summary: Plan of Correction - MHLCS Annual and Complaint

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Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

8. WING

03/16/2023

MHL011-436

STREET ADDRESS, CITY, STATE, ZIP CODE

25 CHOCTAW STREET
ASHEVILLE, NC 28801

NAME OF PROVIDER OR SUPPLIER

ASHEVILLE DETOX CENTER

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D 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

An annual and complaint survey was completed
March 16, 2023. The complaint was substantiated
(Intake # NC00197685). Deficiencies were cited

This facility is licensed for the following service
category: 10A NCAC 27G .3100 Nonhospital

Medical Detoxification for Individuals Who are
Substance Abusers.

The facility is licensed for 16 and has a current
census of 14 clients. The survey sample
consisted of audits of 3 current clients and 1
former client.

27G .0207 Emergency Plans and Supplies

10A NCAC 27G .0207 EMERGENCY PLANS
AND SUPPLIES

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

authority MAR 28 2023
(b) The plan shall be made available to all staff
and evacuation procedures and routes shall be BHSR-MH Licensure Sect

posted in the facility.

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

This Rule is not met as evidenced by:
Based on record review and interview, the facility |
failed to conduct fire and disaster drills quarterly

for each shift. The findings are

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

kr

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Division of Health Service Regulation

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

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
A, BUILDING: COMPLETED

MHL011-436 8, WING —_____ 03/16/2023

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

25 CHOCTAW STREET
ASHEVILLE DETOX CENTER
ASHEVILLE, NC 28801
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES iD PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX {EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

Vv 114 Continued From page 1 Vv 114

Review on 3/14/23 of the facility's fire and
disaster drill logs from July 2022 (when facility
opened) to December 2022 revealed: |
-No documentation of fire drills for |
-July through September 2022, 2nd and 3rd

shifts; a drill was conducted at 11:17, however no

a.m. or p.m. was documented. |
-October through December 2022, 1st and 3rd
shifts; a drill was conducted at 12:30, however no |
a.m. or p.m. was documented.

-No documentation of disaster drills for:
-Any of the quarters reviewed.

Interview on 3/14/23 with the Director of |
Operations revealed: |
-There were 3 shifts - 7:30 a.m. - 4:00 p.m., 3:30
p.m. - 12:00 a.m. and 11:30 p.m. - 8:00 a.m

-He was not aware fire and disaster drills needed
to be conducted each quarter on each shift.

-He would ensure this requirement was met in the
future

V 115 27G .0208 Client Services vi15

410A NCAC 27G .0208 CLIENT SERVICES

(a) Facilities that provide activities for clients shall
assure that:

(1) space and supervision is provided to ensure
the safety and welfare of the clients,

(2) activities are suitable for the ages, interests,
and treatment/habilitation needs of the clients
served; and |
(3) clients participate in planning or determining |
activities.

(h) Facilities or programs designated or described
in these Rules as "24-hour" shall make services
available 24 hours a day, every day in the year.

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Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

B. WING

MHLO011-436 03/16/2023

STREET ADDRESS, CITY, STATE, ZIP CODE
25 CHOCTAW STREET
ASHEVILLE, NC 28801

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

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

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

NAME OF PROVIDER OR SUPPLIER

ASHEVILLE DETOX CENTER

V 115 Continued From page 2

unless otherwise specified in the rule
(c) Facilities that serve or prepare meals for
clients shall ensure that the meals are nutritious.
(d) When clients who have a physical handicap
are transported, the vehicle shall be equipped
with secure adaptive equipment.

(€) When two or more preschool children who
require special assistance with boarding or riding
in a vehicle are transported in the same vehicle,
there shall be one adult, other than the driver, to
assist in supervision of the children

This Rule is not met as evidenced by: |
Based on observation, interview and record
review, the facility failed to provide supervision to
ensure the safety and welfare of 1 of 1 former
client (FC #4) audited. The findings are: |

Review on 3/14/23 of FC #4's record revealed:
-Admitted 10/24/22; Discharged 10/31/22

-Age 18 years old.

-Diagnoses of Sedative, Hypnotic, or Anxiolytic
Use Disorder, severe, Generalized Anxiety
Disorder, Major Depressive Disorder, recurrent
episode, severe, Hallucinogen Abuse with other
Hallucinogen-Induced Disorder, Alcohol Use
Disorder, mild, Cannabis Use Disorder, severe,
and Opioid Use Disorder, severe.

-10/27/22 - "Behavioral Contract" signed by client
and Director of Operations - "... Additional Notes:
broke window seal and opened window to access
the roof during the middle of the night." |
10/28/22 - Psychiatrist note - "The patient (FC
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STATE FORM Cd 7S0B11 If continuation sheet 3 of 13

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FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA

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

MHLO11-436 B. WING

(X2) MULTIPLE CONSTRUCTION

NAME OF PROVIDER OR SUPPLIER
25 CHOCTAW STREET

ASHEVILLE DETOX CENTER
ASHEVILLE, NC 28801

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY
COMPLETED

03/16/2023

(X4) 1D SUMMARY STATEMENT OF DEFICIENCIES ID
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG
Vv 115 Continued From page 3 Vv 115

#4) was asked about breaking out of his window
and going onto the roof...He states he was not
trying to kill himself and knew what he was doing
the entire time. He states he didn't know why he
did it, and knows that he should not have..."
-"Rounds" were documented every 30 minutes by
Former Staff (FS) #4, Behavior Health Technician
(BHT) that FC #4 was "sleeping."

-Nursing rounds were documented at 12:00 a.m
and 4:00 a.m. that FC #4 was observed in his
bedroom

Interview attempt on 3/16/22 with FC #4 was
unsuccessful.

Observation on 3/14/23 at 2:20 p.m. with Staff #4
revealed

-FC #4's bedroom while he was at the facility
-The bed he slept in was next to a window that
led to a small roof that was the overhang for the
patio below

-The window would not open as small metal tabs
were observed on the outside of the window to
ensure it stayed closed.

-If the window opened it would be possible to step
right outside of it onto the small roof.

Review on 3/15/23 of "Notes" dated 11/2/22 by
Staff #2 regarding FS #4 revealed:

-"On October 27, 2022, | had a conversation with
employee about sleeping on the job, correctly
checking on clients during rounds... After
reviewing camera footage | noticed employee
slept for hours a the reception desk with the lights
turned off...! watched, via camera, employee sit in
the same spot while rounds were logged as
completed showing that he did not physically get
up to lay eyes on clients..."

="On 12/2 (2022) [FS #4] and | spoke about
sleeping on shift the night/morning of 12/2

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

e898

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Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERI/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

MHLO11-436 03/16/2023

STREET ADDRESS, CITY, STATE, ZIP CODE

25 CHOCTAW STREET
ASHEVILLE, NC 28801

NAME OF PROVIDER OR SUPPLIER

ASHEVILLE DETOX CENTER

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

DEFICIENCY)

V 115 Continued From page 4

12:00am-8:00am. A client saw him sleeping when
he approached him...[FS #4] was informed that
this is his last and final warning...."

-12/7/22 - "One of the members on the nursing
staff informed me [FS #4] is usually asleep by the |
time she comes into work...a client informed me |
that [FS #4] was sleeping in the tech [technician]

Office the first three nights he was in detox..." |

Review on 3/15/23 of an incident report regarding
FS #4 dated 1/25/23 revealed:

-"Description of the Incident: Staff member was
caught sleeping during his shift...Action
Taken:...management decided to terminate
employee...Follow Up/Next Steps: Employee [FS
#4) was terminated on 1/25/23..."

Interview on 3/15/23 with Staff #2 revealed:
-Responsible to supervise 2nd and 3rd shift

BHT's.
-Had many conversations with FS #4 for sleeping

during his shift, not doing rounds correctly and |
not laying eyes on the clients
-FS #4 sleeping on his shift was "sporadic" as
after conversations he would do "very well."
-After several verbal warnings, him being written |
up for this and not completing other duties

properly, he was terminated.

Interview on 3/15/23 with the Director of
Operations revealed

-It was brought to his attention on 10/27/22 at
approximately 2:00 p.m. by another client that FC
#4's window was open.

-After further investigation FC #4 stated he was
on the roof of the patio just outside of his
bedroom window.

-FC #4 said he just sat there for about 15-20
minutes.

-FC #4 said he was only on the patio roof and that
Division of Health Service Regulation

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

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED
MHL011-436 BEING: ee 03/16/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
ASHEVILLE DETOX CENTER 25 GHOCTAW STREET
ASHEVILLE, NC 28801
(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 115 Continued From page 5 Vv 115

he didn't go all the way up to the top of the facility
-This was when he and FC #4 completed the
"Behavioral Contract."

-The BHT's were to do "Rounds" every 30
minutes and were to conduct visual checks on
clients at that time

-FS #4 was terminated for sleeping on his shift
-He went over policies and procedures with all |
BHT staff on all shifts about expectations during |
"Rounds."

-He did not document this training or take
attendance of the BHT staff who were present.
-He now had all new 3rd shift staff and he and
Staff #2 were doing spot checks every 2-3 weeks |
to ensure BHT's were awake during 3rd shift.

V 131 G.S. 131E-256 (D2) HCPR - Prior Employment v 134
Verification

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

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

This Rule is not met as evidenced by:

Based on record review and interview the facility |
failed to complete Health Care Personnel

Registry (HCPR) checks prior to hire for 1 of 3 |
audited staff (Staff #1). The findings are:

Division of Health Service Regulation
STATE FORM e0s9 7SOB11 If continuation sheet 6 of 13

Division of Health Service Regulation

AND PLAN OF CORRECTION

| (X4) 1D
PREFIX

TAG

NAME OF PROVIDER OR SUPPLIER

ASHEVILLE DETOX CENTER

PRINTED: 03/20/2023
FORM APPROVED

(X41) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER

MHLO11-436

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

Vv 134

V 133

STATE FORM

Continued From page 6

Review on 3/16//23 of Staff #1's personnel record
revealed:

-Hire date 7/12/22, title Behavior Health
Technician.

-HCPR check dated 7/13/22.

Interview on 3/16/23 with the Director of
Operations revealed

-Human Resources was responsible to conduct
HCPR checks.

-He would notify them and ensure this was
corrected.

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

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

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

(b) Requirement. - An offer of employment by a
provider licensed under this Chapter to an
applicant to fill a position that does not require the
applicant to have an occupational license is
conditioned on consent to a State and national
criminal history record check of the applicant. If
the applicant has been a resident of this State for
less than five years, then the offer of employment
is conditioned on consent to a State and national
criminal history record check of the applicant. The
national criminal history record check shall
include a check of the applicant's fingerprints. If
the applicant has been a resident of this State for
five years or more, then the offer is conditioned
on consent to a State criminal history record

STREET ADDRESS, CITY, STATE, ZIP CODE
25 CHOCTAW STREET
ASHEVILLE, NC 28801

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

B. WING __ 03/16/2023

1D PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 131
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|
V 133

Division of Health Service Regulation

lf continuation sheet 7 of 13

oes 7S0B11

Division of Health Service Regulation

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

A. BUILDING:

MHL011-436 Lespuit

(X2) MULTIPLE CONSTRUCTION

PRINTED: 03/20/2023
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

03/16/2023

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

ASH LE DETOX CENTER
SHEVI ASHEVILLE, NC 28801

(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE

PROVIDER'S PLAN OF CORRECTION (x5)
COMPLETE

DATE

DEFICIENCY)

(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES ID
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG
V 133. Continued From page 7 V 133

check of the applicant. A provider shall not
employ an applicant who refuses to consent to a
criminal history record check required by this
section. Except as otherwise provided in this
subsection, within five business days of making
the conditional offer of employment, a provider
shall submit a request to the Department of
Justice under G.S. 114-19.10 to conduct a
criminal history record check required by this
section or shall submit a request to a private
entity to conduct a State criminal history record
check required by this section. Notwithstanding
G.S. 114-19.10, the Department of Justice shall
return the results of national criminal history
record checks for employment positions not
covered by Public Law 105-277 to the
Department of Health and Human Services,
Criminal Records Check Unit. Within five
business days of receipt of the national criminal
history of the person, the Department of Health
and Human Services, Criminal Records Check
Unit, shall notify the provider as to whether the
information received may affect the employability
of the applicant. In no case shall the results of the
national criminal history record check be shared
with the provider. Providers shall make available
upon request verification that a criminal history
check has been completed on any staff covered
by this section. A county that has adopted an
appropriate local ordinance and has access to
the Division of Criminal Information data bank
may conduct on behalf of a provider a State
criminal history record check required by this
section without the provider having to submit a
request to the Department of Justice. In such a
case, the county shall commence with the State
criminal history record check required by this
section within five business days of the
conditional offer of employment by the provider

Division of Health Service Regulation
STATE FORM

ease

7SOB11

If continuation sheet 6 of 13

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Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
A. BUILDING: COMPLETED

03/16/2023

MHL011-436

STREET ADDRESS, CITY, STATE, ZIP CODE
25 CHOCTAW STREET
ASHEVILLE, NC 28801

(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)

NAME OF PROVIDER OR SUPPLIER

ASHEVILLE DETOX CENTER

V 133 Continued From page 8 V 133

All criminal history information received by the
provider is confidential and may not be disclosed,
except to the applicant as provided in subsection |
(c) of this section. For purposes of this |
subsection, the term "private entity" means a
business regularly engaged in conducting
criminal history record checks utilizing public
records obtained from a State agency.

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

(1) The level and seriousness of the crime.

(2) The date of the crime.

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

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

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

(8) The prison, jail, probation, parole,
rehabilitation, and employment records of the
person since the date the crime was committed
(7) The subsequent commission by the person of
a relevant offense. |
The fact of conviction of a relevant offense alone |
shall not be a bar to employment; however, the
listed factors shall be considered by the provider.
if the provider disqualifies an applicant after
consideration of the relevant factors, then the
provider may disclose information contained in
the criminal history record check that is relevant
to the disqualification, but may not provide a copy
of the criminal history record check to the |
applicant.

(d) Limited Immunity. - A provider and an officer

or employee of a provider that, in good faith,

Division of Health Service Regulation
STATE FORM 0088 7SOB11 \f continuation sheet 9 of 13

(4) 1D
PREFIX
TAG

Vv 133

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

(2) MULTIPL

MHL011-436 5. WING __

A. BUILDING:

PRINTED: 03/20/2023
FORM APPROVED

LE CONSTRUCTION (X3) DATE SURVEY

COMPLETED

eS 03/16/2023

STREET ADDRESS, CITY, S
25 CHOCTAW STREET

HEVILLE DI NTER
as ETOX CE ASHEVILLE, NC 28801

STATE, ZIP CODE

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

ID
PREFIX
TAG

Continued From page 9 V 133

complies with this section shall be immune from
civil liability for:

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

(e) Relevant Offense. - As used in this section,
“relevant offense" means a county, state, or
federal criminal history of conviction or pending
indictment of a crime, whether a misdemeanor or
felony, that bears upon an individual's fitness to
have responsibility for the safety and well-being of
persons needing mental health, developmental
disabilities, or substance abuse services. These
crimes include the criminal offenses set forth in
any of the following Articles of Chapter 14 of the
General Statutes: Article 5, Counterfeiting and
Issuing Monetary Substitutes; Article 5A,
Endangering Executive and Legislative Officers;
Article 6, Homicide; Article 7A, Rape and Other
Sex Offenses; Article 8, Assaults; Article 10,
Kidnapping and Abduction; Article 13, Malicious
Injury or Damage by Use of Explosive or
Incendiary Device or Material; Article 14, Burglary
and Other Housebreakings; Article 15, Arson and
Other Burnings; Article 16, Larceny; Article 17,
Robbery; Article 18, Embezzlement; Article 19,
False Pretenses and Cheats; Article 19A,
Obtaining Property or Services by False or
Fraudulent Use of Credit Device or Other Means;
Article 19B, Financial Transaction Card Crime
Act; Article 20, Frauds; Article 21, Forgery; Article
26, Offenses Against Public Morality and
Decency; Article 26A, Adult Establishments;
Article 27, Prostitution; Article 28, Perjury; Article
29, Bribery; Article 31, Misconduct in Public

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

(5)
COMPLETE
DATE

Division of Health Service Regulation
STATE FORM

6899

If continuation sheet 10 of 13

7S0B11

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: sco HUES

PRINTED: 03/20/2023
FORM APPROVED

(%3) DATE SURVEY
COMPLETED

Office; Article 35, Offenses Against the Public

Peace; Article 36A, Riots and Civil Disorders;

Article 39, Protection of Minors; Article 40,

Protection of the Family; Article 59, Public

Intoxication; and Article 60, Computer-Related

Crime. These crimes also include possession or

sale of drugs in violation of the North Carolina

Controlled Substances Act, Article 5 of Chapter
90 of the General Statutes, and alcohol-related
offenses such as sale to underage persons in
violation of G.S. 18B-302 or driving while |
impaired in violation of G.S. 20-138.1 through

G.S. 20-138.5. |
(f) Penalty for Furnishing False Information. - Any
applicant for employment who willfully furnishes,
supplies, or otherwise gives false information on
an employment application that is the basis for a
criminal history record check under this section
shall be guilty of a Class A1 misdemeanor.

(g) Conditional Employment. - A provider may
employ an applicant conditionally prior to
obtaining the results of a criminal history record
check regarding the applicant if both of the
following requiremenis are met:

(1) The provider shall not employ an applicant
prior to obtaining the applicant's consent for
criminal history record check as required in
subsection (b) of this section or the completed
fingerprint cards as required in G.S. 114-19.10.
(2) The provider shall submit the request for a |
criminal history record check not later than five
business days after the individual begins
conditional employment. (2000-154, s. 4;
2001-155, s. 1; 2004-124, ss. 10.19D(c), (h);
2005-4, ss. 1, 2, 3, 4, 5(a); 2007-444, s. 3.)

Division of Health Service Regulation
STATE FORM one 7SOB11

MHL011-436 BAUMNG = 03/16/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
25 CHOCTAW STREET
ASHEVILLE DETOX CENTER
ASHEVILLE, NC 28801
(X4) 1D SUMMARY STATEMENT OF DEFICIENCIES. 1D 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 133. Continued From page 10 V 133

If continuation sheet 11 of 13

Division of Health Service Regulation

PRINTED: 03/20/2023
FORM APPROVED

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

A. BUILDING:

MHL011-436 BEING

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

MLL NTE!
ealee lata fs ASHEVILLE, NC 28801

(x4) ID

V 133 Continued From page 11 V 133

This Rule is not met as evidenced by

Based on record review and interview, the facility
failed to request within 5 days of making the
conditional offer of employment a state criminal
background check and to conduct a national
criminal background check with the applicant's
fingerprints when the applicant was a resident of
this State for less than five years for 3 of 3
audited staff (Staff #1, Staff #2 and Counselor
#1). The findings are:

Review on 3/16//23 of Staff #1's personnel record
revealed:

-Hire date 7/12/22, title Behavior Health
Technician (BHT).

-Criminal history check dated 7/24/22 (12 days
after hire)

-Lived in another state within the last 5 years and
no fingerprint check was completed.

Review on 3/16/23 of Staff #2's personnel record
revealed

-Hire date 7/11/22, title BHT Supervisor.

-Criminal history check dated 7/7/22

-Lived in another state within the last 5 years and |
no fingerprint check was completed |

Review on 3/16/23 of Counselor #1's personnel
record revealed:

-Hire date 7/11/22, title Primary Counselor
-Criminal history check dated 6/26/22.

-Lived in another state within the last 5 years and
no fingerprint check was completed

Interview on 3/16/23 with the Director of

Operations revealed:

-Human Resources was responsible to conduct

criminal background checks.

Division of Health Service Regulation

STATE FORM cose 7S0B11

SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION
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

(X3) DATE SURVEY
COMPLETED

03/16/2023

(x5)

If continuation sheet 12 of 13

PRINTED: 03/20/2023
FORM APPROVED

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X41) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
A. BUILDING: COMPLETED

MHLO011-436 B. WING 03/16/2023

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

25 CHOCTAW STREET
ASHEVILLE, NC 28801

ASHEVILLE DETOX CENTER

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (5)
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 133 Continued From page 12

-He would notify them and ensure this was |
corrected.

Division of Health Service Regulation
STATE FORM ea08 7S0B11 if continuation sheet 13 of 13

27G .0207 Emergency Plans and Supplies

Indicate what measures will be put in place to correct the deficient area of practice (i.e. changes
in policy and procedure, staff training, changes in staffing patterns, etc.). Procedure for
emergency drills has changed to meet standard of quarterly fire and disaster drills for
each shift corrected 03/22/23.

Indicate what measures will be put in place to prevent the problem from occurring again.
Director of Operations has been assigned a QMPI form with checklist to follow each month
to ensure the proper amount of fire and disaster drills are assigned to meet the quarterly
minimum,

Indicate who will monitor the situation to ensure it will not occur again. Chief Compliance
officer will monitor QMPI report submissions.

Indicate how often the monitoring will take place. Chief Compliance officer will monitor QMPI
report submissions monthly.

27G .0208 Client Services

Indicate what measures will be put in place to correct the deficient area of practice (i.e. changes
in policy and procedure, staff training, changes in staffing patterns, etc.). From incident we have
terminated employee and documented incident reports and employee write ups. Also,
from incident we have conducted a retraining session with all staff. During this training
standard of rounds were reviewed to ensure proper operations and client safety. Policy on
sleeping during third shift has been reviewed by necessary staff members. We have
implemented check list duties to staff to complete during shift. We also have reinforced
windows so they cannot be opened now. All items corrected 03/16/23.

Indicate what measures will be put in place to prevent the problem from occurring again.
Windows have been reinforced to prevent destruction of property. We have implemented
check list duties to prevent staff from being unproductive during shift.

Indicate who will monitor the situation to ensure it will not occur again. Director of Operations
will monitor staff performance and client safety.

Indicate how often the monitoring will take place. Director of Operations will monitor daily.

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

Indicate what measures will be put in place to correct the deficient area of practice (i.e. changes
in policy and procedure, staff training, changes in staffing patterns, etc.), Procedure for prior
employment verification has been changed implemented HCPR checks prior to hire date.
Corrected 03/22/23.

Indicate what measures will be put in place to prevent the problem from occurring again. HR
employment checklist has been changed to include HCPR check prior to employment.
Indicate who will monitor the situation to ensure it will not occur again. HR director will
monitor the performance of this procedure to ensure HCPR are done before employment
decision is made.

Indicate how often the monitoring will take place. Hiring process is monitored each month on
QMPI leadership submissions.

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

Indicate what measures will be put in place to correct the deficient area of practice (i.e. changes
in policy and procedure, staff training, changes in staffing patterns, etc.). Prior to employment
candidates are now required to fill out an agency form listing residency for past 5 years,
any applicants with out of state history will be sent for fingerprint checks included in the
background check hiring process. Process corrected 03/23/23.

Indicate what measures will be put in place to prevent the problem from occurring again.
Resident history form implemented for all employment candidates moving forward.
Indicate who will monitor the situation to ensure it will not occur again. HR director will
monitor correct process for candidate hiring.

Indicate how often the monitoring will take place. QMPI hiring submission will be monitored
monthly.

inspection_type: MHLCS Annual and Complaint


state: NC

facility_name: Green Cottage

summary: Statement of Deficiency - MHLCS Annual

raw_content:
PRINTED: 03/03/2026

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL011-444 B. WING 03/03/2026
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

61 COMPTON DRIVE
ASHEVILLE, NC 28806

GREEN COTTAGE

(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 survey was completed on 3/3/26. No
deficiencies were cited.

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

This facility is licensed for 4 and currently has a
census of 6. The survey sample consisted of
audits of 3 current clients.

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

STATE FORM 6899 RZGV11 If continuation sheet 1 of 1

inspection_type: MHLCS Annual

document_type: Statement of Deficiency


summary: Statement of Deficiency - MHLCS Annual

raw_content:
Division of Health Service Regulation

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

MHLO011-441

NAME OF PROVIDER OR SUPPLIER

61 COMPTON DRIVE

GREEN COMMUNITY RESPITE

ASHEVILLE, NC 28806

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 07/18/2025

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

07/15/2025

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000) INITIAL COMMENTS Vv 000

An annual was attempted on July 15, 2025.
According to the Chief Operating Officer there are
no clients being served at the facility. The last
time clients were served at the facility was
January 2025.

This facility is licensed for the following service
categories: 10A NCAC 27G .5100 Community
Respite for Individuals of all Disability Groups
(Day) and 10A NCAC 27G .5100 Community
Respite for Individuals of all Disability Groups
(Residential.

Review on 7/14/25 of Former Client #1's record
revealed:

-Age: 13 years old

-Date of Admission: 12/30/24

-Date of Discharge: 1/4/25

-Diagnosis: Conduct Disorder Unspecified

Review on 7/14/25 of Former Client #2's record
revealed:

-Age: 16 years old

-Date of Admission: 1/14/25

-Date of Discharge: 1/15/25

-Diagnosis: Attention Deficit Hyperactivity
Disorder, unspecified type

Interview on 7/14/25 with the Chief Operating
Officer revealed:

-There were no clients being served at this time.
-"It has been a while" (since clients had been
served).

-The Licensee was currently in the process of
changing the licensure for that program.

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

STATE FORM

6899

ZXIZ11

TITLE

(X6) DATE

If continuation sheet 1 of 1


summary: Statement of Deficiency - MHLCS Annual and Complaint

raw_content:
Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

1400651121

PRINTED: 05/14/2024

(X2) MULTIPLE CONSTRUCTION (x3)
A. BUILDING:

61 COMPTON DRIVE
ASHEVILLE, NC 28806

GREEN COMMUNITY RESPITE

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

) DATE SURVEY
COMPLETED

05/13/2024

An annual and complaint survey was completed
on May 13, 2024. The complaint was
substantiated (Intake #NC00216638). No
deficiencies were cited.

This facility is licensed for the following service
categories: 10A NCAC 27G .5100 Community
Respite Services for Individuals of All Disability
Groups (Day) and 10A NCAC 27G .5100
Community Respite Services for Individuals of All
Disability Groups (Residential).

This facility has a current census of 2. The .5100
Community Respite Services for Individuals of All
Disability Groups (Day) has a current census of 0
and the .5100 Community Respite Services for
Individuals of All Disability Groups (Residential)
has a current census of 2. The survey sample
consisted of 2 current residential clients and 1
former residential client.

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

STATE FORM

6899

LOUK11

TITLE

(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

(X6) DATE

If continuation sheet 1 of 1


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

raw_content:
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA

AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
MHL011-371

NAME OF PROVIDER OR SUPPLIER

GREEN LEVEL Ill

B. WING

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 11/18/2019
FORM APPROVED

11/18/2019

STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE
ASHEVILLE, NC 28806

(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
An annual and follow up survey was attempted on
11/18/19. It was reported no clients have been
served since 10/1/19.
This facility is licensed for the following service
category: 10A NCAC 27G .1700 Residential
Treatment Staff Secure for Children or
Adolescents.
Division of Health Service Regulation
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
STATE FORM 6899 OZ8T11 If continuation sheet 1 of 1

inspection_type: MHLCS Annual and Follow-up


summary: Statement of Deficiency - MHLCS Complaint

raw_content:
PRINTED: 07/12/2019

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
Cc
MHLO011-371 07/01/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE
GREEN LEVEL Ill
ASHEVILLE, NC 28806
(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 July 1,

2019. The complaint was unsubstantiated

(Intake #NC00152984). A deficiency was cited.

This facility is licensed for the following service

category: 10A NCAC 27G .1700 Residential

Treatment Staff Secure for Children or

Adolescents.

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

Assessment/Treatment/Habilitation Plan

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

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

(d) The plan shall include:

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

(2) strategies;

(3) staff responsible;

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

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

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

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

STATE FORM

6899

TITLE

(X6) DATE

If continuation sheet 1 of 4

THBP11

Division of Health Service Regulation

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

MHLO011-371

NAME OF PROVIDER OR SUPPLIER

A. BUILDING:

2 COMPTON DRIVE
ASHEVILLE, NC 28806

GREEN LEVEL Ill

(X2) MULTIPLE CONSTRUCTION

PRINTED: 07/12/2019

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

Cc
07/01/2019

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

This Rule is not met as evidenced by:

Based on record review and interview the facility
failed to revise the treatment plan to develop and
implement strategies and goals in partnership
with the client or legally responsible person
affecting 2 of 3 clients (Clients #2 and #3). The
findings are:

Review on 6/27/19 of Client #2's record revealed:
-admission date 6/3/19.

-diagnoses of Disruptive Mood Dysregulation
Disorder, and other specified Trauma and
Stressor Disorder.

Review on 6/26/19 of incident reports involving
Client #2 revealed:

-6/18/19 - she put on her shoes and began to
walk around the perimeter of the cottage. When
staff attempted to re-direct her to go inside the
cottage, she quickly walked away. She was
eventually able to return to the cottage. At the end
of the night she opened her window to see if the
alarm would go off.

-6/23/19 - she was escalated in cottage; being
disrespectful and throwing items. She took space
on the porch and was reminded this was not
allowed. After numerous prompts to come back
inside, she and a peer took off quickly and started
running off campus into the woods.

Review on 6/27/19 of Client #2's addendum to
Comprehensive Clinical Assessment (CCA) dated
6/24/19 revealed:

-"...consistent pattern of regression since her
step-down to level Ill...engaged in multiple high
risk behaviors including refusing to re-enter the
cottage, and running off campus, when escalated

Division of Health Service Regulation
STATE FORM

6809

THBP11

If continuation sheet 2 of 4

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHLO011-371

A. BUILDING:

2 COMPTON DRIVE
ASHEVILLE, NC 28806

GREEN LEVEL Ill

(X2) MULTIPLE CONSTRUCTION

PRINTED: 07/12/2019

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

Cc
07/01/2019

she will walk out of the cottage and refuse to
return, ran on 6/23/19 and has not returned..."

Review on 6/27/19 of Client #2's
Person-Centered Profile (PCP) dated 5/9/19
revealed:

-goals were last reviewed 5/23/19.

-it was not revised since her admission to the
level 3 cottage.

-it was not revised to reflect her high risk
behaviors of refusing to re-enter the cottage and
running off campus behaviors.

Review on 6/27/19 of Client #3's record revealed:
-admission date 6/6/19.

-diagnoses of Oppositional Defiant Disorder and
Attention-Deficit Hyperactivity Disorder, combined
type.

Review on 6/26/19 of incident reports involving
Client #3 revealed:

-6/11/19 - he engaged with another client who
was off-task and escalating. He walked away
from the group home and continued to engage
with the escalated student. He ran off campus
and collected unsafe items. He communicated he
intended to self-harm with these items. The
client's unsafe behaviors lasted four hours before
he was involuntarily committed.

-6/18/19 - the day he returned from the hospital.
He engaged with another client that was off-task
and walked to the perimeter of the campus. Staff
provided prompts and check-ins and was able to
get client back to the cottage. He walked away
from the cottage two more times due to being
escalated by various triggers and eventually was
in bed by the nights end.

Review on 6/27/19 of Client #3's CCA dated
5/22/19 revealed:

Division of Health Service Regulation
STATE FORM

6809

THBP11

(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

If continuation sheet 3 of 4

Division of Health Service Re

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

NAME OF PROVIDER OR SUPPLIER

MHLO011-371

(X2) MULTIPLE CONSTRUCTION

A. BUILDING:

2 COMPTON DRIVE
ASHEVILLE, NC 28806

GREEN LEVEL Ill

PRINTED: 07/12/2019

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

Cc
07/01/2019

-he engaged in running behaviors while at a
previous facility.
-he had a history of running away from his home.

Review on 6/27/19 of Client #3's PCP last
updated 5/23/19 revealed:

-he had difficulty expressing his emotions
appropriately and displayed running away
behaviors.

-it was not revised since his admission to the
level 3 cottage.

-it was not revised to reflect new strategies in
attempt to resolve his running behaviors.

Interviews on 6/26/19 and 6/27/19 with the
Qualified Professional and Residential Director
revealed:

-Clients #2 and #3 were discussed in treatment
team meetings and staff meetings.

-there had been no child-family treatment team
meetings since being admitted to a level Ill and/or
after both clients displayed high risk behaviors
and ran away.

Division of Health Service Regulation
STATE FORM

6809

THBP11

(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

If continuation sheet 4 of 4

inspection_type: MHLCS Complaint


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

raw_content:
Division of Health ServiceReguiation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
R-C
MHLO011-371 B. WING 02/06/2019

NAME OF PROVIDEROR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE

GREEN LEVEL Ill

SUMMARY STATEMENT OF DEFICIENCIES
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL
TAG REGULATORY ORLSCIDENTIFYING INFORMATION)

V 000 INITIAL COMMENTS

A complaint and limited follow up survey was
completed on February 6, 2019. The complaint
was unsubstantiated (4NC00147475). This was
also a limited follow up survey, only 10A NCAC
27G .0404 Operations (V138), 10A NCAC 27G
.1708 Transfer or Discharge (V300), 10A NCAC
27G .1701 Scope (V293) and 10A NCAC 27G
-0205 Assessment and Treatment, Habilitation or
Service Plan (V112) were reviewed for
compliance. The following were brought back
into compliance: 10A NCAC 27G .0404
Operations (V138), 10A NCAC 27G .1708
Transfer or Discharge (V300), 10A NCAC 27G
1701 Scope (V293) and 10A NCAC 27G .0205
Assessment and Treatment, Habilitation or
Service Plan (V112). Deficiencies were cited.

(X4) ID

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

| Adolescents.

V 110 27G .0204 Training/Supervision
Paraprofessionals

10A NCAC 27G .0204 COMPETENCIES AND
SUPERVISION OF PARAPROFESSIONALS

(a) There shall be no privileging requirements for
paraprofessionals.

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

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

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

ASHEVILLE, NC 28806

ID
PREFIX
TAG

Vv 000

Vv 110

PRINTED; 02/25/2019
FORM APPROVED

RECEIVED

By DHSR - Mental Health Lic. & Cert. Section at 12:35 pm, Mar 11, 2019

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

DEFICIENCY)

27G .0204 Training/Supervision
Paraprofessionals

(x5)
COMPLETE
DATE

‘A formal review of the required Core B49

Competencies has been added to the 30-
60-90 Day Supervision Form completed by
the Cottage Supervisor with each Direct
Service Employee (Para-professionals and
Associate Professionals).

Additionally, the Core Competencies have 3/11/19
been linked to the New Hire Checklist
completed by ail Direct Care Staff to clearly
link the competencies with program staff
responsibilities. This guides the staff to
complete a self-assessment prior to each
formal supervision at 30, 60 and 90 days
post-hire.

This process will be implement for new 3/22/19
hires upon the completion of training for the
pre-service class ending 3/22/19.

Cottage Supervisors will be trained on the 40/19
revised Supervision tool on 3/19/19 and will
complete supervision sessions with current

staff by 4/30/19. |

27G .1704 Residential Tx. Child/Adol
- Min. Staffing
|

Residential Leadership provided clear
interpretation of the minimum staffing
requirements, ensuring that two staff are
Scheduled and present in each of Eliada’s
Level Ill cottages, regardless of combined
campus activities or low census. This
requires a minimum of 6 Level III staff on
campus at all times (providing coverage in
Green Cottage, and Eliada’s two additional
Level III Residential Treatment facilities.

Expectations were reviewed with the

Division of Peal Sees Rein

LABORATORY DIREC

OR IDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
~\

(2), OF Dikectoro

Spr piilerntt" GN fg

following:
Residential Scheduler 2/6/19
Cottage Supervisors 2/12/19
Level Il Direct Program Staff 2/13/19
TITLE (X6) DATE
before ce ork. Cuatike
If continuation’ sheet 1 of 11

Division of Health ServiceRegulation

PRINTED: 02/25/2019
FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA

(X2) MULTIPLE CONSTRUCTION

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED
R-C
MHLO11-371 B. WING __ 02/06/2019

(X3) DATE SURVEY

NAME OF PROVIDEROR SUPPLIER

V 110 Continued From page 1 Vv 110

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

(1) technical knowledge;

(2) cultural awareness;

(3) analytical skills;

(4) decision-making;

(5) interpersonal skills;

(6) communication skills; and

(7) clinical skills.

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

This Rule is not met as evidenced by:

| Based on record review and interviews, 1 of 5
audited paraprofessionals (Staff #2) failed to
demonstrate knowledge, skilis and abilities
required by the population served. The findings
are:

Review on 1/31/19 of the personnel record for
Staff #2 revealed:

-Hired on 6/4/18 as a Residential Counselor.
-On 12/26/18 Staff #2 met with the Residential
Director and assistant residential director for
coaching. They met to address appropriate |
student/staff boundaries. Dress code and ratio
expectations were reviewed. The documentation
indicated that reports were made about
inappropriate dress and for playing inappropriate
music in front of students.

STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE

GREEN LEVEL Il
ASHEVILLE, NC 28806
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D
PREFIX {EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX
TAG REGULATORY ORLSCIDENTIFYINGINFORMATION) TAG

a

(x5)
COMPLETE
DATE

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

R29

Senior Leadership
23/9

RISE Interns

Adjustments have been made to the Direct
(Care Support Positions. No student
appointments are scheduled to occur prior
to 9am to enable the staff assigned to be
available to support and coverage in the
Level Ill programs during school transport.

3/4/19

‘Additionally, the Lead Night Residential 3/4/19

Counselor provides supportive coverage for
Level II| programs in the event that a
student needs to remain in the cottage
during the school transport timeframe.

The Residential Administrative Assistant
reviews the staffing calendars daily to
ensure minimum staffing requirements are
met (pre service delivery) and then
completes a second line review of
timesheets compared to the staffing
calendar (post service delivery)

3/4/19

|
10A NCAC 27G  .0604
INCIDENT REPORTING
REQUIREMENTS FOR
CATEGORY A AND B
PROVIDERS
A corrective action plan has been pii3/io
developed with the PQI Data Coordinator in
response to the late completion and
submission of the identified IRIS reports.
The PQI Director will review the agency's 3/11/19
IRIS entry log three times per week to
monitor timely reporting and submission.

Eliada has revised the Restrictive
Intervention Incident Report in our
Electronic Health Record to ensure all

Interview on 1/31/19 with Staff #2 revealed:

STATE FORM e899

7GFZ211 If continuation sheet 2 of 11

Division of Health ServiceRegulation
STATEMENT OF DEFICIENCIES | (X1) PROVIDER/SUPPLIERICLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

MHL011-371
NAME OF PROVIDEROR SUPPLIER

GREEN LEVEL III

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

(x4) ID
PREFIX
TAG

V 110) Continued From page 2

-She wore leggings and knew she wasn't
supposed to.

-The residential director had met with her and had
her sign a "boundary plan".

-Client #1 had a pre-planned visit with his family
scheduled for Christmas. She had to supervise
the visit because there were no other staff to
facilitate the visit. She indicated she had no idea
how to do that.

-The other students of the facility had to gone to a
sister facility. She remained in the facility from
8:00PM to approximately 10:00Pm alone with
Client #1.

Interview on 1/31/19 with Staff #3 revealed:
-Staff #2 did not display good boundaries with the
students. Students would request music that she

STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE
ASHEVILLE, NC 28806

would play for them.
-A student had reported to her the Staff #2 wore
tight clothing and would sit with her legs open.

Interview on 2/4/19 with Staff #4 revealed:

| -Client #1 was alone in the cottage with Staff #2

| for a couple of hours.

| -Staff were never to be alone with students.
-Staff #2 would play music in the van that "was
filthy and racist". He indicated she was in the
back of the van dancing like “one of them". He
reported this behavior to leadership.

-Staff #2 would hang out with 2 students like
“hanging out with her buddies". He felt her
interactions with students was like "buddies"
-There were “a lot of red flags".

interview on 2/5/19 on Staff #5 revealed:

-Staff #2 seemed hyper focused on Client #1.
She felt that Staff #2 showed favoritism to Client
#1.

-Staff #2 always wore leggings. She was told not —
to wear them.
Division of Heaith Service Regulation
STATE FORM

PRINTED: 02/25/2019
FORM APPROVED

{X3) DATE SURVEY

(X2) MULTIPLE CONSTRUCTION
COMPLETED

A. BUILDING:
R-C

B. WING 02/06/2019

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

iD
PREFIX
TAG

(x5)
COMPLETE
DATE

Incident reports are thoroughly completed == 4/15/19
and have documented supervisory reviews.
Revisions will be adapted to the non-RI

Incident Reports to ensure all data required

for the completion of IRIS report

submissions is obtained in a timely manner.

Vv 110

The responsibilities for IRIS report
completion and submission have been
reviewed with Residential Leadership,
including Eliada’s COO. The Residential
Administrative Assistant will enter in all IRIS
reports excluding reports involved law
enforcement or allegations. Eliada’s PQI
Director, or designee, will complete the
latter.

3/5/19

7GFZ11 If continuation sheet 3 of 11

PRINTED: 02/25/2019
FORM APPROVED

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES __| (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING: —

(X3) DATE SURVEY
COMPLETED

R-C
02/06/2019

MHLO011-371 B. WING

NAME OF PROVIDEROR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE
GREEN LEVEL Ill ASHEVILLE, NC 28806

SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (%5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVEACTION SHOULD BE COMPLETE

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

¥ 110 Continued From page 3

-Other students reported to her that Staff #2 wore
"see through leggings" and would sit with her legs
open. The students also said that she would play
inappropriate music in the van.

Interview on 2/4/19 with the Cottage Supervisor
revealed:

-She wore exercise pants to work which was
against policy. This was addressed with her but
she continued to wear them.

-If music is not played on the radio then it should
not be played in front of students.

-Client #1 had a visit with family but they did not
show up. Staff #2 remained in the cottage with
Client #1. No other staff were present. No
supervisor was notified of this event. Staff #2
was counseled about this event.

interview on 2/1/19 with the Residential Director
revealed:

-It was reported to him that Staff #2 played |
sexually explicit music in front of students. He

and the assistant director addressed this with her.
They reviewed the boundary protocol with
students and had her sign it. Staff #2 said that
“they are in the real world" and would hear that
kind of music. This issue was included in the
boundary plan.

-He stated that Staff #2 pushed the envelope to
do things. Limits were set with her and she was
redirected.

-He was not aware at the time that Staff #2 was |
alone in the cottage with Client #1. She should
have called a supervisor.

V 296 27G .1704 Residential Tx. Child/Adol - Min. V 296
Staffing

10A NCAC 27G .1704. MINIMUM STAFFING

Division of Health Service Regulation
STATE FORM 600 7GFZ11 If continuation sheet 4 of 11

Division of Health ServiceRegulation
STATEMENT OF DEFICIENCIES.
AND PLAN OF CORRECTION

PRINTED: 02/25/2019

FORM APPROVED.

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHL011-371

eo OF PROVIDEROR SUPPLIER

B.WING

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE

|
V 296 Continued From page 4

| REQUIREMENTS
(a) Aqualified professional shall be available by
telephone or page. A direct care staff shall be
able to reach the facility within 30 minutes at all
times.
(b) The minimum number of direct care staff
required when children or adolescents are
present and awake is as follows:

(1) two direct care staff shall be presentfor
one, two, three or four children oradolescents;
(2) three direct care staff shall be present

for five, six, seven or eight children or
adolescents; and
(3) four direct care staff shall be presentfor
nine, ten, eleven or twelve children or
adolescents.
(c) The minimum number of direct care staff
during child or adolescent sleep hours is as
follows:
(1) two direct care staff shall bepresent
and one shall be awake for one through four
children or adolescents;
(2) two direct care staff shall be present
and both shall be awake for five through eight
children or adolescents; and

| (3) three direct care staff shall be present
of which two shall be awake and the third may be
asleep for nine, ten, eleven or twelve children or
adolescents.
(d) In addition to the minimum number ofdirect
care staff set forth in Paragraphs (a)-(c) of this
Rule, more direct care staff shall be required in
the facility based on the child or adolescent's
individual needs as specified in the treatment
plan.
(e) Each facility shall be responsible for ensuring
supervision of children or adolescents when they _
are away from the facility in accordance with the
child or adolescent's individual strengths and

Division of Health Service Regulation

STATE FORM

6899

(3) DATE SURVEY
COMPLETED
R-C
02/06/2019

GREEN LEVEL Ill
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACHCORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY ORLSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

7GFZ11

if continuation sheet 5 of 11

PRINTED; 02/25/2019
FORM APPROVED

Division of Health Service Regulation

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

R-C
02/06/2019

MHLO011-371 B. WING

STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE
ASHEVILLE, NC 28806

SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION %5)
(EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
REGULATORY ORLSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

NAME OF PROVIDEROR SUPPLIER

GREEN LEVEL Ill

(X4) ID
PREFIX
TAG

V 296

Continued From page 5

needs as specified in the treatment plan.

This Rule is not met as evidenced by:

| Based on observation and interview the facility
failed to ensure that two direct care staff are
present for one, two, three, or four children. The
findings are:

Review on 1/31/19 of video tape for 12/25/18
revealed:

-Staff #2 was in the cottage at 8:30PM with Client
#1. There were no other staff present. At
10:06PM the 2nd staff member was observed to
enter the facility.

Review on 1/31/19 of the personnel record for
Staff #2 revealed: |
-Hired on 6/4/18 as a Residential Counselor.

Record review on 1/31/19 for Client #1 revealed:
-Admitted on 12/5/18 with diagnosis of Conduct
Disorder, adolescent onset type.

Interview on 1/31/19 with Staff #2 revealed:
-Client #1 had a pre-pianned visit with his family |
scheduled for Christmas. She had to supervise
the visit because there were no other staff to
facilitate the visit. She indicated she had no idea
how to do that.

-The other students of the facility had to gone to a’
sister facility. She remained in the facility from
8:00PM to approximately 10:00Pm alone with
Client #1.

-She did not contact leadership to indicate that
Division of Health Service Regulation

STATE FORM 880 7GFZ11 lf continuation sheet 6 of 11

Division of Health ServiceRegulation

PRINTED: 02/25/2019
FORM APPROVED

STATEMENT OF DEFICIENCIES: (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED
R-C
MHL011-371 B. WING __ 02/06/2019
NAME OF PROVIDEROR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE
GREEN LEVEL III
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION %5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULDBE COMPLETE
TAG REGULATORY ORLSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

| she was alone in the facility with a student.

| -She indicated that the cottages "combine pretty
consistently". Cottages combined on first shift
when school was out and around the holidays.

Interview on 1/31/19 with Staff #3 revealed:
-She was working recently when cottages had
combined and had 6 students and 3 staff. This
had occurred for a couple of hours.

Interview on 2/4/19 with Staff #4 revealed:

-He had worked alone in the cottage for short
time periods if his co-worker was late.

-He had transported students alone while his
co-worker was alone in the cottage with other
students.

-There were holes in staffing that happened a lot.
-Nurses were pulled to do shifts and then if a
medical emergency occurred they would have to
leave which would leave the facility out of ratio.
-They were told not to combine cottages, then
told could combine if 6 students or less, and then
told could combine if kept at 4 students.
-Combining cottages was frequent on weekends
and after school.

-Client #1 was alone in the cottage with Staff #2
for a couple of hours.

-Staff were never to be alone with students.

Interview on 2/5/19 on Staff #5 revealed:

-There were times she worked alone with 3 or 4
students. This would be for an hour or so.

-Staff may be pulled out of ratio temporarily which
made her feel uncomfortable.

Interview on 2/4/19 with the Cottage Supervisor
revealed:

-Client #1 had a visit with family on Christmas but
they did not show up. Staff #2 remained in the
cottage with Client #1. No other staff were

V 286 Continued From page 6 V 296

DEFICIENCY)

Division of Health Service Regulation
STATE FORM

7GFZ11 if continuation sheet 7 of 11

PRINTED: 02/25/2019
FORM APPROVED

Division of Health ServiceRegulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED

R-C
MHL011-371 B. WING 02/06/2019

NAME OF PROVIDEROR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE
GREEN LEVEL Ill
ASHEVILLE, NC 28806
(X4) 1D | SUMMARY STATEMENT OF DEFICIENCIES 1D | PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY ORLSCIDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
| .
V 296 Continued From page 7 V 296
present.

-Cottages combined of the census was down ina |
cottage. For example, if one level 3 had 3
students and another level 3 had 3 students they
may take 2 students from another level 3 to add
to each facility census to make 4 in each cottage.
This occurred during the day shift on weekends
and after schoo! until approximately 8:30PM.
-The only reason they combined cottages was
due to a lack of staff.

-At times they would combine and have 5
students at the weight barn with 3 staff.

Interview on 2/1/19 with the Residential Director
revealed:

-He was not aware at the time that Staff #2 was
alone in the cottage with Client #1. She should
have called a supervisor.

-There is never 1 student with 1 staff.

V 367 27G .0604 Incident Reporting Requirements V 367

10A NCAC 27G .0604 INCIDENT
| REPORTING REQUIREMENTS FOR
CATEGORY AAND B PROVIDERS.
(a) Category A and B providers shall report all |
level II incidents, except deaths, that occur during | |
the provision of billable services or while the
consumer is on the providers premises or levellII
incidents and level || deaths involving the clients
to whom the provider rendered any service within
90 days prior to the incident to the LME
responsible for the catchment area where
services are provided within 72 hours of
becoming aware of the incident. The report shall
be submitted on a form provided by the
Secretary. The report may be submitted via mail,
in person, facsimile or encrypted electronic
means. The report shall include the following

Division of Health Service Regulation
STATE FORM 6800 7GFZ11 If continuation sheet 8 of 11

Division of Health ServiceRegulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
MHL011-371

PRINTED: 02/25/2019

FORM APPROVED
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
A. BUILDING: COMPLETED
RC
aabailias — 02/06/2019

NAME OF PROVIDEROR SUPPLIER
GREEN LEVEL II

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY ORLSCIDENTIFYING INFORMATION)

(x4) ID
PREFIX
TAG

STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE
ASHEVILLE, NC 28806

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

(x5)
COMPLETE
DATE

ID
PREFIX
TAG

V 367) Continued From page 8

information:

(1) reporting provider contactand
identification information;

(2) client identification information;

(3) type of incident;

(4) description of incident;

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

(6) other individuals or authorities notified
or responding.

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

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

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

(1) hospital records includingconfidential
information;

(2) reports by other authorities; and

| (3) the provider's response to the incident.
(d) Category A and B providers shall send a copy
of all level Ill incident reports to the Division of
Mental Health, Developmental Disabilities and
Substance Abuse Services within 72 hours of
becoming aware of the incident. Category A
providers shall send a copy of all level Ill
incidents involving a client death to the Division of |

Health Service Regulation within 72 hours of
becoming aware of the incident. In cases of
client death within seven days of use of seclusion
or restraint, the provider shall report the death |

Division of Health Service Regulation
STATE FORM

6800

V 367

7GFZ11 If continuation sheet 9 of 11

PRINTED: 02/25/2019
FORM APPROVED
Division of Health ServiceRegulation

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

R-C
MHLO011-371 B. WING 02/06/2019

NAME OF PROVIDEROR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE

GREEN LEVEL Ill ASHEVILLE, NC 28806

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION | (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVEACTION SHOULD BE COMPLETE
TAG REGULATORY ORLSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE. DATE
DEFICIENCY)
V 367 Continued From page 9 V 367

immediately, as required by 10A NCAC 26C.
0300 and 10A NCAC 27E .0104(e)(18).

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

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

(2) restrictive interventions that do not meet
the definition of a level I! or level Illincident;

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

(5) the total number of level II and level III
incidents that occurred; and
(6) a statement indicating that there have

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

This Rule is not met as evidenced by: |
Based on record review and interview the facility
failed to ensure Level Ill incidents were reported
to the Local Management Entity (LME) within 72
hours of becoming aware of the incident effecting
2 of 3 audited clients (#1, #2). The findings are:

Record review on 1/31/19 for Client #1 revealed:
-Admitted on 12/5/18 with diagnosis of Conduct
Disorder, adolescent onset type.

-Age 17.

Record review on 1/31/19 for Client #2 revealed:
Division of Health Service Regulation
STATE FORM e809 7GFZ11 If continuation sheet 10 of 11

PRINTED: 02/25/2019

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-C
MHL011-374 B. WING os — 02/06/2019
NAME OF PROVIDEROR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE
GREEN LEVEL Ill
ASHEVILLE, NC 28806
(%4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D | PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX {EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY ORLSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE | DATE
DEFICIENCY)
V 367 Continued From page 10 V 367

-Admitted on 9/13/18 with diagnoses of
Post-Traumatic Stress Disorder and Adjustment
Disorder with mixed anxiety and depressed
mood.

-Age 16.

Review on 1/31/19 of incident reports revealed:
-On 1/22/19 " ...Staff arrived at [local high school]
a couple of minutes late to pick up [Client #2].
Staff continued to wait around ...Staff notified
administration at school ...had them page [Client
#2] ...Staff informed [Client #2's] guardian that
she was missing from school and that they had
filed a report with [local law enforcement] ..."

-On 1/6/19 " ...Staff did the 12:20am check and
[Client #1] was in his room. At 12:31am staff
checked in with [Client #1] then left his room. At
12:37am staff went back to ask [Client #1] a |
question. When staff open the door [Client #1]
appeared to be in his bed sleep, but staff called
his name 2 times and he didn't answer ...staff
went in [Client #1's] room to check on him and
realized he was not in his bed ...Supervisor made
a report with [local police] ...at 5:15am, staff did a
check in [Client #1's] room and noticed he was
back in his bed ..." IRIS (Incident Response
Improvement System) report completed and

submitted on 1/11/19.

| Review on 1/31/19 of reports in the IRIS system
revealed:
-No IRIS report for the incident on 1/22/19.
-Incident on 1/6/19 was submitted on 1/11/19. |

Interview on 2/6/19 with the Director of
Performance/Quality Improvement revealed:
-She was aware that the IRIS reports were
submitted late for the level II incidents. This was
an oversight.

Division of Health Service Regulation
STATE FORM 8899 7GF2Z11 if continuation sheet 11 of 11

inspection_type: MHLCS Complaint and Follow-up

document_type: Plan of Correction