 118

all drugs administered to each client must be kept
current. Medications administered shall be
recorded immediately after administration. The
MAR is to include the following:

(A) client's name;

(B) name, strength, and quantity of the drug;

(C) instructions for administering the drug;

(D) date and time the drug is administered; and
(E) name or initials of person administering the
drug.

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

This Rule is not met as evidenced by:

Based on record reviews and interviews, the
facility failed to follow the physician's orders for
three of four current clients (#1, #2 and #3) and
one of one former client (FC #5). The findings
are:

a. Review on 5/8/19 of client #1's record
revealed:

-Admission date of 10/31/18.

-Diagnoses of Autism Spectrum Disorder, Major
Depressive Disorder, Conduct Disorder, Attention
Deficit Hyperactivity Disorder and Generalized
Anxiety Disorder.

-Admission Assessment dated 11/1/18 indicated
client #1 had lost several family members and
exhibited signs of grief. He had issues managing
anger and history of assaultive behaviors.
-Physician's order dated 2/6/19 for Zyprexa 10
mg, one tablet two times daily. Zyprexa used to
treat Schizophrenia and manic episodes of
Division of Health Service Regulation

STATE FORM 6899 Ewsu11 If continuation sheet 9 of 25

PRINTED: 05/20/2019
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
MHL001-149 B. WING ____ 05/10/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

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

DEFICIENCY)
V 118| Continued From page 9 V 118

Bipolar Disorder.

-Physician's order dated 2/6/19 for Claritin 10 mg,
one tablet daily. Claritin used to treat allergy
symptoms.
-Physician's order dated 1/9/19 for Melatonin 3
mg, two tablets at bedtime. Melatonin used for
sleep and other sleep disorders.

-Physician's order dated 1/9/19 for Kapvay ER 0.1
mg, two tablets once daily at bedtime. Kapvay
used to treat symptoms of Attention Deficit
Hyperactivity Disorder.

-Physician's order dated 12/17/18 for Minocycline
100 mg, one capsule two times daily. Minocycline
used to treat infections.

-The April 2019 MAR indicated the following
medications were not administered to client #1:
Claritin 10 mg on 4/16 and Melatonin 3 mg on 4/1
through 4/4.
-The March 2019 MAR indicated the following
medications were not administered to client #1:
Claritin 10 mg on 3/28; Zyprexa 10 mg on 3/28
and 3/29 AM doses and 3/27,3/28 PM doses;
Minocycline 100 mg on 3/23 through 3/29 AM
doses and 3/23 through 3/28 PM doses;
Melatonin 3 mg on 3/22 through 3/28.
-The February 2019 MAR indicated the following
medications were not administered to client #1:
Zyprexa 10 mg on 2/23 through 2/25 AM doses
and 2/23, 2/24 PM doses.
-The January 2019 MAR indicated the following
medications were not administered to client #1:
Kapvay ER 0.1 mg on 1/1 and 1/2; Zyprexa 10
mg on 1/18 through 1/24 AM doses and 1/18
through 1/23 PM doses; Minocycline 100 mg on
1/16 through 1/21 AM doses and 1/16 through
1/20 PM doses.

b. Review on 5/8/19 of client #2's record
revealed:

-Admission date of 11/7/18.

Division of Health Service Regulation

STATE FORM 6899 Ewsu11 If continuation sheet 10 of 25

PRINTED: 05/20/2019
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
MHL001-149 B. WING ____ 05/10/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

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

DEFICIENCY)
V 118| Continued From page 10 V 118

-Diagnoses of Oppositional Defiant Disorder,
Attention Deficit Hyperactivity Disorder, Reactive
Attachment Disorder-inhibited type and
Cone-Rod Dystrophy.

-Admission Assessment dated 11/7/18 indicated
client #2 exhibits verbal and physical aggression.
He has poor impulse control, poor insight and
poor judgement.
-Physician's order dated 2/6/19 for Zoloft 100 mg,
one tablet two times daily. Zoloft used to treat
depression, Obsessive Compulsive Disorder,
Panic Disorder and Post Traumatic Stress
Disorder.
-Physician's order dated 2/6/19 for Risperdal 1
mg, one tablet two times daily. Risperdal used to
teat Schizophrenia, Bipolar Disorder and
irritability associated with Autism.

-Physician's order dated 2/6/19 for Catapres 0.2
mg, one tablet two times daily. Catapres used to
eat anxiety.
-Physician's order dated 1/15/19 for Melatonin 5
mg, two tablets at bedtime. Melatonin used for
sleep and other sleep disorders.

-Physician's order dated 12/13/18 for Doxycycline
Hyclate 100 mg, one tablet daily. Doxycycline
Hyclate used to treat and prevent infections.
-Physician's order dated 11/7/18 for Wellbutrin 75
mg, one tablet two times daily. Wellbutrin used to
reat depression.
-Physician's order dated 11/17/18 for Cogentin
0.5 mg, one tablet two times daily. Cogentin used
io treat symptoms of involuntary movements due
io side effects of certain psychiatric drugs.

-The March 2019 MAR indicated the following
medications were not administered to client #2:
Melatonin 5 mg on 3/22 through 3/29;
Doxycycline Hyclate 100 mg on 3/17 and 3/18;
Cogentin 0.5 mg on 3/17 through 3/28 AM doses
and 3/16 through 3/26 PM doses; Catapres 0.2
mg on 3/12 through 3/15 AM doses and 3/11
Division of Health Service Regulation

STATE FORM 6899 Ewsu11 If continuation sheet 11 of 25

g

g

PRINTED: 05/20/2019
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
MHL001-149 B. WING ____ 05/10/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118| Continued From page 11 V 118

through 3/15 PM doses.

-The February 2019 MAR indicated the following
medications were not administered to client #2:
Cogentin 0.5 mg on 2/10 through 2/12 AM and
PM doses; Catapres 0.2 mg on 2/3 through 2/9
AM doses and 2/2 through 2/7 PM doses; Zoloft
100 mg on 2/21 through 2/28 AM doses and 2/21
through 2/27 PM doses; Risperdal 1 mg on 2/11,
2/12 AM doses and 2/11 PM dose; Melatonin 5
mg on 2/18.

-The January 2019 MAR indicated the following
medications were not administered to client #2:
Zoloft 100 mg on 1/20, 1/21 AM doses and 1/19,
1/20 PM doses; Cogentin 0.5 mg on 1/5 through
1/10 AM doses and 1/5 through 1/9 PM dose;
Wellbutrin 75 mg on 1/1 through 1/9 AM doses
and 1/1 through 1/8 PM doses.

c. Review on 5/8/19 of client #3's record revealed:
-Admission date of 7/10/18.

-Diagnoses of Post Traumatic Stress Disorder,
Disruptive Mood Dysregulation Disorder,
Oppositional Defiant Disorder and Attention
Deficit Hyperactivity Disorder.

-Admission Assessment dated 7/10/18 indicated
client #3 had a history of property destruction,
running away, aggression, stealing and being
impulsive.

-Physician's order dated 2/4/19 for Vyvanse 70
mg, one capsule in the morning. Vyvanse used to
treat Attention Deficit Hyperactivity Disorder.
-Physician's order dated 2/4/19 for Lithium
Carbonate ER 450 mg, one tablet two times daily.
Lithium Carbonate ER used to treat Manic
Depressive Disorder.

-Physician's order dated 2/4/19 for Seroquel 25
mg, one tablet at bedtime. Seroquel used to treat
Schizophrenia, Bipolar Disorder and Depression.
-The March 2019 MAR indicated the following
medications were not administered to client #3:
Division of Health Service Regulation

STATE FORM 6899 Ewsu11 If continuation sheet 12 of 25

PRINTED: 05/20/2019

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
MHL001-149 B. WING 05/10/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1710 SYKES STREET
JUST IN TIME YOUTH SERVICES
BURLINGTON, NC 27215
(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

V 118] Continued From page 12 V 118

Vyvanse 70 mg on 3/7 through 3/11; Lithium
Carbonate ER 450 mg on 3/7 through 3/11 AM
doses and 3/6 through 3/11 PM doses; Seroquel
on 3/9 and 3/10.

d. Review on 5/8/19 of FC #5's record revealed:
‘Admission date of 4/29/16.

Diagnoses of Mild Intellectual Disability, Post
Traumatic Stress Disorder, Disruptive Mood
Dysregulation Disorder, Bipolar Disorder and
Attention Deficit Hyperactivity Disorder.
-Discharged from home March 2019.

‘Admission Assessment dated 4/29/16 indicated
FC #5 had a history of physical and verbal
aggression, self harm and property destruction.
-Physician's order dated 2/20/19 for Flonase
0.05% nasal spray, one spray per nostril daily.
Flonase used to relieve seasonal and year round
allergic and non-allergic nasal symptoms.
-Physician's order dated 2/19/19 for Remeron 45
mg, one tablet at bedtime. Remeron used to treat
Depression.
-Physician's order dated 8/18/17 for Haldol 10
mg, one tablet three times daily. Haldol used to
reat Psychotic Disorders.

-The March 2019 MAR indicated the following
medications were not administered to FC #5:
Remeron 45 mg on 3/6 and 3/7; Haldol 10 mg on
2/6-8AM/2PM doses and 2/5 8 PM dose.

-The February 2019 MAR indicated the following
medication was not administered to FC #5:
Flonase 0.05% nasal spray on 2/5 through 2/16.

nterview with client #1 on 5/8/19 revealed:

-He ran out of medication a couple of times.
-Staff had to get a doctor's order to get a refill on
his medication.

-He also missed medications sometimes if he
was on the run.

-He gave no specifics on the type of medications
Division of Health Service Regulation

STATE FORM 6899 Ewsu11 If continuation sheet 13 of 25

PRINTED: 05/20/2019
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
MHL001-149 B. WING ____ 05/10/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118| Continued From page 13 V 118

and how may times the issue occurred.

Interview with client #2 on 5/8/19 revealed:

-He did run out of medication a few times.

-He ran out of medication because staff failed to
get his medications refilled.

-He gave no specifics on the type of medications
and how many times the issue occurred.

Interview with the House Manager on 5/8/19 and
5/10/19 revealed:

-Clients' #1, #2, #3 and FC #5 ran out of
medications between January and April 2019.

-A preauthorization by the physician was required
by the pharmacy in order to refill the medications
-Sometimes there was a delay by staff getting a
client's physician to send the preauthorization to
the pharmacy.

-He confirmed staff failed to follow the physician's
orders for clients' #1, #2, #3 and FC #5.

Interview with the Program Director on 5/8/19 and
5/10/19 revealed:

- Staff did not consistently administer medications
to clients' #1, #2, #3 and FC #5.

-Clients' #1, #2, #3 and FC #5 ran out of
medications.

-Some of the clients had a medication
management agency "that could be difficult to
deal with."

-Staff would often have difficulty getting
medications refilled.

-Most of the time staff had to wait for the
physician to send a preauthorization to the
pharmacy.

-Clients were running out of medications due to
delay of the preauthorization being sent to the
pharmacy.

-He confirmed staff failed to follow the physician's
orders for clients' #1, #2, #3 and FC #5.

Division of Health Service Regulation

STATE FORM 6899 Ewsu11 If continuation sheet 14 of 25

PRINTED: 05/20/2019

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
MHL001-149 B. WING 05/10/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1710 SYKES STREET
JUST IN TIME YOUTH SERVICES
BURLINGTON, NC 27215
(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

V 118| Continued From page 14 V 118

Interview with the Licensee on 5/9/19 revealed:
-She knew that staff were having issues getting
preauthorizations for medications.

-She was not aware clients were running out of
medications.

-The House Manager was the person responsible
for making sure medication orders were refilled
properly.

-She confirmed staff failed to follow the
physician's orders for clients' #1, #2, #3 and FC
#5.

Review on 5/10/19 of a Plan of Protection written
by the House Manager dated 5/10/19 revealed:
What will you immediately do to correct the above
rule violations in order to protect clients from
urther risk or additional harm? "Staff will
implement medication management strategy of
contacting all doctors, therapist or any individual
hat writes prescriptions for client at start of order
and re-order 14 day in advance or request 3
month supply of all med (medications) with
exception of control drugs."

Describe your plans to make sure the above
happens: "All medications will be logged and
check on daily shift change, and sign off with
each staff coming on shift or off shift. All orders
will be ordered in timely manner. Staff will
document medications well before getting low
and reorder according to control policy."

Staff consistently failed to ensure prescribed
medications were refilled for clients' #1, #2, #3
and FC #5 within a timely manner and as
ordered. There was a delay with staff requesting
a preauthorization by a clients physician in order
for the pharmacy to refill the prescribed
medications. Clients' #1, #2, #3 and FC #5 ran
out of medications between the months of
Division of Health Service Regulation

STATE FORM 6899 Ewsu11 If continuation sheet 15 of 25

PRINTED: 05/20/2019
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
MHL001-149 B. WING ____ 05/10/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

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

DEFICIENCY)
V 118| Continued From page 15 V 118

January 2019 and April 2019. The majority of the
medications prescribed for clients' #1, #2, #3 and
FC #5 were to help manage their behaviors and
mental health symptoms. This deficiency
constitutes a Type A2 rule violation for substantial
risk of serious harm and must be corrected within
23 days. No administrative penalty has been
assessed. If the violation is not corrected within
23 days, an administrative penalty of $500 per
day will be imposed each day the facility is out of
compliance beyond the 23rd day.

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

10A NCAC 27E .0107 TRAINING ON
ALTERNATIVES TO RESTRICTIVE
INTERVENTIONS
(a) Facilities shall implement policies and
practices that emphasize the use of alternatives
to restrictive interventions.
(b) Prior to providing services to people with
disabilities, staff including service providers,
employees, students or volunteers, shall
demonstrate competence by successfully
completing training in communication skills and
other strategies for creating an environment in
which the likelihood of imminent danger of abuse
or injury to a person with disabilities or others or
property damage is prevented.

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

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

Division of Health Service Regulation
STATE FORM 6899 Ewsu11 If continuation sheet 16 of 25

PRINTED: 05/20/2019
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
MHL001-149 B. WING ____ 05/10/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

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

DEFICIENCY)
V 536 | Continued From page 16 V 536
course.

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

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

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

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

(2) recognizing and interpreting human
behavior;

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

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

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

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

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

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

(9) positive behavioral supports (providing

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

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

(1) Documentation shall include:

(A) who participated in the training and the

Division of Health Service Regulation
STATE FORM 6899 Ewsu11 If continuation sheet 17 of 25

PRINTED: 05/20/2019

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
MHL001-149 B. WING 05/10/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1710 SYKES STREET
JUST IN TIME YOUTH SERVICES
BURLINGTON, NC 27215
(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 536 | Continued From page 17 V 536
outcomes (pass/fail);
(B) when and where they attended; and
(C) instructor's name;
(2) The Division of MH/DD/SAS may

review/request this documentation at any time.

(i) Instructor Qualifications and Training
Requirements:

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

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

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

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

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

(B) methods for teaching content of the
course;

(C) methods for evaluating trainee
performance; and

(D) documentation procedures.

(6) Trainers shall have coached experience

teaching a training program aimed at preventing,
reducing and eliminating the need for restrictive
interventions at least one time, with positive
review by the coach.

(7) Trainers shall teach a training program
aimed at preventing, reducing and eliminating the

Division of Health Service Regulation
STATE FORM 6899 Ewsu11 If continuation sheet 18 of 25

PRINTED: 05/20/2019
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
MHL001-149 B. WING ____ 05/10/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

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

DEFICIENCY)
V 536 | Continued From page 18 V 536
need for restrictive interventions at least once
annually.
(8) Trainers shall complete a refresher

instructor training at least every two years.

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

(1) Documentation shall include:

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

(B) when and where attended; and

(C) instructor's name.

(2) The Division of MH/DD/SAS may
request and review this documentation any time.
(k) Qualifications of Coaches:

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

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

(3) Coaches shall demonstrate

competence by completion of coaching or
train-the-trainer instruction.

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

This Rule is not met as evidenced by:

Based on record review and interview, the facility
failed to ensure one of six audited staff (The
Qualified Professional) had training on the use of
alternatives to restrictive interventions prior to
providing services. The findings are:

Review on 5/10/19 of the facility's personnel files
revealed:

Division of Health Service Regulation

STATE FORM 6899 Ewsu11 If continuation sheet 19 of 25

PRINTED: 05/20/2019

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
MHL001-149 B. WING 05/10/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1710 SYKES STREET
JUST IN TIME YOUTH SERVICES
BURLINGTON, NC 27215
(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

V 536 | Continued From page 19 V 536

-The Qualified Professional had a hire date of
11/1/14.

-The Qualified Professional had a North Carolina
Interventions Core Training Part A certificate that
expired on 9/30/18.

-There was no documentation that the Qualified
Professional had current training on the use of
alternatives to restrictive interventions.

Interview with the Licensee on 5/10/19 revealed:
-Her agency uses North Carolina Interventions
Plus training on the use of alternatives to
restrictive interventions.

-The Qualified Professional works for another
agency and received her training with that
agency.

-She thought the Qualified Professional had the
"ProACT" training on the use of alternatives to
restrictive interventions.

-She did not have the Qualified Professional
rained in North Carolina Interventions Plus.
-She did not realize all staff were required to have
he same type of training on the use of
alternatives to restrictive interventions.

-She confirmed there was no documentation of
raining on the use of alternative to restrictive
intervention for the Qualified Professional.

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

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

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

Division of Health Service Regulation
STATE FORM 6899 Ewsu11 If continuation sheet 20 of 25

PRINTED: 05/20/2019
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
MHL001-149 B. WING ____ 05/10/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

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

DEFICIENCY)
V 537 | Continued From page 20 V 537

staff authorized to employ and terminate these
procedures are retrained and have demonstrated
competence at least annually.

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

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

(d) The training shall be competency-based,
include measurable learning objectives,
measurable testing (written and by observation of
behavior) on those objectives and measurable
methods to determine passing or failing the
course.
(e) Formal refresher training must be completed
by each service provider periodically (minimum
annually).
(f) Content of the training that the service
provider plans to employ must be approved by
the Division of MH/DD/SAS pursuant to
Paragraph (g) of this Rule.

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

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

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

(3) emphasis on safety and respect for the

rights and dignity of all persons involved (using
concepts of least restrictive interventions and

Division of Health Service Regulation
STATE FORM 6899 Ewsu11 If continuation sheet 21 of 25

PRINTED: 05/20/2019
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
MHL001-149 B. WING ____ 05/10/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

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

DEFICIENCY)
V 537 | Continued From page 21 V 537
incremental steps in an intervention);
(4) strategies for the safe implementation
of restrictive interventions;
(5) the use of emergency safety

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

(6) prohibited procedures;

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

(8) documentation methods/procedures.

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

(1) Documentation shall include:

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

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

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

review/request this documentation at any time.

(i) Instructor Qualification and Training
Requirements:

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

(2) Trainers shall demonstrate competence
by scoring 100% on testing in a training program
teaching the use of seclusion, physical restraint
and isolation time-out.

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

(4) The training shall be
competency-based, include measurable learning
objectives, measurable testing (written and by

Division of Health Service Regulation
STATE FORM 6899 Ewsu11 If continuation sheet 22 of 25

PRINTED: 05/20/2019

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
MHL001-149 B. WING 05/10/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1710 SYKES STREET
JUST IN TIME YOUTH SERVICES
BURLINGTON, NC 27215
(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

V 537 | Continued From page 22 V 537

observation of behavior) on those objectives and
measurable methods to determine passing or
failing the course.

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

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

(A) understanding the adult learner;

(B) methods for teaching content of the
course;

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

(7) Trainers shall be retrained at least

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

Rule.

(8) Trainers shall be currently trained in
CPR.

(9) Trainers shall have coached experience

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

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

(1) Documentation shall include:

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

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

Division of Health Service Regulation
STATE FORM 6899 Ewsu11 If continuation sheet 23 of 25

PRINTED: 05/20/2019
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
MHL001-149 B. WING ____ 05/10/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

BURLINGTON, NC 27215
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE

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

JUST IN TIME YOUTH SERVICES

V 537 | Continued From page 23 V 537

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

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

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

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

This Rule is not met as evidenced by:

Based on record review and interview, the facility
ailed to ensure one of six audited staff (The
Qualified Professional) had training in the use of
seclusion, physical restraints and isolation
ime-out. The findings are:

Review on 5/10/19 of the facility's personnel files
revealed:

-The Qualified Professional had a hire date of
11/1/14.

-The Qualified Professional had a North Carolina
nterventions Core Training Part B certificate that
expired on 9/30/18.

-There was no documentation that the Qualified
Professional had training in the use of seclusion,
physical restraints and isolation time-out.

nterview with the Licensee on 5/10/19 revealed:
-Her agency uses North Carolina Interventions
Plus training in the use of seclusion, physical
restraints and isolation time-out.

-The Qualified Professional works for another
agency and received her training with that
Division of Health Service Regulation

STATE FORM 6899 Ewsu11 If continuation sheet 24 of 25

PRINTED: 05/20/2019

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
MHL001-149 B. WING 05/10/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1710 SYKES STREET
JUST IN TIME YOUTH SERVICES
BURLINGTON, NC 27215
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 537 | Continued From page 24 V 537

agency.
-She thought the Qualified Professional had the
"ProACT" training in the use of seclusion,
physical restraints and isolation time-out.

-She did not have the Qualified Professional
trained in North Carolina Interventions Plus.

-She did not realize all staff were required to have
the same type of training in the use of seclusion,
physical restraints and isolation time-out.

- She confirmed there was no documentation of
training in the use of seclusion, physical restraints
and isolation time-out for the Qualified
Professional.

Division of Health Service Regulation
STATE FORM 6899 Ewsu11 If continuation sheet 25 of 25


raw_content:
Division of Health Service Regulation

PRINTED: 03/04/2019
FORM APPROVED

Acomplaint survey was completed on February
21, 2019. The complaint was unsubstantiated
(Intake #NC00148112). No deficiencies were
cited.

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

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

STATE FORM

6899

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
Cc
MHL001-149 02/21/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1710 SYKES STREET
JUST IN TIME YOUTH SERVICES
BURLINGTON, NC 27215
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000) INITIAL COMMENTS Vv 000

Ov9611

TITLE (X6) DATE

If continuation sheet 1 of 1