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

raw_content:
PRINTED: 05/09/2019

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES AND PLAN pay PROVIDER/SUPPLIER/CLIA) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHLo60968 8. WING 04/30/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY T
CHARLOTTE, NC 28211
(a4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX TAG (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX TAG (EACH CORRECTIVE ACTION SHOULD BE ‘COMOLETE DATE:
REGULATORY OR LSC IDENTIFYING INFORMATION) ‘CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
Vv 000} Vv000

were cited.

Disturbances.

INITIAL COMMENTS

An annual, complaint, and follow up survey was
completed on April 30, 2019. The complaint was
unsubstantiated (Intake # NC150694). Deficiencies

This facility is licensed for the following service
category: 10A NCAC 27G .1400 Day Treatment for
Children and Adolescents with Emotional or Behavioral

DHSR - Mental Health
MAY 2 0 2019
Lic. & Cert. Section

PRINTED: 05/09/2019

FORM APPROVED
Division of Health Service Regulation
Vv 12d Vv 120 What measures will be put in place to correct the deficient area
of practice.
. At the end of each day Program Manager or
another Qualified Professional trained in medication 4/30/19
27G .0209 (E) Medication Requirements administration assigned by program manager will do
check to ensure that all medication counts are accurate.
10A NCAC 27G .0209 MEDICATION es All Charlotte Day Treatment staff will be trained
REQUIREMENTS in Medication administration. 5/13/19
(e) Medication Storage: . Each classroom staff will be responsible for
(1) All medication shalll be stored: their consumer's medication within their classroom. One
‘ locked cabinet inal i staff will give out the meds, and the other staff will back | 5/20/19
(A) lng Securely locked cabinet Ina.cean, weir them up to ensure counts are correct.
lighted, ventilated room between 59 degrees and 86
degrees Fahrenheit; Describe your plans to make sure the above happens.
(B) Ina refrigerator, if required, between 36 s Once a week, RN nurse will go and check
degrees and 46 degrees Fahrenheit. If the refrigerator mesa ion mere seunts and wee sheets (0 5/2/19
is used for food items, medications shall be kept ina Stisune-thatiever/ mine iticets protocol. :
~— . If counts are off the nurse will immediately
separate, locked compartment or container; report to Program Manager and Executive Director and fill
(Cc) separately for each client; out incident report. 5/2/19
(D) Separately for external and internal use ;( E)
in a secure manner if approved by a physician for a Who will monitor the situation to ensure it will not occur
client to self-medicate. again.
(2) Each facility that maintains stocks of controlled
substances shall be currently registered under the x Fi
é dane e All the items on this plan will be
North Carolina Controlled Substances Act, G.S. 90, itarad by thE M
Article 5, including any subsequent amendments. HIRTIOSE BY ENE FORT EME Men@Ber,
This Rule is not met as evidenced by: Based on
interview, record review, and observation, the
facility failed to maintain secure
Division of Health Service Regulation
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (x6) DATE
STATE FORM 839 GNHM11. if continuation sheet_1 of 18

STATEMENT OF DEFICIENCIES AND PLAN
OF CORRECTION

(xa) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

MHLO60968

(02) MULTIPLE CONSTRUCTION (x3) DATE suRVEY

A. BUILDING COMPLETED
R
B. WING 04/30/2019

NAME OF PROVIDER OR SUPPLIER

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY T

STREET ADDRESS, CITY, STATE, ZIP CODE

6220-D THERMAL RD

CHARLOTTE, NC 28211

(x4) 1D
PREFIX TAG

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

ID
PREFIX TAG

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

(x5)
COMPLETE DATE

Division of Health Service Regulation
STATE FORM

6299

GNHM11 If continuation sheet 2 of 21

PRINTED: 05/09/2019
FORM APPROVED

Division of Health Service Regulation

V120] Continued From page 1

Safe storage of medication 4 of 6 audited current clients
(Clients 42, #3, #4, and #5). The findings are:

Review on 4/24/19 of Client #2's record revealed:
-Admission date 8/9/18;

-Diagnoses of Circadian Rhythm Sleep Wake
Disorder, Separation Anxiety Disorder, Attention
Deficit Hyperactivity Disorder (ADHD), History of
Physical Abuse;

-8 years old;

-Physician's order dated 12/5/18 for Vyvanse
(treatment of ADHD) 20mg 1 tab at 12:00pm; -Count
sheet for Vyvanse 20mg revealed there were 8
vyvanse 20mg pills present on the morning of
3/21/19. One was administered at

11am on that date;

-Count sheet for Vyvanse 20mg included the notation
dated 3/21/19 "Counted by PI

(Performance Improvement) and count was off by 2
pills" with the signature of the Performance
Improvement Manager (PIM).

Review on 4/24/19 of Client #3's record revealed:
-Admission date 8/6/18;

-Diagnoses of Oppositional Defiant Disorder,
Attention Deficit Hyperactivity Disorder,

Adjustment Disorder;

-6 years old;

-Physician's order dated 10/16/18 for Adderall XR
(treatment of ADHD) 15mg 1 capsule at 12:00pm; -
Count sheet for Adderrall XR 15mg revealed there
were 14 Adderall XR 15mg pills present on the morning
of 3/21/19. One was administered at

11am on that date;

-Count sheet for Adderrall XR15mg included the
notation dated 3/21/19 "Count was off by 1 capsule”
with the initials of the PIM.

Review on 4/24/19 of Client #4's record revealed:

(x3) DATE SURVEY
COMPLETED

STATEMENT OF DEFICIENCIES AND PLAN
OF CORRECTION

(x1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

R
04/30/2019

MHL060968

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

6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY T

CHARLOTTE, NC 28211

ID
PREFIX TAG

(x5)
COMPLETE DATE

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

(K4) 1D
PREFIX TAG

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

Division of Health Service Regulation

STATE FORM 880 GNHM11 If continuation sheet 3 of 21

PRINTED: 05/09/2019
FORM APPROVED
Division of Health Service Regulation

V 120] Continued From page 2 Vv 120

Admission date 12/27/18;

-Diagnoses of Adjustment Disorder with Mixed
Disturbance of Emotions/Conduct, Oppositional
Defiant Disorder, Attention Deficit Hyperactivity
Disorder, Autism Spectrum Disorder;

-10 years old;

-Physician's order dated 1/16/19 for

Methylphenidate (treatment of ADHD) 10mg 2 tabs at
10:00am and 2:00pm;

-Count sheet for Methylphenidate 10mg revealed
there were 29 pills in the facility just prior to review
on 3/21/19 by the PIM. The date of previous
administration is unclear because the dates had been
crossed out and whited out; -Count sheet for
Methylphenidate 10mg included a notation dated
3/21/19 "count off by 6 tablets” with the initials of the
PIM;

-Count sheet for Methylphenidate 10mg revealed there
were 62 pills in the facility just prior to

review on 4/24/19 by the PIM;

-Count sheet for Methylphenidate 10mg included a
notation dated 4/24/19 "counted by P| and count was
off by 4 pills."

Review on 4/24/19 of Client #5's record revealed:
-Admission date 3/11/19;

-Diagnoses of Oppositional Defiant Disorder,
Attention Deficit Hyperactivity Disorder, Childhood
Onset Fluency Disorder (Stuttering);

-13 years old;

-Physician's order dated 4/2/19 for Focalin XR
(treatment of ADHD) 30mg 1 cap at 9:00am and
Focalin Smg 2 caps at 1:00pm;

-Count sheet for Focalin XR 30mg revealed there
were 12 pills in the facility on 3/21/19. One pill was
administered at 9:00am;

-Count sheet for Focalin XR 30mg included a notation
dated 3/21/19 "Count off by 1 capsule” with the initials
of the PIM;

-Count sheet for Focalin Smg revealed there was

STATEMENT OF DEFICIENCIES AND PLAN (x1) PROVIDER/SUPPLIER/CLIA | (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
OF CORRECTION IDENTIFICATION NUMBER: COMPLETED

A. BUILDING:

R
MHL060968 04/30/2019

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

6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY T
CHARLOTTE, NC 28211

10
PREFIX TAG

(x4) 1D
PREFIX TAG

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

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

Division of Health Service Regulation

STATE FORM ae GNHM11 if continuation sheet 4 of 21

PRINTED: 05/09/2019
FORM APPROVED

Division of Health Service Regulation

V 120] Continued From page 3

47 pills in the facility on 3/21/19. Two pills were
administered at 1:00pm;

-Count sheet for Focalin S5mg included a notation dated
3/21/19 "count was off by 1 pill" with the initials of the
PIM;

-Count sheet for Focalin Smg included multiple cross
outs and pill count re-entries on the count sheet with
notations of "correct count" for each day appearing
that medication counts were off for 8 consecutive
dates of medication administration from 3/28/19
through 4/5/19.

Review on 4/24/19 of Staff #10's record revealed:
-Hire date 9/10/18;
-Hired as Mental Health Counselor.

Review on 4/23/19 of the facility's Incident Reports
revealed:

-Level 1 incident report dated 3/21/19 for Client #2
revealed that during an internal review of
medications, it was discovered that the medication
count was off by 1 pill for Vyvanse

20mg;

-Level 1 incident report dated 3/21/19 for Client #3
revealed that during an internal review of
medications, it was discovered that the medication
count was off by 1 pill for Adderall

15mg;

-Level 1 incident report dated 3/21/19 for Client #4
revealed that during an internal review of
medications, it was discovered that the medication
count was off by 5 pills for

Methylphenidate 10mg;

-Level | incident report dated 3/21/19 for Client #5
revealed that during an internal review of
medications, it was discovered that medication counts
were off by 1 pill each for Focalin XR 30mg and Focalin
Smeg.

Review on 4/26/19 of the facility's Policy on

_|

(x3) DATE SURVEY
COMPLETED

STATEMENT OF DEFICIENCIES AND PLAN 4) PROVIDER/SUPPLIER/CLIA | (2) MULTIPLE CONSTRUCTION
OF CORRECTION IDENTIFICATION NUMBER:

A. BUILDING,
R
MHL060968 B. WING 04/30/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY T
CHARLOTTE, NC 28211

(xs)
‘COMPLETE DATE

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

(xa) ID
PREFIX TAG

Division of Health Service Regulation

STATE FORM 8 GNHM11 If continuation sheet 5 of 21

Division of Health Service Regulation
V 120] Continued From page 4

Storage, Disposal and Control of Medications (Policy 4.8)
effective 1/1/1998 with most recent update on 5/25/10
revealed:

-" Schedule II Controlled Medications: (11) Upon
delivery of Schedule II drugs, an authorized staff
member verifies receipt by adding the count and
initials to the Controlled Drugs Record. Schedule |!
drugs will be placed in the medication closet
immediately; (12) Schedule II drugs are not to be
removed from locked storage until time of
administration and must be signed out at that time;
(13) Two staff members shall count all controlled
medication on a regular basis verify count is correct
The two staff members sing the Controlled Drugs
Record signifying count is accurate. This record is
maintained for three years; (14) If there is a
discrepancy in the count, staff will make every effort
to resolve the discrepancy immediately. If the
discrepancy cannot be resolved, it will be reported
through the Incident Report and accompanying
procedures and recorded on the Controlled Drug
Record..."

Interview on 4/25/19 with Client #2 revealed: -Takes
medication at the facility but does not know the name
of it;

-The medication is "the white pill;"

-Different staff administer medication;

-Never missed receiving his medication.

Interview on 4/25/19 with Client #3 revealed: -Takes
medication at the facility but does not know the name
of it;

-The medication is "the blue pill;"

-Different staff administer medication;

-Never missed receiving his medication.

Interview on 4/25/19 with Client #4 revealed: -Takes
medication at the facility but does not know the name
of it;

PRINTED: 05/09/2019
FORM APPROVED

STATEMENT OF DEFICIENCIES AND PLAN
OF CORRECTION

(a) PROVIDER/SUPPLIER/CLIA

IDENTIFICATION NUMBER: RENE

MHLO60968
NAME OF PROVIDER OR SUPPLIER

6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY T
CHARLOTTE, NC 28211
SUMMARY STATEMENT OF DEFICIENCIES 1D

(EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX TAG
REGULATORY OR LSC IDENTIFYING INFORMATION)

(x4) ID
PREFIX TAG.

Division of Health Service Regulation
STATE FORM

609

(X2) MULTIPLE CONSTRUCTION

GNHM11

(x3) DATE SURVEY
COMPLETED

R
04/30/2019

STREET ADDRESS, CITY, STATE, ZIP CODE

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

(x5)
COMPLETE DATE

If continuation sheet 6 of 21

Division of Health Service Regulation

V120] Continued From page 5

-The medication is the "mint green pill;" -Different
staff administer medication;

-Never missed receiving his medication.

Interview on 4/25/19 with Client #5 revealed:

-Takes medication at the facility;

-Takes "Focalin XR 30;"

-Different staff administer medication;

-Never missed medications at the facility because the
"doctor at mental health send the paperwork."

Interview on 4/25/19 with Staff #10 revealed: -Began
administering medications three weeks ago;

-When administering controlled substance
medications, must have an additional staff present as
a witness;

-After administering the medication to each client, the
staff must make sure to check if the client swallowed
the medication. Staff must then sign the Medication
Administration Record and the count sheet for any
controlled substance medications. The staff witness
does not sign any documents.

Interview on 4/25/19 with the Case Manager revealed:
-When families drop off controlled substance
medications for clients, the medications must be
checked in by staff trained in medication
administration. The controlled substance medication
pills are counted and a Contro! Medication Sheet is
completed documenting the number of pills brought to
the facility. The staff and family member each sign the
Control Medication Sheet verifying the number of pills
brought to the facility.

Interview on 4/25/19 with the Executive Director revealed:

STATEMENT OF DEFICIENCIES AND PLAN (x1) PROVIDER/SUPPLIER/CLIA

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY T

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

OF CORRECTION IFICATION NUMBER:
IDENT! Be weBUUORNE COMPLETED
R
MHLO6G0968 04/30/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

6220-D THERMAL RD

CHARLOTTE, NC 28211

PRINTED: 05/09/2019
FORM APPROVED

(x3) DATE SURVEY

(X2) MULTIPLE CONSTRUCTION

(x5)
COMPLETE DATE

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

ID
PREFIX TAG

Division of Health Service Regulation
STATE FORM.

shes, GNHM11 If continuation sheet 7 of 21

PRINTED: 05/09/2019
FORM APPROVED

Division of Health Service Regulation

Continued From page 6

-There should never be any discrepancies between
the number of pills listed on the count sheet and the
actual number of pills present in the facility;

-There have been discrepancies in the past several

weeks;

-Many staff have administered medications in the past
several weeks;

-Registered Nurses will be assigned to oversee medication
administration, controlled substance count, and storage of
medication at the facility.

Observation on 4/25/19 at approximately 11:00am
revealed:

-Medication stored in a cabinet secured with a large
padlock. The medication cabinet is located behind two
locked closet doors.

Review on 4/26/19 of the Plan of Protection
completed by the Executive Director dated 4/26/19
revealed:

“What immediate action will the facility take to ensure
the safety of the consumers in your care? -At the end of
each day, either the Program Manager or a staff
assigned by Program Manager will check to ensure that
all medication counts are accurate.

-All Charlotte Day Treatment staff will be training in
Medication Administration.

-Each classroom staff will be responsible for their
consumer's medication within their classroom. One
staff will give out the meds (medications), and the

other staff will back them up to ensure counts are
correct.

Describe your plans to make sure the above happens.
-Once a week, RN (Registered Nurse) will check
medications, medication counts, and MAR (Medication
Administration Record) sheets to ensure that everything
meets protocol.

STATEMENT OF DEFICIENCIES AND PLAN oa) PROVIDER/SUPPLIER/CLIA) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
OF CORRECTION IDENTIFICATION NUMBER: MII
A, BUILDING: ETE,
R
MHL060968 8. WING 04/30/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY T
CHARLOTTE, NC 28211
(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES ID

PREFIX TAG (EACH DEFICIENCY MUST BE PRECEDED BY FULL. PREFIX TAG
REGULATORY OR LSC IDENTIFYING INFORMATION)

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

Division of Health Service Regulation

STATE FORM ae GNHM11 If continuation sheet 8 of 21

Division of

V 367)

Health Service Regulation

Continued From page 7

-If counts are off, the nurse will immediately report to
the Program Manager and the Executive Director and
will complete an incident report."

Accurate count records and secure storage were not
maintained for controlled substance

Medications resulting in multiple pills of Adderall,
Methylphenidate, Focalin, and Vyvanse being
unaccounted for. These medications were under the
control and responsibility of the facility and were
prescribed for the treatment of Attention Deficit
Hyperactivity Disorder for clients ranging from 6 - 13
years old. The medications have a high potential for
diversion and misuse. The clients were diagnosed
with mental health needs including, but not limited
to, Attention Deficit Hyperactivity Disorder,
Oppositional Defiant Disorder, Adjustment Disorder,
and Autism Spectrum Disorder. Missing controlled
substance medication is detrimental to the clients’
health, safety, and welfare in that only a limited
amount of controlled substance medications can be
dispensed each month. This deficiency

Constitutes a Type B rule violation. If the violation is
not corrected within 45 days, an administrative penalty
of $200.00 per day will be imposed for each day the
facility is out of compliance beyond the 45th day.

27G .0604 Incident Reporting Requirements

10A NCAC 27G .0604 = INCIDENT

REPORTING REQUIREMENTS FOR

CATEGORY A AND B PROVIDERS

(a) Category A and B providers shall report all level I!
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
|| deaths involving the clients

PRINTED: 05/09/2019
FORM APPROVED

v 367 . What measures will be put in place to correct the
deficient area of practice.
e At the end of each day,
Program Manager will meet | y/sgy15
face to face with a staff
member from each group and
inquire about any incidents
that occurred during the day. | 4/30/19

° — Ifany incidents occur Program
manager will check to ensure
documents are complete, and
determine what level the 4/30/19
incident should be under.

¢ Ifthe incident rises to a level 2
or 3 Program Manager will
ensure that critical incident
information is complete.

. Program manager will ensure
that the proper authorities
have been contacted and
notified of the incident.

—

Division of Health Service Regulation

STATE FORM

ease GNHM11 If continuation sheet 9 of 21

PRINTED: 05/09/2019
FORM APPROVED

Division of Health Service Regulation

Describe your plans to make sure the above
happens.

On 4/30/19, Executive director discussed
with Program Manager the prevention
steps above, and explained to him that
even if an incident doesn’t occur on our
property we as an agency are the clinical
home, and are required to ensure all
documentation is completed.

On 5/20 Program Manager will complete
a refresher to review incident
documentation protocol with his staff to
ensure that they are aware of what
constitutes and incident and how to
document the details.

Program Manager will complete coaching
and other progressive documentation in
situations in which the correct
documentation procedures are not
followed.

Who will monitor the situation to ensure it will not
occur again.

* The Executive Director for the program will
monitor the situation to ensure that it does
not occur again.

STATEMENT OF DEFICIENCIES AND PLAN (x1) PROVIDER/SUPPLIER/CLIA | (2) MULTIPLE CONSTRUCTION (3) DATE SURVEY
NTIFICATION NUMBER: COMPLETED
OF CORRECTION IDENTIFICATION NUMBE cou ie,
R
04/30/2019
MHLO6G0968 B. WING /30/;
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY T
CHARLOTTE, NC 28211

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

Division of Health Service Regulation
STATE FORM 6099 GNHM11 Ifcontinuation sheet 10 of 21

PRINTED: 05/09/2019
FORM APPROVED

Division of Health Service Regulation

V 367! Continued From page 8

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:

(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

(X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY

COMPLETED

STATEMENT OF DEFICIENCIES AND PLAN
OF CORRECTION

(x4) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

A, BUILDING:

R

MHL060968 04/30/2019

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY T
CHARLOTTE, NC 28211

ID
PREFIX TAG

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

(x4) 1D
PREFIX TAG.

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

Division of Health Service Regulation
STATE FORM 5599 GNHM11 If continuation sheet 11 of 21

PRINTED: 05/09/2019
FORM APPROVED
Division of Health Service Regulation

Continued From page 9 V 367

Mental Health, Developmental Disabilities and Substance
Abuse Services within 72 hours of becoming aware of the
incident. Category A providers shall send a copy of all
level Ill

incidents involving a client death to the Division of
Health Service Regulation within 72 hours of

becoming aware of the incident. In cases of client
death within seven days of use of seclusion

or restraint, the provider shall report the death
immediately, as required by 10A NCAC 26C .0300

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

B providers shall send a report quarterly to the LME
responsible for the catchment area where services

are provided. The report shall be submitted on a

form provided by the Secretary via electronic means
and shall include summary information as follows:

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

(2) restrictive interventions that do not meet

the definition of a level I! or level Ill incident; (3)
searches of a client or his living area; (4)

seizures of client property or property in the

possession of a client;

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

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

This Rule is not met as evidenced by:

Based on interview and record review, the facility failed to
report all level Il incidents to the Local

Management Entity (LME) responsible for the

STATEMENT OF DEFICIENCIES AND PLAN
OF CORRECTION

(xa) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

A, BUILDING: COMPLETED

R

MHLO60968 04/30/2019

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY T
CHARLOTTE, NC 28211

ID
PREFIX TAG

(x4) 10
PREFIX TAG

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

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

Division of Health Service Regulation

STATE FORM J GNHM11 if continuation sheet 12 of 21

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Division of Health Service Regulation

V 367] Continued From page 10

catchment area where services are provided within 72
hours of becoming aware of the incident. The
findings are:

Review on 4/24/19 of Client #6's record revealed:
-Admission date 12/6/18;

-Diagnoses of Disruptive Mood Dysregulation
Disorder, Attention Deficit Hyperactivity Disorder,
Major Depressive Disorder, Generalized Anxiety
Disorder, Persistent Depressive Disorder,
Borderline Intellectual Functioning; -13 years

old.

Review on 4/24/19 of Former Client #7's record revealed:
-Admission date 7/9/18;

-Diagnoses of Nocturnal Enuresis, Other

Specified Trauma or Stressor Disorder, Attention

Deficit Hyperactivity Disorder, Borderline

Intellectual Developmental Disability, Disruptive

Mood Dysregulation Disorder; - 11 years old.

Review on 4/23/19 of the facility's Incident Reports
revealed:

-Level | incident report dated 3/20/19 regarding an
incident of aggression and suicidal ideation for Client
#6 which resulted in a report to local law
enforcement;

-Level | incident report dated 3/6/19 regarding in
incident of aggression and assault for Former Client
#7 which resulted in a report to law enforcement and
returning the client to the facility.

Interview on 4/25/19 with the Executive Director revealed:
-Will make sure all Level I! incident reports are completed
as needed in the future;

-Did not realize the incident involving Former

STATEMENT OF DEFICIENCIES AND PLAN (x1) PROVIDER/SUPPLIER/CLIA) (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
(OF CORRECTION IDENTIFICATION NUMBER:
e |UMBEI ‘A. BUILDING: COMPLETED
R
MHLO60968 B. WING 04/30/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY T
CHARLOTTE, NC 28211

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

(x4) ID
PREFIX TAG

Division of Health Service Regulation
STATE FORM oes. GNHM11 If continuation sheet 13 of 21

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FORM APPROVED

Division of Health Service Regulation

Continued From page 11

Client #7 needed to be completed as a Level || incident;
-Had instructed the staff to complete a Level II incident
for Client #6. It must have been an oversight that staff
did not complete the Level || report.

What measures will be put in place to correct
the deficient area of practice.

Formal refresher training on physical
restraints will be provided to all staff
on 5/20.

e — Self-awareness training will be
provided to all staff on 5/20.

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

10A NCAC 27E .0108 TRAINING IN
SECLUSION, PHYSICAL RESTRAINT AND

ISOLATION TIME-OUT

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

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

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

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

All staff will be required to complete
TCI training prior to working with
clients and be required to complete
TCI refreshers every 6 months
following employment with the
company.

Describe your plans to make sure the above
happens.

¢ Executive Director trained as a TCI

trainer has scheduled and will be

conducting TCI refresher and self-

awareness training on 5/20 for all

staff.

¢ All staff have received advance

notification of mandatory requirement

of attendance to scheduled trainings.
TCI refreshers will continue to be
required for all staff every 6 months

Who will monitor the situation to ensure it
will not occur again.

eProgram Manager will ensure that all

Division of Health Service Regulation

STATE FORM ease GNHM11 If continuation sheet 14 of 21

PRINTED: 05/09/2019
FORM APPROVED

Division of Health Service Regulation

action plan and as required by the

company.

staff complete TCI trainings and
refreshers as specified by corrective

STATEMENT OF DEFICIENCIES AND PLAN (ay PROVIDER/SUPPLIER/CLIA | (2) MULTIPLE CONSTRUCTION (%3) DATE SURVEY
OF CORRECTION IDENTIFICATION NUMBER: COMPLETED

‘A. BUILDING:
R

MHL060968 04/30/2019

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

6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY T
CHARLOTTE, NC 28211

(x5)
COMPLETE DATE

(xa) 1D SUMMARY STATEMENT OF DEFICIENCIES 10 PROVIDER'S PLAN OF CORRECTION
PREFIX TAG (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX TAG (EACH CORRECTIVE ACTION SHOULD BE
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)

Division of Health Service Regulation
STATE FORM ete GNHM11 If continuation sheet 15 of 21

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FORM APPROVED
Division of Health Service Regulation

V 537) Continued From page 12 course.

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

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

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

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

(2) guidelines on when to intervene
(understanding imminent danger to self and others);
(3) emphasis on safety and respect for the rights
and dignity of all persons involved (using concepts of
least restrictive interventions and incremental steps in
an intervention);

(4) strategies for the safe implementation of
restrictive interventions;

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

(6) prohibited procedures;

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

(8) documentation methods/procedures.(h)
Service providers shall maintain documentation of
initial and refresher training for at least three years.
(1) Documentation shall include:

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

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

STATEMENT OF DEFICIENCIES AND PLAN
OF CORRECTION

oa) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION (3) DATE SURVEY

COMPLETED

A. BUILDING:

R
04/30/2019

MHLO60968 B. WING

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY T

CHARLOTTE, NC 28211

(xay10 SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX TAG (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX TAG (EACH CORRECTIVE ACTION SHOULD BE COMPLETE DAT:
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)

Division of Health Service Regulation

STATE FORM a8 GNHM11 If continuation sheet 16 of 21

Division of Health Service Regulation

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V 537] Continued From page 13

(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,
physical restraint and isolation time-out, as specified
in Paragraph (a) of this Rule.

(8) Trainers shall be currently trained in

STATEMENT OF DEFICIENCIES AND PLAN, (XL) PROVIDER/SUPPLIER/CLIA | (X2} MULTIPLE CONSTRUCTION (x3) DATE SURVEY
OF CORRECTION IDENTIFICATION NUMBER:
BE! A. BUILDING: COMPLETED
R
MHLO60968 B. WING 04/30/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY T
CHARLOTTE, NC 28211

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

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

Division of Health Service Regulation

STATE FORM bd

GNHM11 If continuation sheet 17 of 21

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V 537] Continued From page 14 V537

CPR.

(9) Trainers shall have coached experience in
teaching the use of restrictive interventions at least
two times with a positive review by the coach.

(10) Trainers shall teach a program on the use of
restrictive interventions at least once annually.

(11) Trainers shall complete a refresher instructor
training at least every two years. (k) Service providers
shall maintain documentation of initial and refresher
instructor training for at least three years.

(1) Documentation shall include:

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

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

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

this documentation at any time.

(I) Qualifications of Coaches:

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

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

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

This Rule is not met as evidenced by:

Based on interview and record review, facility staff
failed to display competency while implementing
physical restraints affecting 1 of 3 audited staff
members (Staff #8). The findings are:

STATEMENT OF DEFICIENCIES AND PLAN
OF CORRECTION

(ki) PROVIDER/SUPPLIER/CLIA | (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

TIFICATI 7
IDENTIFICATION NUMBER: ‘ReRUTEBINE COMPLETED

R

MHLO60968 04/30/2019

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

6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY T
CHARLOTTE, NC 28211
(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES. 1D PROVIDER'S PLAN OF CORRECTION (xs)

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

Division of Health Service Regulation
STATE FORM ene GNHM11 If continuation sheet 18 of 21

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FORM APPROVED

Division of Health Service Regulation

V 537} Continued From page 15 Vv 537

Review on 4/24/19 of Client #1's record revealed:
-Admission date 3/4/19;

-Diagnoses of Obsessive Compulsive Disorder,
Other Specific Impulse Control and Conduct
Disorder, Unspecified Schizophrenia Spectrum and
Other Psychotic Disorder, Unspecified Depression
Disorder, Unspecified Attention Hyperactivity
Disorder; -10 years old.

Interview on 4/25/19 with Client #1 revealed:

-Had not been restrained at the facility;

-Staff #1 grabbed him by the wrist and the neck the
day his most recent Child and Family Team (CFT)
meeting (4/12/19), but he was not grabbed by his legs
or feet.

Review on 4/22/19 of Staff #8's record revealed:
-Hire date 9/12/16;

-Employed as Mental Health Counselor; -Completed
training in Seclusion, Physical Restraint and Isolation
Time-Out on 6/25/18.

Review on 4/22/19 of Staff #9's record revealed
-Hire date 2/25/19;

-Employed as Mental Health Counselor; -Completed
training in Seclusion, Physical Restraint and Isolation
Time-Out on 3/1/19.

Review on 4/24/19 of the Video Surveillance of the
facility for 4/12/19 at approximately 2:12 pm - 2:20pm
revealed:

-2:12pm: Client #1 walked out of the classroom and
was redirected by staff back to the classroom. Client
#1 walked into a large storage area inside the
classroom;

-2:19pm: Staff #8 went to talk with Client #1; -2:20pm:
Staff #8 dragged Client #1 by the feet out of the
classroom storage area and into the

STATEMENT OF DEFICIENCIES AND PLAN (xa) PROVIDER/SUPPLIER/CLIA | (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
OF CORRECTION IDENTIFICATION NUMBER: AoBUILDING? COMPLETED
R
MHLoeo968 04/30/2019

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

6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY T

CHARLOTTE, NC 28211

1D
PREFIX TAG

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

0s)
‘COMPLETE DATE

(xa) ID
PREFIX TAG

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

Division of Health Service Regulation
STATE FORM Ld GNHM11 If continuation sheet 19 of 21

Division of Health Service Regulation

Vv 537

Continued From page 16

actual classroom area. Staff #9 was at her side but did
not touch Client #1. Client #1 kicked and attempted to
fight with Staff #8. Within minutes, Client #1 and Staff
#8 calmly walked from the classroom without incident.

Interview on 4/23/19 with Staff #8 revealed: -
Identified job responsibilities to include "provide
strategies and coping skills to manage behaviors
..remove kids when aggressive or upset to process
feelings on what is going on...;"

-Client #1 is an attention-seeking child who has a
history of self-harm, banging his head and stomping his
feet and has a hard time accepting

"NO;"

-When Client #1 was argumentative and upset
demanding to join his CFT meeting prior to the team
being ready, he became upset and refused to move.
Staff #8 "grabbed [Client #1] by his upper arm and
took him back to classroom;" -Staff #8 and Staff #9
grabbed Client #1 by the arms and "pulled [Client #1]
out of the closet;" -Client #1 eventually joined the
CFT Meeting.

Interview on 4/23/19 with Staff #9 revealed: -Identified
job responsibilities to include "keep clients in a safe
environment and in compliance with the rules;"

-Client #1 was looking to enter his CFT Meeting and was
upset that the rest of the CFT was not ready for him to
join, so Client #1 went into a storage area for "quiet
time" and refused to leave. Client #1 began to tantrum
and fell to the ground. Staff #8 grabbed Client #1 by the
arm and walked to another classroom. Staff #9 denied
touching Client #1.

Interview on 4/25/19 with the Executive Director revealed:
-Staff #8 was suspended regarding another

PRINTED: 05/09/2019
FORM APPROVED

STATEMENT OF DEFICIENCIES AND PLAN
OF CORRECTION

a) PROVIDER/SUPPLIER/CLIA

CATION NUMBER:
IDENTIFICATION ‘A. BUILDING:

MHL060968 B. WING

(X2) MULTIPLE CONSTRUCTION

(x3) DATE SURVEY
COMPLETED

R
04/30/2019

NAME OF PROVIDER OR SUPPLIER

6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY T
CHARLOTTE, NC 28211

STREET ADDRESS, CITY, STATE, ZIP CODE

(x4) ID
PREFIX TAG

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

1D
PREFIX TAG

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

(xs)
COMPLETE DATE

Division of Health Service Regulation

STATE FORM 399

GNHM11

If continuation sheet 20 of 21

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V 537] Continued From page 17 Vv 537

matter;

-Staff #9 was coached regarding the incident; -Staff
will continue to be trained on appropriate physical
restraints.

Eeeuhve vector | Leonard Shobak CC 5 17/19

Division of Health Service Regulation

STATE FORM a GNHM11 Hfcontinuation sheet 21 of 21


state: NC

facility_name: Alexander Youth Network - Charlotte Day Treatment

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

raw_content:
Division of Health Service Regulation

PRINTED: 05/09/2019
FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED
R
MHL060968 04/30/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1
CHARLOTTE, NC 28211
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000} INITIAL COMMENTS V 000
An annual, complaint, and follow up survey was
completed on April 30, 2019. The complaint was
unsubstantiated (Intake # NC150694).
Deficiencies were cited.
This facility is licensed for the following service
category: 10A NCAC 27G .1400 Day Treatment
for Children and Adolescents with Emotional or
Behavioral Disturbances.
V 120| 27G .0209 (E) Medication Requirements Vv 120

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 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.

This Rule is not met as evidenced by:
Based on interview, record review, and
observation, the facility failed to maintain secure

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

STATE FORM

6899

GNHM11

TITLE

(X6) DATE

If continuation sheet 1 of 18

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

STATEMENT OF DEFICIENCIES

PRINTED: 05/09/2019

(X2) MULTIPLE CONSTRUCTION

FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL060968 04/30/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1
CHARLOTTE, NC 28211
(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 1 Vv 120

safe storage of medication 4 of 6 audited current
clients (Clients #2, #3, #4, and #5). The findings
are:

Review on 4/24/19 of Client #2's record revealed:
-Admission date 8/9/18;

-Diagnoses of Circadian Rhythm Sleep Wake
Disorder, Separation Anxiety Disorder, Attention
Deficit Hyperactivity Disorder (ADHD), History of
Physical Abuse;

-8 years old;

-Physician's order dated 12/5/18 for Vyvanse
(treatment of ADHD) 20mg 1 tab at 12:00pm;
-Count sheet for Vyvanse 20mg revealed there
were 8 Vyvanse 20mg pills present on the
morning of 3/21/19. One was administered at
11am on that date;

-Count sheet for Vyvanse 20mg included the
notation dated 3/21/19 "Counted by PI
(Performance Improvement) and count was off by
2 pills" with the signature of the Performance
Improvement Manager (PIM).

Review on 4/24/19 of Client #3's record revealed:
-Admission date 8/6/18;

-Diagnoses of Oppositional Defiant Disorder,
Attention Deficit Hyperactivity Disorder,
Adjustment Disorder;

-6 years old;

-Physician's order dated 10/16/18 for Adderall XR
(treatment of ADHD) 15mg 1 capsule at 12:00pm;
-Count sheet for Adderrall XR 15mg revealed
there were 14 Adderall XR 15mg pills present on
the morning of 3/21/19. One was administered at
11am on that date;

-Count sheet for Adderrall XR15mg included the
notation dated 3/21/19 "Count was off by 1
capsule" with the initials of the PIM.

Review on 4/24/19 of Client #4's record revealed:

Division of Health Service Regulation
STATE FORM

6808 GNHM11

If continuation sheet 2 of 18

Division of Health Service Regulation

PRINTED: 05/09/2019
FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
R
MHL060968 04/30/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1
CHARLOTTE, NC 28211
(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 2

-Admission date 12/27/18;

-Diagnoses of Adjustment Disorder with Mixed
Disturbance of Emotions/Conduct, Oppositional
Defiant Disorder, Attention Deficit Hyperactivity
Disorder, Autism Spectrum Disorder;

-10 years old;

-Physician's order dated 1/16/19 for
Methylphenidate (treatment of ADHD) 10mg 2
tabs at 10:00am and 2:00pm;

-Count sheet for Methylphenidate 10mg revealed
there were 29 pills in the facility just prior to
review on 3/21/19 by the PIM. The date of
previous administration is unclear because the
dates had been crossed out and whited out;
-Count sheet for Methylphenidate 10mg included
a notation dated 3/21/19 "count off by 6 tablets"
with the initials of the PIM;

-Count sheet for Methylphenidate 10mg revealed
there were 62 pills in the facility just prior to
review on 4/24/19 by the PIM;

-Count sheet for Methylphenidate 10mg included
a notation dated 4/24/19 "counted by PI and
count was off by 4 pills."

Review on 4/24/19 of Client #5's record revealed:
-Admission date 3/11/19;

-Diagnoses of Oppositional Defiant Disorder,
Attention Deficit Hyperactivity Disorder, Childhood
Onset Fluency Disorder (Stuttering);

-13 years old;

-Physician's order dated 4/2/19 for Focalin XR
(treatment of ADHD) 30mg 1 cap at 9:00am and
Focalin 5mg 2 caps at 1:00pm;

-Count sheet for Focalin XR 30mg revealed there
were 12 pills in the facility on 3/21/19. One pill
was administered at 9:00am;

-Count sheet for Focalin XR 30mg included a
notation dated 3/21/19 "Count off by 1 capsule"
with the initials of the PIM;

-Count sheet for Focalin 5mg revealed there was

Division of Health Service Regulation
STATE FORM

Vv 120

6808 GNHM11

If continuation sheet 3 of 18

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/09/2019
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL060968 04/30/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1
CHARLOTTE, NC 28211
(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 Vv 120

47 pills in the facility on 3/21/19. Two pills were
administered at 1:00pm;

-Count sheet for Focalin 5mg included a notation
dated 3/21/19 "count was off by 1 pill" with the
initials of the PIM;

-Count sheet for Focalin 5mg included multiple
cross outs and pill count re-entries on the count
sheet with notations of "correct count" for each
day appearing that medication counts were off for
8 consecutive dates of medication administration
from 3/28/19 through 4/5/19.

Review on 4/24/19 of Staff #10's record revealed:
-Hire date 9/10/18;
-Hired as Mental Health Counselor.

Review on 4/23/19 of the facility's Incident
Reports revealed:

-Level 1 incident report dated 3/21/19 for Client
#2 revealed that during an internal review of
medications, it was discovered that the
medication count was off by 1 pill for Vyvanse
20mg;

-Level 1 incident report dated 3/21/19 for Client
#3 revealed that during an internal review of
medications, it was discovered that the
medication count was off by 1 pill for Adderall
15mg;

-Level 1 incident report dated 3/21/19 for Client
#4 revealed that during an internal review of
medications, it was discovered that the
medication count was off by 5 pills for
Methylphenidate 10mg;

-Level | incident report dated 3/21/19 for Client #5
revealed that during an internal review of
medications, it was discovered that medication
counts were off by 1 pill each for Focalin XR
30mg and Focalin 5mg.

Review on 4/26/19 of the facility's Policy on

Division of Health Service Regulation
STATE FORM

6809

GNHM11

If continuation sheet 4 of 18

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/09/2019
FORM APPROVED

(X3) DATE SURVEY

Storage, Disposal and Control of Medications
(Policy 4.8) effective 1/1/1998 with most recent
update on 5/25/10 revealed:

-" ...Schedule II Controlled Medications: (11)
Upon delivery of Schedule II drugs, an authorized
staff member verifies receipt by adding the count
and initials to the Controlled Drugs Record.
Schedule II drugs will be placed in the medication
closet immediately; (12) Schedule II drugs are not
to be removed from locked storage until time of
administration and must be signed out at that
time; (13) Two staff members shall count all
controlled medication on a regular basis verify
count is correct. The two staff members sing the
Controlled Drugs Record signifying count is
accurate. This record is maintained for three
years; (14) If there is a discrepancy in the count,
staff will make every effort to resolve the
discrepancy immediately. If the discrepancy
cannot be resolved, it will be reported through the
Incident Report and accompanying procedures
and recorded on the Controlled Drug Record ..."

Interview on 4/25/19 with Client #2 revealed:
-Takes medication at the facility but does not
know the name of it;

-The medication is "the white pill;"

-Different staff administer medication;
-Never missed receiving his medication.

Interview on 4/25/19 with Client #3 revealed:
-Takes medication at the facility but does not
know the name of it;

-The medication is "the blue pill;"

-Different staff administer medication;
-Never missed receiving his medication.

Interview on 4/25/19 with Client #4 revealed:
-Takes medication at the facility but does not
know the name of it;

Division of Health Service Regulation
STATE FORM

6809

GNHM11

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL060968 04/30/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1
CHARLOTTE, NC 28211
(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 4 Vv 120

If continuation sheet 5 of 18

Division of Health Service Regulation

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

MHL060968

NAME OF PROVIDER OR SUPPLIER

A. BUILDING:

6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1

CHARLOTTE, NC 28211

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/09/2019

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

R
04/30/2019

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 120] Continued From page 5 Vv 120

-The medication is the "mint green pill;"
-Different staff administer medication;
-Never missed receiving his medication.

Interview on 4/25/19 with Client #5 revealed:
-Takes medication at the facility;

-Takes "Focalin XR 30;"

-Different staff administer medication;

-Never missed medications at the facility because
the "doctor at mental health send the paperwork."

Interview on 4/25/19 with Staff #10 revealed:
-Began administering medications three weeks
ago;

-When administering controlled substance
medications, must have an additional staff
present as a witness;

-After administering the medication to each client,
the staff must make sure to check if the client
swallowed the medication. Staff must then sign
the Medication Administration Record and the
count sheet for any controlled substance
medications. The staff witness does not sign any
documents.

Interview on 4/25/19 with the Case Manager
revealed:

-When families drop off controlled substance
medications for clients, the medications must be
checked in by staff trained in medication
administration. The controlled substance
medication pills are counted and a Control
Medication Sheet is completed documenting the
number of pills brought to the facility. The staff
and family member each sign the Control
Medication Sheet verifying the number of pills
brought to the facility.

Interview on 4/25/19 with the Executive Director
revealed:

Division of Health Service Regulation
STATE FORM

6809

GNHM11

If

continuation sheet 6 of 18

PRINTED: 05/09/2019

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL060968 04/30/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1
CHARLOTTE, NC 28211
(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 6 Vv 120

-There should never be any discrepancies
between the number of pills listed on the count
sheet and the actual number of pills present in
the facility;

-There have been discrepancies in the past
several weeks;

-Many staff have administered medications in the
past several weeks;

-Registered Nurses will be assigned to oversee
medication administration, controlled substance
count, and storage of medication at the facility.

Observation on 4/25/19 at approximately
11:00am revealed:

-Medication stored in a cabinet secured with a
large padlock. The medication cabinet is located
behind two locked closet doors.

Review on 4/26/19 of the Plan of Protection
completed by the Executive Director dated
4/26/19 revealed:

"What immediate action will the facility take to
ensure the safety of the consumers in your care?
-At the end of each day, either the Program
Manager or a staff assigned by Program Manager
will check to ensure that all medication counts are
accurate.

-All Charlotte Day Treatment staff will be training
in Medication Administration.

-Each classroom staff will be responsible for their
consumer's medication within their classroom.
One staff will give out the meds (medications),
and the other staff will back them up to ensure
counts are correct.

Describe your plans to make sure the above
happens.

-Once a week, RN (Registered Nurse) will check
medications, medication counts, and MAR
(Medication Administration Record) sheets to
ensure that everything meets protocol.

Division of Health Service Regulation

STATE FORM

6809

GNHM11

If continuation sheet 7 of 18

Division of Health Service Regulation

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

MHL060968

NAME OF PROVIDER OR SUPPLIER

A. BUILDING:

6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1

CHARLOTTE, NC 28211

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/09/2019
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
04/30/2019

STREET ADDRESS, CITY, STATE, ZIP CODE

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

(x4) ID
PREFIX
TAG

ID
PREFIX
TAG

PROVIDER'S PLAN OF CORRECTION (xs)
(EACH CORRECTIVE ACTION SHOULD BE. COMPLETE

CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

V 120] Continued From page 7

-lf counts are off, the nurse will immediately
report to the Program Manager and the Executive
Director and will complete an incident report."

Accurate count records and secure storage were
not maintained for controlled substance
medications resulting in multiple pills of Adderall,
Methylphenidate, Focalin, and Vyvanse being
unaccounted for. These medications were under
the control and responsibility of the facility and
were prescribed for the treatment of Attention
Deficit Hyperactivity Disorder for clients ranging
from 6 - 13 years old. The medications have a
high potential for diversion and misuse. The
clients were diagnosed with mental health needs
including, but not limited to, Attention Deficit
Hyperactivity Disorder, Oppositional Defiant
Disorder, Adjustment Disorder, and Autism
Spectrum Disorder. Missing controlled substance
medication is detrimental to the clients' health,
safety, and welfare in that only a limited amount
of controlled substance medications can be
dispensed each month. This deficiency
constitutes a Type B rule violation. If the violation
is not corrected within 45 days, an administrative
penalty of $200.00 per day will be imposed for
each day the facility is out of compliance beyond
the 45th day.

V 367] 27G .0604 Incident Reporting Requirements

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

Division of Health Service Regulation
STATE FORM

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V 367

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PRINTED: 05/09/2019

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL060968 04/30/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1
CHARLOTTE, NC 28211
(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 8 V 367

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:

(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 III incident reports to the Division of

Division of Health Service Regulation
STATE FORM

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If continuation sheet 9 of 18

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/09/2019
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL060968 04/30/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1
CHARLOTTE, NC 28211
(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 9 V 367

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.
.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 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 interview and record review, the facility
failed to report all level II incidents to the Local

Management Entity (LME) responsible for the

Division of Health Service Regulation
STATE FORM

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If continuation sheet 10 of 18

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/09/2019
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL060968 04/30/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1
CHARLOTTE, NC 28211
(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

catchment area where services are provided
within 72 hours of becoming aware of the
incident. The findings are:

Review on 4/24/19 of Client #6's record revealed:
-Admission date 12/6/18;

-Diagnoses of Disruptive Mood Dysregulation
Disorder, Attention Deficit Hyperactivity Disorder,
Major Depressive Disorder, Generalized Anxiety
Disorder, Persistent Depressive Disorder,
Borderline Intellectual Functioning;

-13 years old.

Review on 4/24/19 of Former Client #7's record
revealed:

-Admission date 7/9/18;

-Diagnoses of Nocturnal Enuresis, Other
Specified Trauma or Stressor Disorder, Attention
Deficit Hyperactivity Disorder, Borderline
Intellectual Developmental Disability, Disruptive
Mood Dysregulation Disorder;

- 11 years old.

Review on 4/23/19 of the facility's Incident
Reports revealed:

-Level | incident report dated 3/20/19 regarding
an incident of aggression and suicidal ideation for
Client #6 which resulted in a report to local law
enforcement;

-Level | incident report dated 3/6/19 regarding in
incident of aggression and assault for Former
Client #7 which resulted in a report to law
enforcement and returning the client to the
facility.

Interview on 4/25/19 with the Executive Director
revealed:

-Will make sure all Level Il incident reports are
completed as needed in the future;

-Did not realize the incident involving Former

Division of Health Service Regulation
STATE FORM

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If continuation sheet 11 of 18

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/09/2019
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL060968 04/30/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1
CHARLOTTE, NC 28211
(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 11 V 367
Client #7 needed to be completed as a Level II
incident;
-Had instructed the staff to complete a Level II
incident for Client #6. It must have been an
oversight that staff did not complete the Level II
report.
V 537] 27E .0108 Client Rights - Training in Sec Rest & V 537

ITO

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

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

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

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

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

Division of Health Service Regulation
STATE FORM

6809

GNHM11

If continuation sheet 12 of 18

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/09/2019
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL060968 04/30/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1
CHARLOTTE, NC 28211
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 537] Continued From page 12 V 537

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

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

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

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

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

(3) emphasis on safety and respect for the
rights and dignity of all persons involved (using
concepts of least restrictive interventions and
incremental steps in an intervention);

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

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

(6) prohibited procedures;

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

(8) documentation methods/procedures.

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

(1) Documentation shall include:

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

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

Division of Health Service Regulation
STATE FORM

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If continuation sheet 13 of 18

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/09/2019
FORM APPROVED

(X3) DATE SURVEY

(2) The Division of MH/DD/SAS may
review/request this documentation at any time.
(i) Instructor Qualification and Training
Requirements:

need for restrictive interventions.

teaching the use of seclusion, physical restraint
and isolation time-out.

by scoring a passing grade on testing in an
instructor training program.

(4) The training shall be

objectives, measurable testing (written and by

measurable methods to determine passing or
failing the course.

service provider plans to employ shall be

to Subparagraph (j)(6) of this Rule.

of seclusion, physical restraint and isolation
time-out, as specified in Paragraph (a) of this
Rule.

(8) Trainers shall be currently trained in

Division of Health Service Regulation
STATE FORM

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

(3) Trainers shall demonstrate competence

competency-based, include measurable learning

observation of behavior) on those objectives and

(5) The content of the instructor training the

approved by the Division of MH/DD/SAS pursuant

(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

6809

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AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL060968 04/30/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1
CHARLOTTE, NC 28211
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 537 Continued From page 13 V 537

If continuation sheet 14 of 18

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/09/2019
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL060968 04/30/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1
CHARLOTTE, NC 28211
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 537 Continued From page 14 V 537
CPR.
(9) Trainers shall have coached experience

in teaching the use of restrictive interventions at
least two times with a positive review by the
coach.

(10) Trainers shall teach a program on the
use of restrictive interventions at least once
annually.

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

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

(1) Documentation shall include:

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

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

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

review/request this documentation at any time.
(!) Qualifications of Coaches:

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

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

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

This Rule is not met as evidenced by:

Based on interview and record review, facility
staff failed to display competency while
implementing physical restraints affecting 1 of 3
audited staff members (Staff #8). The findings
are:

Division of Health Service Regulation
STATE FORM

6809

GNHM11

If continuation sheet 15 of 18

Division of Health Service Regulation

PRINTED: 05/09/2019
FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
R
MHL060968 04/30/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1
CHARLOTTE, NC 28211
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

V 537] Continued From page 15

Review on 4/24/19 of Client #1's record revealed:
-Admission date 3/4/19;

-Diagnoses of Obsessive Compulsive Disorder,
Other Specific Impulse Control and Conduct
Disorder, Unspecified Schizophrenia Spectrum
and Other Psychotic Disorder, Unspecified
Depression Disorder, Unspecified Attention
Hyperactivity Disorder;

-10 years old.

Interview on 4/25/19 with Client #1 revealed:
-Had not been restrained at the facility;

-Staff #1 grabbed him by the wrist and the neck
the day his most recent Child and Family Team
(CFT) meeting (4/12/19), but he was not grabbed
by his legs or feet.

Review on 4/22/19 of Staff #8's record revealed:
-Hire date 9/12/16;

-Employed as Mental Health Counselor;
-Completed training in Seclusion, Physical
Restraint and Isolation Time-Out on 6/25/18.

Review on 4/22/19 of Staff #9's record revealed:
-Hire date 2/25/19;

-Employed as Mental Health Counselor;
-Completed training in Seclusion, Physical
Restraint and Isolation Time-Out on 3/1/19.

Review on 4/24/19 of the Video Surveillance of
the facility for 4/12/19 at approximately 2:12 pm -
2:20pm revealed:

-2:12pm: Client #1 walked out of the classroom
and was redirected by staff back to the
classroom. Client #1 walked into a large storage
area inside the classroom;

-2:19pm: Staff #8 went to talk with Client #1;
-2:20pm: Staff #8 dragged Client #1 by the feet
out of the classroom storage area and into the

Division of Health Service Regulation
STATE FORM

V 537

6808 GNHM11

If continuation sheet 16 of 18

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/09/2019
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL060968 04/30/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1
CHARLOTTE, NC 28211
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 537] Continued From page 16 V 537

actual classroom area. Staff #9 was at her side
but did not touch Client #1. Client #1 kicked and
attempted to fight with Staff #8. Within minutes,
Client #1 and Staff #8 calmly walked from the
classroom without incident.

Interview on 4/23/19 with Staff #8 revealed:
-Identified job responsibilities to include "provide
strategies and coping skills to manage behaviors
..remove kids when aggressive or upset to
process feelings on what is going on...;"

-Client #1 is an attention-seeking child who has a
history of self-harm, banging his head and
stomping his feet and has a hard time accepting
"NO;"

-When Client #1 was argumentative and upset
demanding to join his CFT meeting prior to the
team being ready, he became upset and refused
to move. Staff #8 "grabbed [Client #1] by his
upper arm and took him back to classroom;"
-Staff #8 and Staff #9 grabbed Client #1 by the
arms and "pulled [Client #1] out of the closet;"
-Client #1 eventually joined the CFT Meeting.

Interview on 4/23/19 with Staff #9 revealed:
-Identified job responsibilities to include "keep
clients in a safe environment and in compliance
with the rules;"

-Client #1 was looking to enter his CFT Meeting
and was upset that the rest of the CFT was not
ready for him to join, so Client #1 went into a
storage area for "quiet time" and refused to leave.
Client #1 began to tantrum and fell to the ground.
Staff #8 grabbed Client #1 by the arm and walked
to another classroom. Staff #9 denied touching
Client #1.

Interview on 4/25/19 with the Executive Director
revealed:
-Staff #8 was suspended regarding another

Division of Health Service Regulation
STATE FORM

6809

GNHM11

If continuation sheet 17 of 18

Division of Health Service Regulation

PRINTED: 05/09/2019

FORM APPROVED

matter;

-Staff #9 was coached regarding the incident;
-Staff will continue to be trained on appropriate
physical restraints.

Division of Health Service Regulation
STATE FORM

6809

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL060968 04/30/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1
CHARLOTTE, NC 28211
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 537] Continued From page 17 V 537

If

continuation sheet 18 of 18

inspection_type: MHLCS Annual, Complaint, and Follow-up

document_type: Statement of Deficiency


summary: Statement of Deficiency - MHLCS Complaint

raw_content:
PRINTED: 08/02/2018

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
Cc
MHL060968 08/02/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1
CHARLOTTE, NC 28211
(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 8/2/18.
The complaint was unsubstantiated (Intake NC #
00141296). No deficiencies were cited.

This facility is licensed for the following service
category: 10A NCAC 27G .1400 Day Treatment
for Children and Adolescents with Emotional or
Behavioral Disturbances.

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

STATE FORM

6899

KM2C11

TITLE (X6) DATE

If continuation sheet 1 of 1

inspection_type: MHLCS Complaint


summary: Statement of Deficiency - MHLCS Annual and Complaint

raw_content:
Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL060968

A. BUILDING:

6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1
CHARLOTTE, NC 28211

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/16/2018

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

05/15/2018

(x4) ID
PREFIX
TAG

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

ID
PREFIX
TAG

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

(xs)
COMPLETE
DATE

V 000!

Vv 131

INITIAL COMMENTS

An annual and complaint survey was completed
on 5/15/18. The complaint was unsubstantiated
(Intake NC # 00138222). A deficiency was cited.

This facility is licensed for the following service
category: 10A NCAC 27G .1400 Day Treatment
for Children and Adolescents with Emotional or
Behavioral Disturbances.

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

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

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

This Rule is not met as evidenced by:

Based on interview and record review, the facility
failed to ensure that the Health Care Personnel
Registry (HCPR) be accessed and the results
documented prior to an offer of employment for
all employees affecting 1 of 5 audited staff
members (Program Manager). The findings are:

Review on 5/15/18 of the Program Manager's
record revealed:

-Hire date of 11/30/09;

-HCPR completed 12/04/09.

Interview on 5/15/18 with the Human Resource

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

STATE FORM

V 000

Vv 131

6899

DRZJ11

TITLE

(X6) DATE

If continuation sheet 1 of 2

PRINTED: 05/16/2018

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
MHL060968 05/15/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1
CHARLOTTE, NC 28211
(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 131] Continued From page 1 Vv 131

Associate revealed:

-The HCPR was completed late;

-It is the policy for all HCPR to be completed prior
to an offer of employment.

Division of Health Service Regulation
STATE FORM

6809

DRZJ11

If continuation sheet 2 of 2

inspection_type: MHLCS Annual and Complaint


summary: Plan of Correction - MHLCS Annual and Complaint

raw_content:
” STATE FORM

PRINTED: 05/16/2018

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
MHLo6ag968 B. WING. 05/15/2018

NAME OF PROVIDER OR SUPPLIER
ALEXANDER YOUTH NETWORK - CHARLOTTE DAYT

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

INITIAL COMMENTS

An annual and complaint survey was completed
on 5/15/18. The complaint was unsubstantiated
(Intake NC # 00138222). A deficiency was cited.

This facility is licensed for the following service
category: 10A NCAC 27G .1400 Day Treatment
for Children and Adolescents with Emotional or
Behavioral Disturbances.

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

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

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

This Rule is not met as evidenced by:

Based on interview and record review, the facility
failed to ensure that the Health Care Personnel
Registry (HCPR) be accessed and the results
documented prior to an offer of employment for
all employees affecting 1 of 5 audited staff
members (Program Manager). The findings are:

Review on 5/15/18 of the Program Manager's
record revealed:

-Hire date of 11/30/09;

-HCPR completed 12/04/09.

Interview on 5/15/18 with the Human Resource
Division of Health Service Regulation

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

Vv 000

STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
CHARLOTTE, NC 28211

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

luman resources has since
implemented various auditing measures
to ensure all required pre-employment
background screens are completed prior
o hire. HR completes a double

erification process to hire- one that is
completed by HR Compliance
Associate and the other by the Director
lof HR or designee. The date and staff
initials are documented in the new

12/4/09

5899

V131 Jemployee checklist in their personnel
file.
DHSR - Mental Health
MAY 302018
Lic. & Cert. Section
TITLE (X6) DATE
DRZJ11 if continuation sheet 1 of 2

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
MHL060968

NAME OF PROVIDER OR SUPPLIER

ALEXANDER YOUTH NETWORK - CHARLOTTE DAYT

B. WING _

STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
CHARLOTTE, NC 28211

(X2) MULTIPLE CONSTRUCTION
A. BUILDING: _

PRINTED: 05/16/2018
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

05/15/2018

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

1D
PREFIX
TAG

V 131] Continued From page 1

Associate revealed:

-The HCPR was completed late;

-It is the policy for all HCPR to be completed prior
to an offer of employment.

V 131

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

IHuman resources has since
implemented various auditing measures
to ensure all required pre-employment
background screens are completed prior
to hire. HR completes a double
erification process to hire- one that is
ompleted by HR Compliance

Associate and the other by the Director
lof HR or designee. The date and staff
initials are documented in the new
employee checklist in their personnel

Division of Health Service Regulation
STATE FORM

6838

If continuation sheet 2 of 2

DR2J11

NC DEPARTMENT OF ROY COOPER - Governor

SEMAN SERV MANDY COHEN, MD,
HUMAN SERVICES MD, MPH * Secretary
Division of Health Service Regulation MARK PAYNE - Director

Mr. Leonard Shinhoster
Alexander Youth Network
6220 Thermal Road
Charlotte, NC 28211

May 17, 2018

Re: Annual and Complaint Survey completed May 15, 2018
Alexander Youth Network — Charlotte Day Treatment, 6220 Thermal Road, Charlotte, NC 28211
MHL # 060-968
E-mail Address: Ishinhoster@alexanderyouthnetwork.org;

bplummer@alexanderyouthnetwork.org
Intake #NC00138222

Dear Mr. Shinhoster:

Thank you for the cooperation and courtesy extended during the annual and complaint survey completed
May 15, 2018. The complaint was unsubstantiated.

Ericlosed you will find all deficiencies cited listed on the Statement of Deficiencies Form. The purpose of
the Statement of Deficiencies is to provide you with specific details of the practice that does not comply
with state regulations. You must develop one Plan of Correction that addresses each deficiency listed on
the State Form, and return it to our office within ten days of receipt of this letter. Below you will find
details of the type of deficiencies found, the time frames for compliance plus what to include in the Plan of
Correction.

Type of Deficiencies Found
e Standard level deficiency.

Time Frames for Compliance ;
e Standard level deficiency must be corrected within 60 days from the exit of the survey, which is
June 14, 2018.

What to include in the Plan of Correction

e Indicate what measures will be put in place to correct the deficient area of practice (i.e. changes
in policy and procedure, staff training, changes in staffing patterns, etc.).
Indicate what measures will be put in place to prevent the problem from occurring again.
Indicate who will monitor the situation to ensure it will not occur again.
Indicate how often the monitoring will take place.
Sign and date the bottom of the first page of the State Form.

Make a copy of the Statement of Deficiencies with the Plan of Correction to retain for your records.
Please do not include confidential information in your plan of correction and please remember
never to send confidential information (protected health information) via email.

NC DEPARTMENT OF HEALTH AND HUMAN SERVICES « DIVISION OF HEALTH SERVICE REGULATION
MENTAL HEALTH LICENSURE AND CERTIFICATION SECTION

LOCATION: 1800 Umstead Drive, Williams Building, Raleigh, NC 27603
MAILING ADDRESS: 2718 Mail Service Center, Raleigh, NC 27699-2718
www.nedhhs.gov/dhsr/ » TEL: 919-855-3795 » FAX: 919-715-8078

AN EQUAL OPPORTUNITY / AFFIRMATIVE ACTION EMPLOYER

s May 17, 2018
Alexander Youth Network
Mr. Leonard Shinhoster

Send the original completed form to our office at the following address within 10 days of receipt of this
letter.

Mental Health Licensure and Certification Section
NC Division of Health Service Regulation
‘2718 Mail Service Center
Raleigh, NC 27699-2718

A follow up visit will be conducted to verify all violations have been corrected. If we can be of further
assistance, please call Lynn Grier, Team Leader at 704-596-4072.

Sincerely,

CGileweey.

Eileen Sanchez, MA
Facility Compliance Consultant |
Mental Health Licensure-& Certification Section

Co: Rob Robinson, Director, Alliance Behavioral Health LME/MCO
Wes Knepper, Quality Management Director, Alliance Behavioral Health LME/MCO
Trey Sutten, Interim Director, Cardinal Innovations LME/MCO
Onika Wilson, Quality Management Director, Cardinal Innovations LME/MCO
Leza Wainwright, Director, Trillium Health Resources LME/MCO
Kim Keehn, Quality Management Director, Trillium Health Resources LME/MCO
Sarah Stroud, Director, Eastpointe LME/MCO
Jeanette Jordan-Huffam, Quality Management Director, Eastpointe LME/MCO
W. Rhett Melton, Director, Partners Behavioral Healthcare LME/MCO :
Selenna Moss, Quality Management Director, Partners Behavioral Healthcare LME/MCO
Victoria Whitt, Director, Sandhills Center LME/MCO
Carol Robertson, Quality Management Director, Sandhills Center LME/MCO
Brian Ingraham, Director, Vaya Health LME/MCO
Patty Wilson, Quality Management Director, Vaya Health LME/MCO

document_type: Plan of Correction