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

B. WING

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 09/21/2018
FORM APPROVED

09/07/2018

STREET ADDRESS, CITY, STATE, ZIP CODE
ES STREET

BURLINGTON, NC 27215

(X3) DATE SURVEY
COMPLETED

Allegations, & Protection

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

(g) Health care facilities shall ensure that the
Department is notified of all allegations against
health care personnel, including injuries of
unknown source, which appear to be related to
any act listed in subdivision (a)(1) of this section.
(which includes:

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

c. Misappropriation of the property of a
healthcare facility.

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

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

Facilities must have evidence that all alleged

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
Acomplaint survey was completed on September
7, 2018. The complaint was unsubstantiated
(Intake #NC00142337). 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 Level
Il.
V 132) G.S. 131E-256(G) HCPR-Notification, V 132

TITLE

68CM11

(X6) DATE

If continuation sheet 1 of 3

PRINTED: 09/21/2018

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 ____ 09/07/2018
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 132] Continued From page 1 V 132

acts are investigated and must make every effort
to protect residents from harm while the
investigation is in progress. The results of all
investigations must be reported to the
Department within five working days of the initial
notification to the Department.

This Rule is not met as evidenced by:

Based on interview and record review, the facility
ailed to assure that all allegations of harm or
abuse against healthcare personnel was reported
io the Health Care Personnel Registry (HCPR).
The findings are:

Review on 9/6/18 of Client #1's record revealed
he following information;

-- Admitted to the facility on 6/15/18.

-- Age 11 years old.

-- Diagnoses include Attention Deficit
Hyperactivity Disorder, Oppositional Defiant
Disorder - Moderate to Severe, Post Traumatic
Stress Disorder, Unspecified Depressive Disorder
and Unspecified Bipolar Disorder.

Psychological Testing on 3/9/17 produced a Full
Scale IQ of 87.

Interview on 9/6/18 with the facility Director
revealed that a Child Protective Services worker
had come to the facility to investigate an
allegation that Client #1 made that a named staff
Division of Health Service Regulation

STATE FORM 6899 68CM11 If continuation sheet 2 of 3

PRINTED: 09/21/2018

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 ____ 09/07/2018
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 132] Continued From page 2 V 132

had hurt dim during a therapeutic intervention that
had happened (date unknown).

Review on 9/6/18 of the North Carolina Incident

Response Improvement System (IRIS) revealed
no incident report had been completed regarding
the above event.

Interview on 9/7/18 with the facility Director
revealed that she was unaware that any
allegation of harm/abuse/neglect or exploitation
made by a client receiving services should be
reported to the HCPR, and that no one had done
this for this event.

Division of Health Service Regulation
STATE FORM 6899 68CM11 If continuation sheet 3 of 3


state: NC

facility_name: Just In Time Youth Services

summary: Plan of Correction - MHLCS Complaint

raw_content:
Division of Health Service Regulation

PRINTED: 09/21/201

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

MHLOO01-149)

FORM APPROVED
(X2) MULTIPLE + CONSTRUCTION (X3) DATE SURVEY
A BUI COMPLETED
LDING:
09/07/2018

NAME OF PROVIDER OR SUPPLIER

JUST IN TIME Y~UTH SERVICES

STREET ADDRESS, CITY, STATE, ZIP CODE
1710 SYKES STREET

BURLINGTON, NC 27215

[RECEIVED

By DHSR - Mental Health Lic. & Cert. Section at 10:02 am, Oct 03, 2018

Notification, Allegations, & Protection

GS. §131E-256 HEALTH CARE
PERSONNEL REGISTRY

(g) Health care facilities shall ensure that the
Department is notified of all allegations against
health care personnel, including injuries of
unknown source, which appear to be related to
any act listed in subdivision (a)(1) of this
section. (which includes:

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

c. Misappropriation of the property of

a healthcare facility.

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

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

Facilities must have evidence that all alleged

ervices in formed facility that they
ere responsible for completing an
INC IRIS and notifying the NC
[Healthcare Personnel Registry of
he allegations/compliant within 72
hours of learning of situation.
Facility at this time complied with
completing the online NC IRIS and
notifying the NC Healthcare
Personnel Registry. Facility also
uring in-house staff meeting
informed all staff members of these
procedures when learning of
llegation/complaint against
healthcare personnel.

(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)
he facility was unaware that they
V 000) INITIAL COMMENTS V 000 ’
needed to notify/report to NC IRIS or
A complaint survey was completed on September INC Healthcare Registry when they
7, 201 8. The complaint was unsubstantiated earned of allegations abuse against
(Intake #NC00142337). A deficiency was cited. healthcare personnel on
This facility is licensed for the following 11712018, which is when the facility
service category: as informed of compliant through
10A NCAC 27G .1700 Residential Treatment (Guildford County DSS initiation of
Staff Secure For Children or Adolescents investigation. Johanna Edwards,
Level Ill. RN (Nurse Consultant) for NC
Department of Health and Human
V 132) G.S. 131E-256(G) HCPR- V 132

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

TITLE

(x6) DATE

STATE FORM

6899

68CM11

If continuation sheet 1 of 3

PRINTED: 09/21/201
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 BUI COMPLETED
LDING:

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

1710 SYKES STREET
JUST IN TIME Y~UTH 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 132 | Continued From page 1 V 132

acts are investigated and must make every effort
to protect residents from harm while the
investigation is in progress. The results of all
investigations must be reported to the
Department within five working days of the initial
notification to the Department.

This Rule is not met as evidenced by:

Based on interview and record review, the facility
failed to assure that all allegations of harm or
abuse against healthcare personnel was reported
to the Health Care Personnel Registry (HCPR).
The findings are:

Review on 9/6/1 8 of Client #1's record revealed
the following information;

-- Admitted to the facility on 6/15/1 8.

-- Age 11 years old.

-- Diagnoses include Attention Deficit
Hyperactivity Disorder, Oppositional Defiant
Disorder - Moderate to Severe, Post Traumatic
Stress Disorder, Unspecified Depressive
Disorder and Unspecified Bipolar Disorder.

-- Psychological Testing on 3/9/17 produced a
Full Scale IQ of 87.

Interview on 9/6/1 8 with the facility Director
revealed that a Child Protective Services worker
had come to the facility to investigate an
allegation that Client #1 made that a named staff

Division of Health Service Regulation
STATE FORM 6899 68CM11 If continuation sheet 2 of 3

PRINTED: 09/21/201
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 BUI COMPLETED
LDING:
MHLOO1-149) 09/07/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET
BURLINGTON, NC 27215

JUST IN TIME Y~UTH SERVICES

(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 132 | Continued From page 2 Vv 132

had hurt dim during a therapeutic intervention
that had happened (date unknown).

Review on 9/6/1 8 of the North Carolina Incident
Response Improvement System (IRIS) revealed
no incident report had been completed regarding
the above event.

Interview on 9/7/1 8 with the facility Director
revealed that she was unaware that any
allegation of harm/abuse/neglect or exploitation
made by a client receiving services should be
reported to the HCPR, and that no one had done
this for this event.

Division of Health Service Regulation
STATE FORM 6899 68CM11 If continuation sheet 3 of 3

- | NORTH CAROLINA
4 SAFETY ASSESSMENT
£,, Page 1 of 8

County Name: ail

Social Worker Name:
Children:

Date Report Received:

Part A. FACTORS INFLUENCING CHIL.) VULNERABILITY
These are conditions resulting in child’s inability to pjotect self. Mark all that apply to any child.

Child is age 0-5. © Child has diminished mental capacity.
Child has diagnosed or suspected medical © Child has diminished physical capacity.
or mental condition, including medically fragile. DI None apply

CO Child has limited or no readily accessible support network.

The vulnerability of each child needs to be conside/‘ed throughout the assessment. Younger children and children with diminished mental or
physical capacity or repeated victimization should be ;onsidered more vulnerable. Complete this assessment based on the most vulnerable child.

Part B. CURRENT INDICATORS OF SAFI/TY

The following list is comprised of safety indicators, diifined as behaviors or conditions that describe a child being in imminent danger of serious
harm. Assess the above household for each of the saf ty indicators. Mark “yes” for any and all safety indicators present in the family’s current
situation and mark “no” for any and all of the safety ii|dicators absent from the family’s current situation based on the information at the time.
Mark all that apply.

1. Yes No Caretaker caused and/or alliiwed serious physical harm to the child or made a plausible threat to cause serious
physical harm in the current assessment as indicated by:

Serious injury or abuse to the child other than accidental.

Caretaker fears he/she jvill maltreat the child.

Threat to cause harm ot retaliate against the child.

Substantial or unreason ble use of physical force.

Drug-exposed infant/child

Caretaker committed act that placed child at risk of significant/serious pain that could result in
impairment or loss of b))dily function.

O Caretaker intended to hurt child and does not show remorse.

DO Death of a child.

\
oo00000

Comments:

2. Yes (No Child sexual abuse is suspet ted to have been committed by:

© Parent;
Other caretaker; OR

O Unknown person AND the parent or other caretaker cannot be ruled out, AND circumstances suggest
that the child’s safety may be of immediate concern.

Comments:

i DSS-5231 Revised 01/17 Initials
Child Welfare Services )

GC 1305 Initials

NORTH CAROLINA
_ SAFETY ASSESSMENT
Page 2 of 8

3.) | Yes No/ Caretaker is aware of the po, J ential harm AND unwilling, OR unable to protect the child from serious harm or
threatened harm by others. ‘This may include physical abuse, emotional abuse, sexual abuse, or neglect.
(Domestic violence behavio’s should be captured under Indicator 10.)

© Caretaker fails to protect child from serious harm or threatened harm by other family members, other

household members, o1 other having regular access to the child.

© An individual(s) with i chronic, or severe violent behavior resides in the home or caretaker allows

Com

access to the child.

iments:

|
4, Yes No ) Caretaker’s explanation or llick of explanation for the injury to the child is questionable or inconsistent with
the type of injury, and the njiture of the injury suggests that the child’s safety may be of immediate concern.

|

O Medical exam shows in ury is the result of abuse; caretaker offers no explanation, denies, or attributes to
an accident. |

O Caretaker’s explanation for the observed injury is inconsistent with the type of injury.

O Caretaker’s description of the cause of the injury minimizes the extent of harm to the child.

O Caretaker’s and/or co lateral contacts’ explanation for the injury has significant discrepancies or

Com

contradictions.

iments:

5)
)

Ss Yes’ No Caretaker fails to provide supervision to protect child from potentially serious harm.

© Caretaker present but ¢ tild wanders outdoors alone, plays with dangerous objects, or on window ledges,

ete.

O Caretaker leaves child i lone (period of time varies with age and developmental status).
© Caretaker makes inade<juate/inappropriate child care arrangements or plans very poorly for child’s care.

O Caretaker’s whereabouts are unknown

aD 7 mal } lf ,

Comments: } Va t “
1. Wills J Kk ,°

6. Yes No Caretaker does not meet the child’s immediate needs for food or clothing. For sh We be l re h
v ay

© _No food provided or av hilable to the child, or child is starved/deprived of food/drink for long periods. ¢
© Child appears malnourished.

b50 dak radon ae bake 3 OA J¥inw Cuvol Ai? itn® fk ate

vo A

“ro

ey /il «nch on

© Child is without minim illy warm clothing in cold months.

Comments:

DSS-5231 Revised 01/17
Child Welfare Services

iF
wnials 7 C ey ho ff

Initials

t Yes re)

9. Yes {No,

4

10. Yes | No

NORTH CAROLINA

| SAFETY ASSESSMENT
Page 3 of 8

Caretaker does not meet thd

(suicidal/homicidal). |

|

child’s immediate needs for medical or critical mental health care

© Caretaker does not seel treatment for child’s immediate medical condition(s) or does not follow
prescribed treatments. |

Child has exceptional needs that parents cannot/will not meet.

Child is suicidal and parents will not take protective action.

Child is homicidal and parents will not take protective action.

Child shows effects of naltreatment (i.e. emotional symptoms, lack of behavior control, or physical
symptoms).

ooog

Comments:

Physical living conditions a’e hazardous and immediately threatening to the health and/or safety of the child.

Leaking gas from a sto}/e or heating unit.

Dangerous substances (jr objects stored in unlocked lower shelves or cabinets, under sink, or in the
open.

Lack of water, heat, pli mbing, or electricity and provisions are inappropriate (i.e. using stove as heat
source).

Open/broken/ missing }vindows.

Exposed electrical wires.

Excessive garbage or riitted or spoiled food that threatens health.

Serious illness/significi nt injury due to current living conditions (i.e. lead poisoning, rat bites, etc.)
Evidence of human or [pial waste throughout the living quarters.

Guns and other weapors are not stored in a locked or inaccessible area.
Dangerous drugs are ohne manufactured on premises with child present.

OH000000 0 ao

Comments:

Caretaker’s current substan‘ ¢ abuse seriously impacts his/her ability to supervise, protect, or care for the
child.

© The caretaker is currenily high on drugs or alcohol.

‘There is a current, ong¢ ing pattern of substance abuse that leads directly to neglect and/or abuse of the
child.

Comments:

Domestic violence exists in [he household and poses an imminent danger of serious physical harm and/or
emotional harm to the child

© Child was in immediate danger of serious physical harm by being in close proximity to an incident(s) of
assaultive behavior/domes| ic violence between adults in the household. This includes the child(ren) being
in visual or hearing proximity of domestic violence events in the home.

Comments:

Ly 44, ”

oe DSS-5231 Revised 01/17 initials Cy} 27
Child Welfare Services

Initials

“Wh teas, pile

12% Yes.) No

NORTH CAROLINA
SAFETY ASSESSMENT

Page 4 of 8
Caretaker persistently deser bes the child in predominantly negative terms or acts toward the child in negative
ways, AND these actions make the child a danger to self or others, suicidal, act out aggressively, or severely
withdrawn.

Caretaker repeatedly d¢ scribes the child in a demeaning or degrading manger (i.e. as evil, possessed,
stupid, ugly, etc.)

Caretaker repeatedly cy rses and/or puts child down.

Caretaker repeatedly scapegoats a particular child in the family.

Caretaker blames child for a particular incident, or distorts child’s behavior as a reason to abuse.
Caretaker repeatedly e3 pects unrealistic behavior(s) for the child’s age/developmental stage.
Caretaker views child és responsible for the caretaker’s or family’s problems.

OoH000 a

Comments:

Caretaker’s physical ability, emotional stability, developmental status, or cognitive deficiency seriously
impairs his/her current abilijy to supervise, protect, or care for the child.

Caretaker has a physicé| condition that seriously impairs his/her ability to parent the child.
Emotional instability, | out, or distorted perception is seriously impeding ability to parent.

Depression or feelings >f hopelessness/helplessness immobilize the caretaker, who then fails to maintain
child/home. |

Caretaker is overwhelnjed by child’s dysfunctional emotional, physical, or mental characteristics.
Caretaker’s cognitive d clays result in lack of knowledge about basic parenting skills.

OO oo0

Comments:

13, Yes No Family currently refuses acc ess to or hides the child and/or seeks to hinder an assessment.
1 Family currently refuse § access to the child and cannot or will not provide the child’s location.
1 Family removed the ch Id from a hospital against medical advice.
O Family has previously ‘led in response to a CPS assessment.
OD Family has a history of keeping the child away from peers, school, or other outsiders for extended
periods to avoid CPS assessment.
0 Family is otherwise atti mpting to block or avoid CPS assessment.
Comments:
DSS-5231 Revised 01/17 Initials 5 ES
Child Welfare Services eS

Initials

oO000000

NORTH CAROLINA
SAFETY ASSESSMENT

Page 5 of 8

14. Yes /No) Current circumstances, combined with information that the caretaker has or may have previously maltreated

a child in his/her care, sugg(ist that the child’s safety may be of immediate concern based on the severity of
the previous maltreatment or the caretaker’s response to the previous incident.

Prior death of a child.

Prior serious harm to aty child.

Termination of parental rights.

Prior removal of any ckild.

Prior CPS substantiatian or services needed finding.

Prior threat of serious arm to child.

Caretaker failed to beni(fit from previous professional help.

Comments:___

oOo
Oo

Oo

15. Yes No ) Child is fearful of caretaker other family members, or people living in or having access to the home.

Child cries, cowers, cri ages, trembles, or exhibits or verbalizes fear in relation to certain individuals.
Child exhibits anxiety, nightmares, or insomnia related to a situation associated with a person in the
home.

Child fears unreasonab e retribution/retaliation from caretaker, others in the home, or others having
access to the child.

Comments:

16... Yes No. Other (specify):

Initials

Initials

THE ALLEGATIONS ALO!E DO NOT CONSTITUTE THE NEED FOR A SAFETY

INTER /ENTION/SAFETY AGREEMENT.

If any Indicators of Immediate Safety are marked “Yes”, skip the bottom of this page and continue on the next page.

If all Indicato +s of Immediate Safety 1 through 16 are “No”,

| check this box [) Safe and complet the part below (the remaining pages do not need to be completed).

Child’s Parent or Legal Guardian: Late Signed: | Child’s Parent or Legal Guardian: Date Signed:
Child’s Parent or Legal Guardian: Late Signed: | CPS Social Worker: Date Signed:
Other Party: Late Signed: | CPS Supervisor: Date Signed:

CPS Social Worker’s Name: Phone Number:

Email Address:

CPS Supervisor’s Name:

| Phone Number: Email Address:

DSS-5231 Revised 01/17
Child Welfare Services

aa DSS-5231 Revised 01/17 Initials.

NORTH CAROLINA
SAFETY ASSESSMENT

Page 6 of 8
PAR/[ C: SAFETY INTERVENTIONS
Directions: For each factor identified in Sectior B, consider the resources available in the family and the community that might
help to keep the child(ren) safe. Check each response necessary to protect the child(ren) and explain below.

Family Sati interventions (Safe with a plin)
1. Monitoring and/or use of dire¢t services by county child welfare agency.

©) 2. Use family, neighbors, or oth¢r individuals in the community in the development and implementation of a

/ safety agreement.
3. Use community agencies or s¢rvices.

O 4. The alleged perpetrator will leive or has left the home--either voluntarily or in response to legal action.
O 5. A protective caretaker will mave or has moved to a safe environment with the child(ren) and there are no
restrictions on protective caretiker’s access to the child(ren)
© 6. Identification of a Temporary |safety Provider by the parent with the social worker monitoring
O A Temporary Safety Provider will move into the family home.
© The child(ren) will reside in the home of a Temporary Safety Provider.
Explain why responses 1-5 wete insufficient.

Child Welfare Safety Intervention (Unsafe) _
© 1. Removal of any child in the hesehold; interventions 1-6 do not adequately ensure the child(ren)’s safety.
Explain why a Family Safety Intervention (1-6) could not be used to protect the child.

PART D: SAFETY DECISION

Directions: Identify the safety decision by chec ting the appropriate line below. Check one line only. This decision should be
based on the assessment of all safety indicators, child vulnerability, and any other information known about this case.

A. — Safe: There are no children | kely to be in immediate danger of serious harm. (Indicators of Immediate Safety
all marked No, Marked Safe on Page 5).

B. Safe with a plan: al One or tnore safety indicators are present; Safety Agreement required.
Fan ily Safety Interventions 1, 2, and/or 3 will address safety indicators
1 The alleged perpetrator left the home.
0 A protective caretaker moved to a safe environment with the child(ren).
1 Us¢ of a Temporary Safety Provider.

C. Unsafe: 1 Oni or more children were removed in response to legal action.

Are all safety indicators in Part B marked No (no
indicators apply to the household)?

Safe with a Plan, Complete

Do Family Safety Interventions #1, 2, 3,4 and/or 5 addi 2ss Safety Agreement (page 7).

the safety indicators identified in Part B?

Safe with a Plan. Complete
Safety Agreement (page 7). Also
complete an Initial Safety
Provider Assessment,

Will a Temporary Safety Provider, # 6 address
the safety indicators identified in Part B?

Do any children require removal from the caretakers
(Child Welfare Safety Intervention #1)?

Child Welfare Services
Initials

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TEMPORARY PARENTAL SAFETY AGREEMENT
Page 8 of 8

STANDING AND AGREEMENT

PARENT OR CARETAKER INITIALS

1. I (the parent or caretaker) agree {hat I participated in the development of and reviewed
this safety agreement. I agree t¢ work with the providers and services as described above.

2. My participation in this agreemént is not an admission of child abuse or neglect on my
part and cannot be used as an admission of child abuse or neglect.

3. Tunderstand that I have the righ’ to revoke and/or have the Temporary Parental Safety
Agreement reviewed at any time. (See bottom of page.) I also understand that ifa
Safety Agreement cannot be agred upon or if the actions in the Safety Agreement are not
followed, the county child welfate agency may have the authority to request that the court
make a determination on how th? child(ren)’s safety will be assured.

4. I (the parent or caretaker) confirjn that this agreement does not conflict with any existing
court order, or if I am affected by a court order, all parties affected by the court order
agree to this safety agreement or, a temporary basis.

) 5. I (the parent or caretaker) understand that CPS may refer for further services, may restrict Sd
access to my child(ren), or may jisk the court to order that I complete services or place the
child in foster care.

6. Ifa Temporary Safety Provider js utilized, I understand that CPS will share any )
information with the Temporary Safety Provider for the safety and welfare of my child
while the child lives in that hom) or the Temporary Safety Provider resides in the family
home.

7. This safety agreement will cea‘ to be in effect when I am notified by my social
worker or CPS is no longer prividing services to my family during the assessment J
phase. If needed, this agreement will be reviewed by this date: appeotr Onn ee

TEMPORARY SAFETY PROVIDER

1. If the parent is unable to provide a safe environment for the child and the court names the
county child welfare agency as t Je child’s legal custodian, I will be given consideration as

" a placement for the child if I agrije and continued placement is determined to be safe.

2. If 1 (the person providing care as Temporary Safety Provider) am unable to carry out this
plan successfully, or if the child In my care is considered to be in an unsafe situation, the
child will be moved to a different placement and further CPS involvement may be

i wae court interv ntion.

Child’s Parent or Legal Guardian: Date Signed: Child’s Parent or Legal Guardian: Date Signed:
\ {aw ao : fim
Child’s Parent or Legal Guardian: Date Signed: | CPS Social Worker Ly Date Sigted: ty
’ ) }
. 4 Date Signed: 7[CPS Supervisor: # t Date Signed:
Temporaty Safety Pfowider: Date Signed: | Temporary Safety Provider: Date Signed:

Who Can I ¢
qu
GPS Social Worker's Name:

ct? ~— (Who can I con ment, or if | have

s about thi

t iffcircumstances change, if | have questions about CPS involy

s of this agreement?)
y (| Binail, Address;

| {EmaibAddress: 2 {éo

ent? Who do I contact to revoke any or all p:

_ Phon¢ Numb:

LA ]
CPS Supervisof's Name: be Phone, Number:

byl dWhi

REVOCATION: I revoke my consent ti) the Temporary Parental Safety Agreement.

Signed: Date:

DSS-5231 Revised 01/17
Child Welfare Services

NC DEPARTMENT OF ROY COOPER - Governor

=P H EA LT H A ND MANDY COHEN, MD, MPH Secretary
HUMAN SERVICES
Division of Health Service Regulation MARK PAYNE - Director

September 18, 2018

Mr. Lewis Pinnix, Director
Just In Time Youth Services
1710 Sykes Street
Burlington, NC 27244

Dear Mr. Pinnix:

Thank you for the report to the Health Care Personnel Registry Section regarding the following incident: |
allegedly abused a resident (D.L.) on or about August 17, 2018. .

The Department is responsible for screening allegations to determine if the reported allegation requires an investigation by the
State for listing on the Health Care Personnel Registry. In screening the reported allegations, the Department strives to ensure
the safety of residents and to assure that the rights of the accused are protected. After carefully reviewing the reported
allegation, the Department has determined that an investigation will not be conducted in this case.

I would appreciate you contacting me if you disagree with our assessment of the case or have reason to believe a full
investigation should be initiated. If you have any questions or we may be of assistance, please contact us. Please reference
the control NA number shown below with any future correspondence.

Sincerely,

oO Leten,
|

Joi B. Deberry

HCPI Investigator

Health Care Personnel Investigations

PO Box 13761

Durham, NC 27709

Phone: 919-714-2009 Fax: 919-405-3827

NA-09-0181-18

NC DEPARTMENT OF HEALTH AND HUMAN SERVICES*DIVISION OF HEALTH SERVICE REGULATION
COMPLAINT INTAKE AND HEALTH CARE PERSONNEL INVESTIGATIONS

LOCATION: 1205 Umstead Drive, Lineberger Building, Raleigh, NC 27603
MAILING ADDRESS: 2719 Mail Service Center, Raleigh, NC 27699-2719
www.ncdhhs.gov/dhsr/ * TEL: 919-855-3968 » FAX: 919-733-3207

AN EQUAL OPPORTUNITY / AFFIRMATIVE ACTION EMPLOYER

inspection_type: MHLCS Complaint

document_type: Plan of Correction


facility_name: New Possibilities Home For Children  LLC

summary: Plan of Correction - MHLCS Annual

raw_content:
PRINTED: 09/29/2025
FORM APPROVED

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

MHL001-155 B. WING _______________ 09/25/2025

NAME OF PROVIDER OR SUPPLIER. STREET ADDRESS, CITY, STATE, ZIP CODE
813 TRAIL ONE
BURLINGTON, NC 27215

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE

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

NEW POSSIBILITIES HOME FOR CHILDREN, L

INITIAL COMMENTS

An annual survey was completed on
September 25, 2025. Deficiencies were cited.

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

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

27G .0209 (C) Medication Requirements

410A NCAC 27G .0209 MEDICATION
REQUIREMENTS

(c) Medication administration:

(1) Prescription or non-prescription drugs shall
only be administered to a client on the written
order of a person authorized by law to prescribe
drugs.

(2) Medications shall be self-administered by
clients only when authorized in writing by the
client's physician.

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

recorded immediately after administration. The RECEIVED
MAR is to include the following:

{A) client's name; "? DEC 1 6 2025
(B) name, strength, and quantity of the drug;
(C) instructions for administering the drug; DHSR-MH Licensure Sect
(D) date and time the drug is administered; and
(E) name or initials of person administering the

Division of Health Service Regulation
LABORATORY DIRECTOR'S OR yO REPRESENTATIVE'S SIGNATURE TITLE

© lithe Qurter I alas—

STATE FORM 6809 £63811 If continuation sheet 1 of 16

PRINTED: 09/29/2025
FORM APPROVED

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

MHL001-155 8. WING _______________ 09/25/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
813 TRAIL ONE
BURLINGTON, NC 27215

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

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

NEW POSSIBILITIES HOME FOR CHILDREN, L

Continued From page 1

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 interviews and record reviews the
facility failed to keep the MAR current affecting
two of three audited clients (#2 and #3). The
findings are:

Review on 9/25/25 of Client #2's record revealed:
-Admission date of 2/13/24.

-She was 18 years old.

-Diagnoses of Post Traumatic Stress Disorder;
Attention Deficit Hyperactivity Disorder;
Oppositional Defiant Disorder; Generalized
Anxiety Disorder, Disinhibited Social Engagement
Disorder, and Reactive Attachment Disorder.
-Physician order dated 4/8/25 for Buspirone 5
milligrams (mg)(anti-anxiety)- Take one tablet
daily.

Observation on 9/25/25 at 11:20 am of Client #2's
medications revealed:
~Buspirone 5 mg was available.

Review on 9/17/25 of Client #2's MARs for the
month of September 2025 revealed:
-Staff did not sign off on the MAR indicating
medication had been administered for the
following:

-Buspirone 5 mg- on 9/7 and 9/14.
Division of Health Service Regulation
STATE FORM Lord £63811 ifcontinuation sheet 2 of 16

PRINTED: 09/29/2025
FORM APPROVED

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

MHLO01-155 8. WING

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

813 TRASL ONE

BURLINGTON, NC 27215

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

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

NEW POSSIBILITIES HOME FOR CHILOREN, L

Continued From page 2

Review on 9/25/25 of Client #3's record revealed:
-Admission date of 6/25/25.
-She was 17 years old.
-Diagnoses of Major Depressive Disorder,
Recurrent Episode with Psychotic Features;
Attention Deficit/ Hyperactivity Disorder,
Predominantly inattentive; Unspecified Trauma
and Stressors-Related Disorder.
-Physician order dated 6/24/24:

-Oxcarbazepine 300 mg (antiepileptic)- Take
one tablet twice a day.

-Metformin 750 mg (weight management)-
Take one tablet daily.

Observation on 9/25/25 at 11:20 am of Client #3's
medications revealed:
-Medications mentioned were available.

Review on 9/25/25 of Client #3's MARs for the
month of September 2025 revealed:

-Staff did not sign off on the MAR indicating
medication had been administered for the
following:

-Oxcarbazepine 300 mg- 9/4 @ 8pm, 9/6 @
8pm, 9/7 @ 8pm, 9/14 @ 8pm, 9/15 @ 8pm, 9/22
@ 8pm.

-Metformin 750 mg- 9/6, 9/7, 9/15, 9/21,
9/22, 9/24.

Interview on 9/25/25 with Client #3 revealed:

-She had never had an issue in receiving her
medications.

~She had never skipped her medications.

-Staff would always hand her the medications that
she needed to take.

Interview on 9/25/25 with the Program
Coordinator revealed:

-She was not aware that some of the client's
Division of Health Service Regulation

STATE FORM e898 £63811 Hf continuation sheet 3 of 16

PRINTED: 09/29/2025
FORM APPROVED

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

MHL001-155 B. WING __________ 09/25/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
813 TRAIL ONE
BURLINGTON, NC 27215

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

NEW POSSIBILITIES HOME FOR CHILDREN, L

V 118] Continued From page 3

medications had not been logged properly on
their MARs.

-She did not know why staff did not mark some oo
medications as given. 27G .0209 Medication Require-

“Glen's medications came in "bubble packs.” ments non documenting administered} 10/9/25
-She knew that the medications were given icati

because they were inside the bubble pack. medication an d or misceg medication

-She would be reviewing with staff that as been reviewed with stair an

administered medication to make sure they Medication training was conducted
marked the MARs appropriately. in October 2025. All staff were remined
-She acknowledged that staff failed to maintain of disciplinary actions for future errors

Client #2 and Client #3's MARS current. Ex. Director, QP and Program Coordinator

Due to the failure to accurately document will monitor MAR’s daily.
medication administration for clients #1 and #2, it
could not be determined if they received
medication as ordered by their physicians.

98, 27G .1706 Residential Tx. Child/Adol -
Operations

410A NCAC 27G .1706 OPERATIONS

(a) Each facility shall serve no more than a total
of 12 children and adolescents.

(b) Family members or other legally responsible
persons shall be involved in development of plans
in order to assure a smooth transition to a less
restrictive setting.

(c) The residential treatment staff secure facility
shall coordinate with the local education agency
to ensure that the child's educational needs are
met as identified In the child's education plan and
the treatment plan. Most of the children will be
able to attend school; for others, the facility will
coordinate services across settings such as
alternative learning programs, day treatment, or a
job placement.

(d) Psychiatric consultation shail be available as
needed for each child or adolescent.

Division of Health Service Regulation
STATE FORM 6299 £63811 Hfcontinuation sheet 4 of 16

PRINTED: 09/29/2025
FORM APPROVED

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

MHL001-155 8. WING _________ 09/25/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

813 TRAIL ONE
BURLINGTON, NC 27215

NAME OF PROVIDER OR SUPPLIER

NEW POSSIBILITIES HOME FOR CHILDREN, L

Division of Health Service Regulation
STATE FORM

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

Continued From page 4

(e) #f an adolescent has his 18th birthday while
receiving treatment in the facility, he may remain
for six months or until the end of the state fiscal
year, whichever is longer.

(f) Each child or adolescent shall be entitled to
age-appropriate personal belongings unless such
entitlement is counter-indicated in the treatment
plan.

(g) Each facility shall operate 24 hours per day,
seven days per week, and each day of the year.

This Rule is not met as evidenced by:

Based on record review and interviews, the
facility allowed a client to remain in the facility in
excess of the maximum allowed time of six
months following clients 18 th birthday or until end
of the state fiscal year affecting one of three
audited current client (#2). The findings are:

Review on 9/25/25 of Client #2's record revealed:
-Admission date of 2/13/24.

-Date of Birth: 1/9/07. She was 18 years and 8
months old.

-Client #2 was her own guardian.

Interview on 9/25/25 with the Program
Coordinator revealed:

-She thought Client #2 was able to remain at the
facility until she was 21 due to her diagnoses.
-Facility had tried to find placement for Client #2,
but it did not fall through due to her Supplemental
Security Income (SSI).

-Client #2's SSI would not have covered the
services at the other facility.

£63611

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

27G .1706 Residential Tx Child/ Adol
Operations

10ANCAC 27G. 1706 Operations 12/2/25
Ex. Director and Program Coordinator
have obtained necessary LOS / Waiver
from 18 year old MCO (Alliance) and orper

documents to submit Waiver request from
DHSR on 12/3/2025.
Ex. Director and Program Coordinator will
follow through on waiver request and
continue to seek alternative placement
for consumer. Consumer is also awaiting

ISS benefit decision for other resources

Ex. Director will adhere to Age Waiver
rule and continue to monitor the waive}
request status.

If continuation sheet 5 of 16

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIERICLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

MHL001-155

NAME OF PROVIDER OR SUPPLIER:

NEW POSSIBILITIES HOME FOR CHILDREN, L

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

Continued From page 5

Interview on 9/25/25 with the Program Director
revealed:

-She was not aware that she needed to have an
age waiver in order for Client #2 to be able to
remain at the facility.

-Client #2 was not under the Department of
Social Services custody.

-Client #2 became her own guardian when she
turned 18 years old.

-They had been trying to get Client #2 into a
group home, but because her SS! had not been
approved yet, she was not able to go.

-They had been looking into placing Client #2 ina
level 2 group home.

Client #2's SSI would not had covered room and
board.

-They were also trying to have family counseling
with Client #2's adoptive mother.

-If things would work out, they would be able to
place Client #2 with her family.

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

4OANCAC 27E .0107 TRAINING ON
ALTERNATIVES TO RESTRICTIVE
INTERVENTIONS

(a) Facitities 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, shail
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.

Division of Health Service Regulation
STATE FORM

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 09/29/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

09/25/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

813 TRAIL ONE
BURLINGTON, NC 27215

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

£63811 If continuation sheet 6 of 16

PRINTED: 09/29/2025
FORM APPROVED

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

MHL001-155 8B. WING 09/25/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
813 TRAIL ONE
BURLINGTON, NC 27215

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

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

NEW POSSIBILITIES HOME FOR CHILDREN, L

Continued From page 6

(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
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

Division of Health Service Regulation
STATE FORM 6399 £63811 If continuation sheet 7 of 16

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER
NEW POSSIBILITIES HOME FOR CHILDREN, L

(x4) 1D
PREFIX
TAG

Division of Health Service Regulation

IDENTIFICATION NUMBER:

MHL001-155

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

Continued From page 7

(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 shail 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 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

STATE FORM

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 09/29/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

09/25/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

813 TRAIL ONE
BURLINGTON, NC 27215

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

63811 ff continuation sheet 8 of 16

PRINTED: 09/29/2025
FORMAPPROVED

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

MHL001-155 B. WING _________ 09/25/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

813 TRAIL ONE
NEW POSSIBILITIES HOME FOR CHILDREN, L BURLINGTON, NC 27215

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

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

Continued From page 8

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
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.

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

Division of Health Service Regulation
STATE FORM baal £63811 If continuation sheat 9 of 16

PRINTED: 09/29/2025
FORM APPROVED

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

MHL001-155 B. WING __________—___ 09/25/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
813 TRAIL ONE
BURLINGTON, NC 27215

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

NEW POSSIBILITIES HOME FOR CHILDREN, L

Continued From page 9

This Rule is not met as evidenced by: 27E .0107 Clients Rights -Training
Based on record reviews and interview, the on Alt.to Rest. Int
facility failed to ensure two of three staff (Staff #4
and the Licensed Professional) received annual
training updates in alternatives to restrictive
interventions. The findings are: 1OANCAC 27E. 0107 TRAINING ON
ALTERNATIVES TO RESTRICTIVE
Review on 9/25/25 of Staff #4's personnel record INTERVENTIONS

revealed:

-Hire date of 1/7/16.
-She was hired as a Paraprofessional. All staff are to have EBPI/ Alternative:
~Evidence Based Protective Interventions (EBPI) restrictive intervention training annually.

Interventions - Base Plus training in alternatives Training has been facilitated on necessary

torecunctive interventions had expired on staff in September 2025. To ensure

-No current training in alternatives to restrictive Clients Rights and safety are upheld.
interventions.

Review on 9/25/25 of the Licensed Professional's x. Director and QP will review staff
personnel record revealed: charts to ensure trainings are held

-Hire date of 1/3/15. annually and timely to be in compliance.
-She was hired as a Licensed Professional.
-EBPI interventions - Base Plus training in
alternatives to restrictive interventions had
expired on 8/29/25.

-No current training in alternatives to restrictive
interventions.

Interview on 9/25/25 with Staff #4 revealed:
-She acknowledged missing the latest EBPI
training due to health issues.

-Acknowledged not having a current training on
Alternatives to Restrictive Interventions.

Interview on 9/25/25 with the Program Director
revealed:
-Staff #4 missed last week's training.

Division of Health Service Regulation
STATE FORM 6299 £63811 If continuation sheet 10 of 16

PRINTED: 09/29/2025
FORM APPROVED
Division of Health Service Regulation
‘STATEMENT OF DEFICIENCIES (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED

MHLO01-155 B. WING —__________—— 09/25/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
813 TRAIL ONE
BURLINGTON, NC 27215

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

NEW POSSIBILITIES HOME FOR CHILDREN, L

Continued From page 10

-Son recently passed away a few months ago and
she has had had some health issues.

-Couldn't make it to the last training.

-She was not aware that the Licensed
Professiona!'s EBPI training had expired.

-She acknowledged that staff #4 and the
Licensed professional's training on alternatives to
restrictive interventions.

27E .0108 Client Rights - Training in Sec Rest &
ITO

10ANCAC 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. Facilitles 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

Division of Health Service Regulation
STATE FORM e209 £63811 If continuation sheet 11 of 16

PRINTED: 09/29/2025
FORM APPROVED

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

MHL001-155 8. WING ___. 09/25/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
813 TRAIL ONE
NEW POSSIBILITIES HOME FOR CHILDREN, L BURLINGTON, NC 27215

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

Continued From page 11

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 ail 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 shail include:

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

Division of Health Service Regulation
STATE FORM 6808 £63811 if continuation sheet 12 of 16

PRINTED: 09/29/2025
FORM APPROVED

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
IDENTIFICATION NUMBER: A. BUILDING: COMPLETED

MHLO001-155 ———— 09/25/2025

STREET ADDRESS, CITY, STATE, ZiP CODE

813 TRAIL ONE
BURLINGTON, NC 27215

NAME OF PROVIDER OR SUPPLIER

NEW POSSIBILITIES HOME FOR CHILDREN, L

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

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

DEFICIENCY)

Continued From page 12

(B) when and where they attended; and

(C) instructor's name.

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

(i) Instructor Qualification and Training
Requirements:

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

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

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

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

(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, physica! restraint and isolation
time-out, as specified in Paragraph (a) of this

Division of Health Service Regulation

STATE FORM 6099 £63811 if continuation shest 13 of 16

PRINTED: 09/29/2025
FORM APPROVED

ervice Regulation

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

MHL001-155 B. WING ________________ 09/25/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
813 TRAIL ONE
NEW POSSIBILITIES HOME FOR CHILDREN, L BURLINGTON, NC 27215

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

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

Continued From page 13

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 shail 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.
(l) 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 shail be the same
preparation as for trainers.

This Rule is not met as evidenced by:
Based on record reviews and interview, the
Division of Health Service Regulation
STATE FORM cd £63614 'foontinuation sheet 14 of 16

PRINTED: 09/29/2025
FORM APPROVED

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

MHL001-155 B. WING 09/25/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
813 TRAIL ONE
BURLINGTON, NC 27215

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

NEW POSSIBILITIES HOME FOR CHILDREN, L

Continued From page 14

facility failed to ensure two of three staff (Staff #4
and the Licensed Professional) received annual
training updates in seclusion, physical restraint
and isolation time-out. The findings are:

Review on 9/25/25 of Staff #4's personnel record
revealed:

-Hire date of 1/7/16.

-She was hired as a Paraprofessional.
-Evidence Based Protective interventions (EBPI)
Interventions - Base Plus training in seclusion,
physical restraint and isolation expired effective
8/29/25.

-No current training in seclusion, physical
restraint and isolation time-out.

Review on 9/25/25 of the Licensed Professional's
personnel record revealed:

-Hire date of 1/3/15.

-She was hired as a Licensed Professional.
-EBPt Interventions - Base Plus training in
seclusion, physical restraint and isolation expired
effective 8/29/25.

-No current training in seclusion, physical
restraint and isolation time-out.

Interview on 9/25/25 with Staff #4 revealed:
~She acknowledged missing the latest EBPI
training due to health issues.
-Acknowledged not having a current training
update on seclusion, physical restraint and
isolation time-out.

Interview on 9/25/25 with the Program Director
revealed:
-Staff #4 missed tast week's training.
-Son recently passed away a few months ago and
she has had had some health issues.
-Couldn't make it to the last training.
-She was not aware that the Licensed
Division of Health Service Regulation
STATE FORM e099 £63811 if continuation shest 15 of 16

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

MHL001-155

NAME OF PROVIDER OR SUPPLIER
NEW POSSIBILITIES HOME FOR CHILDREN, L

(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL.
TAG REGULATORY OR LSC IDENTIFYING INFORMATION)

Continued From page 15

Professional's EBPI training had expired.
-Facllity had not done a restraint in along time.
-Facility was able to perform restraints if needed
as it was part of their policy.

-She acknowledged that staff #4 and the
Licensed professional's training on seclusion,
restraint and isolation time out had expired last
month,

Division of Health Service Regulation
STATE FORM

(X2) MULTIPLE CONSTRUCTION

63811

PRINTED: 09/29/2025
FORM APPROVED

STREET ADDRESS, CITY, STATE, ZIP CODE

813 TRAIL ONE
BURLINGTON, NC 27215

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

27E .0108 Clients Rights -Traininj
In Sec. Rest. & ITO

1OANCAC 27E. 0108 TRAINING IN
SECLUSION, PHYSICAL RESTRAINT AN
ISOLATIONTIME OUT

All staff are to have EBP! PLUS/ |

Alternatives to restrictive interventio|
training annually. Training In EBP! Plus
uses dressed down physical techniques
to reduce challenges and aggressive
behaviors. Best practice to ensure
Clients Rights and safety are by using
verbalized alternatives of interventions.

Ex. Director and OP will review staff
charts to ensure trainings are held
annually and timely to be in compliance.

(X3) DATE SURVEY
COMPLETED

If continuation sheet 16 of 16

inspection_type: MHLCS Annual