facility_name: Union Point

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

raw_content:
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

NAME OF PROVIDER O!

UNION POINT

(X4) ID
PREFIX
TAG

(X2) MULTIPLE CONSTRUCTION

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

INITIAL COMMENTS

Acomplaint and follow up survey was completed
on 2/13/26. The complaints were unsubstantiated
(Intake #NC00235745, #NC00235813).
Deficiencies were cited.

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

This facility is licensed for 6 and has a current
census of 4. 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
MAR is to include the following:

(A) client's name;

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

(C) instructions for administering the drug;

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

PRINTED: 02/20/2026
FORM APPROVED

(X3) DATE SURVEY

COMPLETED

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

RECEIVED
MAR 04 2626
DHSR-MH Licensure Sect

V118

Turing Point was not notified that the medication was
ready for pick up due to the pharmacy contacting the
legal guardian. The legal guardian did not want to

pay for the medicaitons resulting in a laspe in pick up.

When TPH was notified of this we paid out of pocket
and picked up the medication once we were notified
it was ready.

TPH also went through staff changes from October-
present.

TPH did fail to document missed medication on the
MAR when mother declined to pay and pick up
medications.

The Medical provider has another training
scheduled on March 3rd and March 6th to train new
staff on MAR documentation and requirements to
document missed meds even if there is a delay in
pharmacy pick up or due to waiting fegal guaridan
consent.

)
COMPLETE
DATE

(X6) DATE

If continuation sheet 1 of 14

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIER/CLIA

AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

 &
NAME OF PROVIDER OR SURE

UNION POINT

MHL013-226

PRINTED: 02/20/2026
FORM APPROVED

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

WING

R-C
02/13/2026

STREET ADDRESS, CITY, STATE, ZIP CODE
519 UNION STREET SOUTH

CONCORD, NC 28025

(X4) ID
PREFIX
TAG

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

Continued From page 1

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

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

This Rule is not met as evidenced by:

Based on record review and interviews, the
facility failed to ensure all medications were
administered on the written order of a physician
and failed to keep the MARs current affecting 1
of 3 audited clients (Client #1). The findings are:

Review on 2/10/26 of Client #1’s record revealed:
- Admission date 1/5/26;

- Age 13 years old;

- Diagnoses: Disruptive Mood Dysregulation
Disorder, Attention Deficit Hyperactivity Disorder;
- Physician's order dated 1/29/26 Vitamin D-1000
units, Take one capsule by mouth daily.

Review on 2/9/26 of Client #1's MARs from
January 5, 2026 - February 9, 2026 revealed:

- Vitamin D was not listed on the January MAR;
- Aline was drawn through dates 2/1/26 and
2/2/26 of the February MAR.

Interview on 2/6/26 with Client #1 revealed:
- Received medications daily.

Interview on 2/9/26 and 2/13/26 with the Program
Manager revealed:

Division of Health Service Regulation
STATE FORM

e899

ID
PREFIX
TAG

PROVIDER'S PLAN OF CORRECTION (5)
(EACH CORRECTIVE ACTION SHOULD BE COMPLETE
CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

NOSY11 If continuation sheet 2 of 14

PRINTED: 02/20/2026

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
MHL013-226 B. WING —__________. 02/13/2026

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

519 UNION STREET SOUTH
UNION POINT
CONCORD, NC 28025
(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

Continued From page 2

- Was responsible for the medications and the
MAR;

- "I don't put the medication on the MAR until we
receive the medication;"

~ The dash on the MAR indicated Client #1 was
not administered the Vitamin D on 2/1/26-2/2/26;
- The pharmacy contacted Client #1's mom (legal
guardian), rather than the facility, due to her
having legal custody of client #1, to request
purchase of the Vitamin D after it was determined
it was not covered under the client's medical
insurance;

- Client #1's mom wanted to pay for the Vitamin D
through [online retailer] because she didn't want
to give her

card information to the pharmacy over the phone;
- Client #1's mom told the Program Manager she
would order the Vitamin D through [online retailer)
but by 2/2/26 she had not purchased the Vitamin
D, so the facility picked up the Vitamin D from the
pharmacy on 2/2/26;

- Had documentation of the communication with
the legal guardian about paying for the
medication;

- Never received the documentation of the
communication by the survey exit on 2/12/26.

Interview on 2/13/26 with the Quality
Management Director revealed:

- "Went to 'billing’ and asked what are we doing
for the client (Client #1) without her medication
(Vitamin D) and we paid for it;"

- Had a tentative date (2/20/26) for the medical
provider to come to the facility to review the all of
the client medications and Medication
Administration Records (MARs).

27G .0209 (E) Medication Requirements

Division of Health Service Regulation
STATE FORM 6889 NDS5Y11 If continuation sheet 3 of 14

PRINTED: 02/20/2026
FORM APPROVED

Division of Health Service Regulation

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

MHL013-226
NAME OF PROVIDER OR SUPPLIER

UNION POINT

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION )

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

DEFICIENCY)

Continued From page 3 v20

QM director met with Medical provider on
10A NCAC 27G .0209 MEDICATION how to organize medications at the house.

REQUIREMENTS | TPH ordered more medicine bags to

(e) Medication Storage: seperate exteral medications from internal
(1) All medication shall be stored: medications.

(A) in a securely locked cabinet in a clean,
well-lighted, ventilated room between 59 degrees
and 86 degrees Fahrenheit;

(B) in a refrigerator, if required, between 36 QM director and Medical provider created
degrees and 46 degrees Fahrenheit. If the a Med Apointment checklist, that lists out |
refrigerator is used for food items, medications | all expectations staff need to follow and obtain

i at medical appointments. Part of this
shale kept ina separate, locked compartment checklist lists out the 7 standards of a Med

og, Order and an example of what a valid
(C) separately for each client; med order looks like was provided.
(D) separately for external and internal use;
(E) in a secure manner if approved by a physician
for a client to self-medicate.
(2) Each facility that maintains stocks of
controlled substances shall be currently
registered under the North Carolina Controlled
Substances Act, G.S. 90, Article 5, including any
subsequent amendments.

Medication bags will be labled external or
internal use when applicable.

This Rule is not met as evidenced by:

Based on observation, record review and
interviews, the facility failed to ensure that
external medication were stored separately from
internal medications affecting 1 of 3 audited
clients (Client #1). The findings are:

Review on 2/10/26 of Client #1's record revealed:
- Admission date 1/5/26;

- Age 13 years old;

- Diagnoses: Disruptive Mood Dysregulation
Disorder (DMDD), Attention Deficit Hyperactivity
Disorder (ADHD);

- Physician's order dated 1/22/26 for

Division of Health Service Regulation

STATE FORM cess ND5Y11 If continuation sheet 4 of 14

NAME OF PROVIDER OR SUPPLIER

UNION POINT

(X4) ID
PREFIX
TAG

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES 1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION

IDENTIFICATION NUMBER:

MHL013-226

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

B. WING

PRINTED: 02/20/2026
FORM APPROVED

R-C

(X3) DATE SURVEY
COMPLETED

02/13/2026

STREET ADDRESS, CITY, STATE, ZIP CODE
519 UNION STREET SOUTH

CONCORD, NC 28025

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

Continued From page 4

Hydrocortisone Cream 2.5% (irritation), Apply
topically twice daily for fourteen days then repeat
as needed;

- Physician's order dated 1/29/26 for Melatonin
3mg (milligram) (sleep), Take one tablet by mouth
every evening; Lurasidone HCL (hydrochloride)
20mg (Depression) mouth every evening;
Trazodone 150mg (antidepressant) by mouth
every evening; Vitamin D-1000 units, Take one
capsule by mouth daily; Clonidine 0.2mg tablet
(ADHD), Take 4 tablet by mouth at bedtime;
Clonidine HCL ER (Extended Release) 0.1mg,
Take one tablet by mouth every morning;
Oxcarbazepine 600mg (bipolar), Take one tablet
by mouth twice daily.

Observation on 2/9/26 at approximately 3:44pm
of Client #1's medications revealed:

- Hydrocortisone Cream was stored with
Melatonin, Lurasidone HCL, Trazodone, Viatmin
D, Clonidine and Oxcarbazepine in a ziplock bag.

Interview on 2/9/26 with the Program Manager
tevealed:

- "I have another ziplock bag, | can put the cream
in;"

- Would make sure the external medication was
separated from the internal medication.

Interview on 2/13/26 with the Quality
Management Director revealed:

- Had a tentative date (2/20/26) for the medical
provider to come to the facility to review the all of
the client medications, storage and Medication
Administration Records (MARs).

27G .0603 Incident Response Requirements
10A NCAC 27G .0603_ = INCIDENT

Division of Health Service Regulation
STATE FORM

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

(x5)
COMPLETE
DATE

NDSY11 If continuation sheet 5 of 14

NAME OF PROVIDER OR SUPPLIER

UNION POINT

(X4) ID
PREFIX
TAG

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X41) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

MHL013-226

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

B.

WING

PRINTED: 02/20/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R-C
02/13/2026

STREET ADDRESS, CITY, STATE, ZIP CODE
519 UNION STREET SOUTH

CONCORD, NC 28025

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

Continued From page 5

RESPONSE REQUIREMENTS FOR
CATEGORY AAND B PROVIDERS
(a) Category A and B providers shall develop and
implement written policies governing their
response to level I, Il or Ill incidents. The policies
shall require the provider to respond by:
(1) attending to the health and safety needs
of individuals involved in the incident;
(2) determining the cause of the incident;
(3) developing and implementing corrective
measures according to provider specified
timeframes not to exceed 45 days;
(4) developing and implementing measures
to prevent similar incidents according to provider
specified timeframes not to exceed 45 days;
(5) assigning person(s) to be responsible
for implementation of the corrections and
preventive measures;
(6) adhering to confidentiality requirements
set forth in G.S. 75, Article 2A, 10A NCAC 26B,
42 CFR Parts 2 and 3 and 45 CFR Parts 160 and
164; and
(7) Maintaining documentation regarding
Subparagraphs (a)(1) through (a)(6) of this Rule.
(b) In addition to the requirements set forth in
Paragraph (a) of this Rule, ICF/MR providers
shall address incidents as required by the federal
regulations in 42 CFR Part 483 Subpart I.
(c) In addition to the requirements set forth in
Paragraph (a) of this Rule, Category A and B
providers, excluding ICF/MR providers, shall
develop and implement written policies governing
their response to a level Ill incident that occurs
while the provider is delivering a billable service
or while the client is on the provider's premises.
The policies shall require the provider to respond
by:

immediately securing the client record

Division of Health Service Regulation

STATE FORM

6808

ID
PREFIX
TAG

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

v 366

The QM director met with both new staff
on 2/24/2026 and trained each on the
following

-incident type and level

-special focus on Med Error incidents
-time frame submission

-review of how to submit a IRIS report
-protcol for Incident report tracking

(Note: The QM director intended to meet
with staff on 2/20/2026 however; there was
a schedling conflict and was resheduled

to 2.24.26)

The QM director will update the level |
incident reports to cover Risk Cause
Analysis. This document will be updated
by 2/26/2026, and provided to staff to start
utilizing on all incidents on 2/26/2026 and
on going.

NODSY11

If continuation sheet 6 of 14

PRINTED: 02/20/2026
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
MHL013-226 i 02/13/2026

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

519 UNION STREET SOUTH
INION POINT
UNIO CONCORD, NC 28025
(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE

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

Continued From page 6

(A) obtaining the client record;

(B) making a photocopy;

(C) certifying the copy's completeness; and
(D) transferring the copy to an internal
review team;

(2) convening a meeting of an internal
review team within 24 hours of the incident. The
internal review team shall consist of individuals
who were not involved in the incident and who
were not responsible for the client's direct care or
with direct professional oversight of the client's
services at the time of the incident. The internal
review team shall complete all of the activities as
follows:

(A) review the copy of the client record to
determine the facts and causes of the incident
and make recommendations for minimizing the
occurrence of future incidents;

(B) gather other information needed;

(C) issue written preliminary findings of fact
within five working days of the incident. The
preliminary findings of fact shall be sent to the
LME in whose catchment area the provider is
located and to the LME where the client resides,
if different; and

(D) issue a final written report signed by the
owner within three months of the incident. The
final report shall be sent to the LME in whose
catchment area the provider is located and to the
LME where the client resides, if different. The
final written report shall address the issues
identified by the internal review team, shall
include all public documents pertinent to the
incident, and shall make recommendations for
minimizing the occurrence of future incidents. If
all documents needed for the report are not
available within three months of the incident, the
LME may give the provider an extension of up to
three months to submit the final report; and

Division of Health Service Regulation
STATE FORM eas ND5Y11 {f continuation sheet 7 of 14

PRINTED: 02/20/2026
FORM APPROVED

Division of Health Service Requlation

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

R-C
MHLO013-226 8. WING ____.____ 02/13/2026

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
519 UNION STREET SOUTH
CONCORD, NC 28025

(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)

UNION POINT

V 366! Continued From page 7

(3) immediately notifying the following:

(A) the LME responsible for the catchment
area where the services are provided pursuant to
Rule .0604;

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

(C) the provider agency with responsibility
for maintaining and updating the client's
treatment plan, if different from the reporting
provider;

(D) the Department;

(E) the client's legal guardian, as
applicable; and

(F) any other authorities required by law.

This Rule is not met as evidenced by:
Based on record reviews and interviews, the
facility failed to implement written policies
governing their response to Level | and II
incidents. The findings are:

Review on 2/3/26 and 2/9/26 of the North
Carolina Incident Response Improvement System
(IRIS) from 1/1/26- 2/6/26 revealed:

~ No IRIS reports during the reviewed timeframe.

Review on 2/6/26 and 2/9/26 of the facility's
internal incident reports from 1/1/26-2/6/26
revealed:
- 1/4/26 Client #3's property destruction and law
enforcement involvement incident;
- 1/11/26 Former Client #5's aggressive behavior,
property destruction, law enforcement
involvement and transported to local

Division of Health Service Regulation

STATE FORM 6899, ND5Y11 If continuation sheet 8 of 14

PRINTED: 02/20/2026
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X41) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED

R-C
MHLO013-226 B. WING 02/13/2026

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
519 UNION STREET SOUTH
CONCORD, NC 28025

(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)

UNION POINT

V 366] Continued From page 8

hospital incident;
- 1/29/26 Client #2's emotional deregulation and
hospitalization incident;
- 2/2/26 Client #1's AWOL (absent without leave),
law enforcement involvement, transported to local
hospital incident;
- 1/9/26 Client #3's vape search and seizure
incident;
- 2/2/26 Client #1's sensual gummies search and
seizure incident;
- 2/2/26- No incident report for Client #1's welfare
check from law enforcement incident;
- No incident reports for Client #1 not receiving
her Vitamin D from 1/30/26-2/2/26.

Review on 2/6/26 and 2/9/26 of the facility's
internal incident reports from 1/1/26-2/6/26
revealed:
-There was no documented Risk Cause Analysis
for the cited incidents to demonstrate that the
facility:
-Developed and implemented measures to
prevent similar incidents within the
provider-specified timeframe, not to

exceed 45 days;
- Developed and implemented corrective
measures within the provider-specified
timeframe, not to exceed 45 days;

and;
-Assigned responsible individuals to ensure
implementation of corrective and preventive
measures.

Interview on 2/9/26 with the Program Manager
revealed:
- Was responsible for completing incident reports;
- Completed the IRIS reports and received a
confirmation number;
~ Would make sure she completed incident
reports for medication errors.

Division of Health Service Regulation

STATE FORM bss NDSY14 if continuation sheet 9 of 14

PRINTED: 02/20/2026

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

B. WING 02/13/2026

MHL013-226

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

519 UNION STREET SOUTH

UNION POINT CONCORD, NC 28025

(X4) ID
PREFIX
TAG

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

Continued From page 9

Interview on 2/11/26 with the Residential Director
revealed:

- Program Manager was in charge of IRIS
reports;

-"[Program Manager] was trained (incident
reporting) by [Quality Management Director] and
myself.”

Interview on 2/13/26 with the Quality
Management Director revealed:

- Planned a tentative meeting on 2/20/26 for
training on incident reports;

- Would update the level | incident reports to
cover Risk Cause Analysis;

- The Program Manager had attended trainings
on incident reporting, but would be retrained on
2/20/26.

27G .0604 Incident Reporting Requirements

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

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

Division of Health Service Regulation
STATE FORM

6899

NDSY11

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

v367

The QM director met with both new staff
and Program Director on 2/24/2026 and
trained each on the following:

-incident type and level

-special focus on Med Error incidents
-time frame submission

-review of how to submit a IRIS report
-protcol for Incident report tracking
-special focus on incident reporting as it
pertains to law enforcement.

The QM director reviewed internal protocol
as it pertains to Incient reporting and
completing the supervisor section to close
out all IRIS reports within 72 hours of
learning of a incident.

(Note: The QM director intended to meet
with staff on 2/20/2026 however; there was
a schedling conflict and was resheduled

to 2.24.26)

If continuation sheet 10 of 14

PRINTED: 02/20/2026
FORM APPROVED
Division of Health Service Requlation

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

R-C
MHL013-226 8. WING _________ 02/13/2026

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
519 UNION STREET SOUTH
CONCORD, NC 28025

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

DEFICIENCY)

UNION POINT

Continued From page 10

(1) reporting provider contact and
identification information;

(2) client identification information;

(3) type of incident;

(4) description of incident;

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

(6) other individuals or authorities notified
or responding.

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

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

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

(1) hospital records including confidential
information;

(2) reports by other authorities; and

(3) the provider's response to the incident.
(d) Category A and B providers shall send a copy
of all level Ill incident reports to the Division of
Mental Health, Developmental Disabilities and
Substance Abuse Services within 72 hours of
becoming aware of the incident. Category A
providers shall send a copy of all levet 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
immediately, as required by 10A NCAC 26C

Division of Health Service Regulation
STATE FORM Gass ND5Y11 If continuation sheet 11 of 14

PRINTED: 02/20/2026

FORM APPROVED

Division of Health Service Regulation

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

RC
MHL013-226 8. WING ae 02/13/2026

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

619 UNION STREET SOUTH
UNION POINT CONCORD, NC 28025

(X4) 1D SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (x8)

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)

Continued From page 11

0300 and 10A NCAC 27E .0104(e)(18).

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

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

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

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

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

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

This Rule is not met as evidenced by:
Based on record reviews and interviews, the
facility failed to report all level II incidents in the
Incident Response Improvement System (IRIS)
and failed to notify the Local Management Entity
(LME)/ Managed Care Organization (MCO)
responsible for the catchment area where
services are provided within 24 hours and 72
hours of becoming aware of the incident. The
findings are:

Division of Health Service Regulation

STATE FORM cess NDS5Y11 If continuation sheet 12 of 14

PRINTED: 02/20/2026
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X4) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED

R-C
MHLO013-226 B. WING —__________. 02/13/2026

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

519 UNION STREET SOUTH
UNION POINT CONCORD, NC 28025
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 12

Review on 2/3/26 and 2/9/26 of the North
Carolina Incident Response Improvement System
(IRIS) from 1/1/26- 2/6/26 revealed:

- No IRIS reports during the reviewed timeframe.

Review on 2/6/26 and 2/9/26 of the facility's
internal incident reports from 1/1/26-2/6/26
revealed:

- Unsubmitted IRIS reports:

- 1/4/26 Client #3's property destruction and law
enforcement involvement incident;

- 1/11/26 FC #5's aggressive behavior, property
destruction, law enforcement involvement and
transported to local hospital incident;

- 1/29/26 Client #2's emotional deregulation and
hospitalization incident;

- 2/2/26 Client #1's AWOL (absent without
leave), law enforcement involvement, transported
to local hospital incident;

- 2/2/26 No incident report for Client #1's welfare
check from law enforcement incident, when the
local school system requested the local police do
a welfare check on Client #1 due to her sending
her teacher a message and peer a message of
feeling depressed and needing help with
emotions.

Interview on 2/9/26 with the Program Manager
revealed:

- Was responsible for completing IRIS reports;

- Completed the IRIS reports and received a
confirmation number;

- Would make sure she received a thumbs up
when completing IRIS reports;

- Was not provided details from law enforcement
about the welfare check, "There is no reason why
| didn't do an incident report (2/2/26)."

Interview on 2/11/26 with the Residential Director
Division of Health Service Regulation
STATE FORM 6899 ND5Y11 If continuation sheet 13 of 14

PRINTED: 02/20/2026
FORM APPROVED

Division of Health Service Regulation

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

RC
MHL013-226 8. WING 02/13/2026

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
519 UNION STREET SOUTH
CONCORD, NC 28025

(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)

UNION POINT

Continued From page 13

revealed:

- Program Manage was in charge of IRIS reports;
- "[Program Manager] was trained (incident
reporting) by [Quality Management Director] and
myself.”

Interview on 2/13/26 with the Quality
Management Director revealed:

- Planned a tentative meeting on 2/20/26 for
training on incident reports.

Division of Health Service Regulation
STATE FORM e689 ND5Y11 If continuation sheet 14 of 14

inspection_type: MHLCS Complaint and Follow-up

document_type: Plan of Correction


state: NC

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

raw_content:
Division of Health Service Regulation

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

MHL013-226 B. WING

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

UNION POINT CONCORD, NC 28025

PRINTED: 02/20/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R-C
02/13/2026

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

DEFICIENCY)

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

COMPLETE

V 000} INITIAL COMMENTS Vv 000

Acomplaint and follow up survey was completed
on 2/13/26. The complaints were unsubstantiated
(Intake #NC00235745, #NC00235813).
Deficiencies were cited.

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

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

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

10A NCAC 27G .0209 MEDICATION
REQUIREMENTS

(c) Medication administration:

(1) Prescription or non-prescription drugs shall
only be administered to a client on the written
order of a person authorized by law to prescribe
drugs.
(2) Medications shall be self-administered by
clients only when authorized in writing by the
client's physician.
(3) Medications, including injections, shall be
administered only by licensed persons, or by
unlicensed persons trained by a registered nurse,
pharmacist or other legally qualified person and
privileged to prepare and administer medications.
(4) A Medication Administration Record (MAR) of
all drugs administered to each client must be kept
current. Medications administered shall be
recorded immediately after administration. The
MAR is to include the following:

(A) client's name;

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

(C) instructions for administering the drug;

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

(X6) DATE

STATE FORM 6899 ND5Y11

If continuation sheet 1 of 14

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-226 B. WING

NAME OF PROVIDER OR SUPPLIER
519 UNION STREET SOUTH

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 02/20/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R-C
02/13/2026

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

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

This Rule is not met as evidenced by:

Based on record review and interviews, the
acility failed to ensure all medications were
administered on the written order of a physician
and failed to keep the MARs current affecting 1
of 3 audited clients (Client #1). The findings are:

Review on 2/10/26 of Client #1's record revealed:
- Admission date 1/5/26;

- Age 13 years old;

- Diagnoses: Disruptive Mood Dysregulation
Disorder, Attention Deficit Hyperactivity Disorder;
- Physician's order dated 1/29/26 Vitamin D-1000
units, Take one capsule by mouth daily.

Review on 2/9/26 of Client #1's MARs from
January 5, 2026 - February 9, 2026 revealed:

- Vitamin D was not listed on the January MAR;
- Aline was drawn through dates 2/1/26 and
2/2/26 of the February MAR.

Interview on 2/6/26 with Client #1 revealed:
- Received medications daily.

Interview on 2/9/26 and 2/13/26 with the Program
Manager revealed:

Division of Health Service Regulation

STATE FORM

6899 ND5Y11

UNION POINT
CONCORD, NC 28025
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118] Continued From page 1 V 118

If continuation sheet 2 of 14

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-226 B. WING

NAME OF PROVIDER OR SUPPLIER
519 UNION STREET SOUTH

UNION POINT CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 02/20/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R-C
02/13/2026

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

(X4) ID
PREFIX
TAG

ID
PREFIX
TAG

CROSS-REFERENCED TO THE APPROPRIATE

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

(x5)
COMPLETE
DATE

DEFICIENCY)

V 118| Continued From page 2 V 118

- Was responsible for the medications and the
MAR;

- "| don't put the medication on the MAR until we
receive the medication;"

- The dash on the MAR indicated Client #1 was
not administered the Vitamin D on 2/1/26-2/2/26;
- The pharmacy contacted Client #1's mom (legal
guardian), rather than the facility, due to her
having legal custody of client #1, to request
purchase of the Vitamin D after it was determined
it was not covered under the client's medical
insurance;

- Client #1's mom wanted to pay for the Vitamin D
hrough [online retailer] because she didn't want
io give her

card information to the pharmacy over the phone;
- Client #1's mom told the Program Manager she
would order the Vitamin D through [online retailer]
but by 2/2/26 she had not purchased the Vitamin
D, so the facility picked up the Vitamin D from the
pharmacy on 2/2/26;

- Had documentation of the communication with
he legal guardian about paying for the
medication;

- Never received the documentation of the
communication by the survey exit on 2/12/26.

nterview on 2/13/26 with the Quality
Management Director revealed:

- "Went to 'billing' and asked what are we doing
or the client (Client #1) without her medication
(Vitamin D) and we paid for it;"

- Had a tentative date (2/20/26) for the medical
provider to come to the facility to review the all of
he client medications and Medication
Administration Records (MARs).

V 120] 27G .0209 (E) Medication Requirements V 120

Division of Health Service Regulation

STATE FORM 6899

ND5Y11

If continuation sheet 3 of 14

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-226 B. WING

NAME OF PROVIDER OR SUPPLIER
519 UNION STREET SOUTH

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 02/20/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R-C
02/13/2026

10A NCAC 27G .0209 MEDICATION
REQUIREMENTS

(e) Medication Storage:

(1) All medication shall be stored:

(A) in a securely locked cabinet in a clean,
well-lighted, ventilated room between 59 degrees
and 86 degrees Fahrenheit;

(B) in a refrigerator, if required, between 36
degrees and 46 degrees Fahrenheit. If the
refrigerator is used for food items, medications
shall be kept in a separate, locked compartment
or container;

(C) separately for each client;

(D) separately for external and internal
(E) in a secure manner if approved by
for a client to self-medicate.

(2) Each facility that maintains stocks of
controlled substances shall be currently
registered under the North Carolina Controlled
Substances Act, G.S. 90, Article 5, including any
subsequent amendments.

use;
a physician

This Rule is not met as evidenced by:

Based on observation, record review and
interviews, the facility failed to ensure that
external medication were stored separately from
internal medications affecting 1 of 3 audited
clients (Client #1). The findings are:

Review on 2/10/26 of Client #1's record revealed:
- Admission date 1/5/26;

- Age 13 years old;

- Diagnoses: Disruptive Mood Dysregulation
Disorder (DMDD), Attention Deficit Hyperactivity
Disorder (ADHD);

- Physician's order dated 1/22/26 for

Division of Health Service Regulation

STATE FORM

6899 ND5Y11

UNION POINT
CONCORD, NC 28025
(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 120} Continued From page 3 V 120

If continuation sheet 4 of 14

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-226 B. WING

NAME OF PROVIDER OR SUPPLIER
519 UNION STREET SOUTH

UNION POINT CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 02/20/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R-C
02/13/2026

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

(X4) ID
PREFIX
TAG

ID
PREFIX
TAG

CROSS-REFERENCED TO THE APPROPRIATE

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

(x5)
COMPLETE
DATE

DEFICIENCY)

V 120} Continued From page 4 V 120

Hydrocortisone Cream 2.5% (irritation), Apply
topically twice daily for fourteen days then repeat
as needed;

- Physician's order dated 1/29/26 for Melatonin
3mg (milligram) (sleep), Take one tablet by mouth
every evening; Lurasidone HCL (hydrochloride)
20mg (Depression) mouth every evening;
Trazodone 150mg (antidepressant) by mouth
every evening; Vitamin D-1000 units, Take one
capsule by mouth daily; Clonidine 0.2mg tablet
(ADHD), Take 1 tablet by mouth at bedtime;
Clonidine HCL ER (Extended Release) 0.1mg,
Take one tablet by mouth every morning;
Oxcarbazepine 600mg (bipolar), Take one tablet
by mouth twice daily.

Observation on 2/9/26 at approximately 3:44pm
of Client #1's medications revealed:

- Hydrocortisone Cream was stored with
Melatonin, Lurasidone HCL, Trazodone, Viatmin
D, Clonidine and Oxcarbazepine in a ziplock bag.

Interview on 2/9/26 with the Program Manager
revealed:

- "| have another ziplock bag, | can put the cream
in;"

- Would make sure the external medication was
separated from the internal medication.

Interview on 2/13/26 with the Quality
Management Director revealed:

- Had a tentative date (2/20/26) for the medical
provider to come to the facility to review the all of
the client medications, storage and Medication
Administration Records (MARs).

V 366} 27G .0603 Incident Response Requirements V 366

10A NCAC 27G .0603 INCIDENT

Division of Health Service Regulation

STATE FORM 6899

ND5Y11

If continuation sheet 5 of 14

PRINTED: 02/20/2026
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA. (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
R-C
MHL013-226 B. WING _____ 02/13/2026
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

519 UNION STREET SOUTH

UNION POINT
CONCORD, NC 28025
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 366] Continued From page 5 V 366

RESPONSE REQUIREMENTS FOR
CATEGORY AAND B PROVIDERS

(a) Category A and B providers shall develop and
implement written policies governing their
response to level I, Il or Ill incidents. The policies
shall require the provider to respond by:

(1) attending to the health and safety needs
of individuals involved in the incident;

(2) determining the cause of the incident;
(3) developing and implementing corrective

measures according to provider specified
timeframes not to exceed 45 days;

(4) developing and implementing measures
to prevent similar incidents according to provider
specified timeframes not to exceed 45 days;

(5) assigning person(s) to be responsible
for implementation of the corrections and
preventive measures;

(6) adhering to confidentiality requirements
set forth in G.S. 75, Article 2A, 10A NCAC 26B,
42 CFR Parts 2 and 3 and 45 CFR Parts 160 and
164; and

(7) maintaining documentation regarding
Subparagraphs (a)(1) through (a)(6) of this Rule.
(b) In addition to the requirements set forth in
Paragraph (a) of this Rule, ICF/MR providers
shall address incidents as required by the federal
regulations in 42 CFR Part 483 Subpart |.

(c) In addition to the requirements set forth in
Paragraph (a) of this Rule, Category A and B
providers, excluding ICF/MR providers, shall
develop and implement written policies governing
their response to a level III incident that occurs
while the provider is delivering a billable service
or while the client is on the provider's premises.
The policies shall require the provider to respond
by:

(1) immediately securing the client record
by:

Division of Health Service Regulation
STATE FORM 6899 ND5Y11 If continuation sheet 6 of 14

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-226 B. WING

NAME OF PROVIDER OR SUPPLIER
519 UNION STREET SOUTH

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 02/20/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R-C
02/13/2026

(A) obtaining the client record;

(B) making a photocopy;

(C) certifying the copy's completeness; and
(D) transferring the copy to an internal
review team;

(2) convening a meeting of an internal

review team within 24 hours of the incident. The
internal review team shall consist of individuals
who were not involved in the incident and who
were not responsible for the client's direct care or
with direct professional oversight of the client's
services at the time of the incident. The internal
review team shall complete all of the activities as
follows:

(A) review the copy of the client record to
determine the facts and causes of the incident
and make recommendations for minimizing the
occurrence of future incidents;

(B) gather other information needed;

(C) issue written preliminary findings of fact
within five working days of the incident. The
preliminary findings of fact shall be sent to the
LME in whose catchment area the provider is
located and to the LME where the client resides,
if different; and

(D) issue a final written report signed by the
owner within three months of the incident. The
final report shall be sent to the LME in whose
catchment area the provider is located and to the
LME where the client resides, if different. The
final written report shall address the issues
identified by the internal review team, shall
include all public documents pertinent to the
incident, and shall make recommendations for
minimizing the occurrence of future incidents. If
all documents needed for the report are not
available within three months of the incident, the
LME may give the provider an extension of up to
three months to submit the final report; and

Division of Health Service Regulation

STATE FORM 6899

ND5Y11

UNION POINT
CONCORD, NC 28025
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 366 | Continued From page 6 V 366

If continuation sheet 7 of 14

PRINTED: 02/20/2026
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA. (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
R-C
MHL013-226 B. WING _____ 02/13/2026
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

519 UNION STREET SOUTH

UNION POINT CONCORD, NC 28025
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 366] Continued From page 7 V 366
(3) immediately notifying the following:
(A) the LME responsible for the catchment
area where the services are provided pursuant to
Rule .0604;
(B) the LME where the client resides, if
different;
(C) the provider agency with responsibility

for maintaining and updating the client's
treatment plan, if different from the reporting
provider;

(D) the Department;

(E) the client's legal guardian, as
applicable; and

(F) any other authorities required by law.

This Rule is not met as evidenced by:
Based on record reviews and interviews, the
acility failed to implement written policies
governing their response to Level | and II
incidents. The findings are:

Review on 2/3/26 and 2/9/26 of the North
Carolina Incident Response Improvement System
(IRIS) from 1/1/26- 2/6/26 revealed:

- No IRIS reports during the reviewed timeframe.

Review on 2/6/26 and 2/9/26 of the facility's
internal incident reports from 1/1/26-2/6/26
revealed:

- 1/4/26 Client #3's property destruction and law
enforcement involvement incident;

- 1/11/26 Former Client #5's aggressive behavior,
property destruction, law enforcement
involvement and transported to local

Division of Health Service Regulation

STATE FORM 6899 ND5Y11 If continuation sheet 8 of 14

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-226 B. WING

NAME OF PROVIDER OR SUPPLIER
519 UNION STREET SOUTH

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 02/20/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R-C
02/13/2026

hospital incident;
- 1/29/26 Client #2's emotional deregulation and
hospitalization incident;
- 2/2/26 Client #1's AWOL (absent without leave),
law enforcement involvement, transported to local
hospital incident;
- 1/9/26 Client #3's vape search and seizure
incident;
- 2/2/26 Client #1's sensual gummies search and
seizure incident;
- 2/2/26- No incident report for Client #1's welfare
check from law enforcement incident;
- No incident reports for Client #1 not receiving
her Vitamin D from 1/30/26-2/2/26.

Review on 2/6/26 and 2/9/26 of the facility's
internal incident reports from 1/1/26-2/6/26
revealed:
-There was no documented Risk Cause Analysis
for the cited incidents to demonstrate that the
facility:
-Developed and implemented measures to
prevent similar incidents within the
provider-specified timeframe, not to

exceed 45 days;
- Developed and implemented corrective
measures within the provider-specified
timeframe, not to exceed 45 days;

and;
-Assigned responsible individuals to ensure
implementation of corrective and preventive
measures.

Interview on 2/9/26 with the Program Manager
revealed:

- Was responsible for completing incident reports;
- Completed the IRIS reports and received a
confirmation number;

- Would make sure she completed incident
reports for medication errors.

Division of Health Service Regulation

STATE FORM

6899 ND5Y11

UNION POINT
CONCORD, NC 28025
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 366} Continued From page 8 V 366

If continuation sheet 9 of 14

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-226 B. WING

NAME OF PROVIDER OR SUPPLIER
519 UNION STREET SOUTH

UNION POINT CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 02/20/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R-C
02/13/2026

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

(X4) ID
PREFIX
TAG

ID
PREFIX
TAG

CROSS-REFERENCED TO THE APPROPRIATE

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

(x5)
COMPLETE
DATE

DEFICIENCY)

V 366] Continued From page 9 V 366

Interview on 2/11/26 with the Residential Director
revealed:

- Program Manager was in charge of IRIS
reports;

- "[Program Manager] was trained (incident
reporting) by [Quality Management Director] and
myself."

Interview on 2/13/26 with the Quality
Management Director revealed:

- Planned a tentative meeting on 2/20/26 for
training on incident reports;

- Would update the level | incident reports to
cover Risk Cause Analysis;

- The Program Manager had attended trainings
on incident reporting, but would be retrained on
2/20/26.

V 367| 27G .0604 Incident Reporting Requirements V 367
10A NCAC 27G .0604 INCIDENT
REPORTING REQUIREMENTS FOR
CATEGORY AAND B PROVIDERS

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

Division of Health Service Regulation

STATE FORM 6899

ND5Y11

If continuation sheet 10 of 14

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-226 B. WING

NAME OF PROVIDER OR SUPPLIER
519 UNION STREET SOUTH

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 02/20/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R-C
02/13/2026

(1) reporting provider contact and
identification information;

(2) client identification information;

(3) type of incident;

(4) description of incident;

(5) status of the effort to determine the

cause of the incident; and

(6) other individuals or authorities notified
or responding.

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

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

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

(1) hospital records including confidential
information;

(2) reports by other authorities; and

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

Division of Health Service Regulation

STATE FORM 6899

ND5Y11

UNION POINT
CONCORD, NC 28025
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 367 | Continued From page 10 V 367

If continuation sheet 11 of 14

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-226 B. WING

NAME OF PROVIDER OR SUPPLIER
519 UNION STREET SOUTH

UNION POINT CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 02/20/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R-C
02/13/2026

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

(X4) ID
PREFIX
TAG

ID
PREFIX
TAG

CROSS-REFERENCED TO THE APPROPRIATE

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

(x5)
COMPLETE
DATE

DEFICIENCY)

V 367 | Continued From page 11 V 367

.0300 and 10A NCAC 27E .0104(e)(18).

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

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

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

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

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

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

This Rule is not met as evidenced by:

Based on record reviews and interviews, the
facility failed to report all level II incidents in the
Incident Response Improvement System (IRIS)
and failed to notify the Local Management Entity
(LME)/ Managed Care Organization (MCO)
responsible for the catchment area where
services are provided within 24 hours and 72
hours of becoming aware of the incident. The
findings are:

Division of Health Service Regulation

STATE FORM

6899 ND5Y11

If continuation sheet 12 of 14

PRINTED: 02/20/2026
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA. (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
R-C
MHL013-226 B. WING _____ 02/13/2026
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

519 UNION STREET SOUTH

UNION POINT
CONCORD, NC 28025
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 367 | Continued From page 12 V 367

Review on 2/3/26 and 2/9/26 of the North
Carolina Incident Response Improvement System
(IRIS) from 1/1/26- 2/6/26 revealed:

- No IRIS reports during the reviewed timeframe.

Review on 2/6/26 and 2/9/26 of the facility's
internal incident reports from 1/1/26-2/6/26
revealed:

- Unsubmitted IRIS reports:

- 1/4/26 Client #3's property destruction and law
enforcement involvement incident;

- 1/11/26 FC #5's aggressive behavior, property
destruction, law enforcement involvement and
ransported to local hospital incident;

- 1/29/26 Client #2's emotional deregulation and
hospitalization incident;

- 2/2/26 Client #1's AWOL (absent without
leave), law enforcement involvement, transported
io local hospital incident;

- 2/2/26 No incident report for Client #1's welfare
check from law enforcement incident, when the
local school system requested the local police do
a welfare check on Client #1 due to her sending
her teacher a message and peer a message of
eeling depressed and needing help with
emotions.

nterview on 2/9/26 with the Program Manager
revealed:

- Was responsible for completing IRIS reports;

- Completed the IRIS reports and received a
confirmation number;

- Would make sure she received a thumbs up
when completing IRIS reports;

- Was not provided details from law enforcement
about the welfare check, "There is no reason why
| didn't do an incident report (2/2/26)."

Interview on 2/11/26 with the Residential Director
Division of Health Service Regulation
STATE FORM 6899 ND5Y11 If continuation sheet 13 of 14

PRINTED: 02/20/2026

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL013-226 B. WING 02/13/2026
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
519 UNION STREET SOUTH
UNION POINT
CONCORD, NC 28025
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 367 | Continued From page 13 V 367
revealed:

- Program Manage was in charge of IRIS reports;
- "[Program Manager] was trained (incident
reporting) by [Quality Management Director] and
myself."

Interview on 2/13/26 with the Quality
Management Director revealed:

- Planned a tentative meeting on 2/20/26 for
training on incident reports.

Division of Health Service Regulation
STATE FORM 6899 ND5Y11 If continuation sheet 14 of 14

document_type: Statement of Deficiency