summary: Statement of Deficiency - MHLCS Complaint

raw_content:
PRINTED: 07/02/2024

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
MHL001-103 B. WING 06/20/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
3309-A NC HIGHWAY 49
FALCON CREST RESIDENTIAL CARE 3 INC BURLINGTON, NC 27217
(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 June 20,
2024. The complaints were unsubstantiated
(#NC00216245 and #NC00216804). No
deficiencies were cited.
This facility is licensed for the following service
category: 10A NCAC 27G. 1700 Residential
Treatment Staff Secure for Children or
Adolescents.
This facility is licensed for four and currently has
a census of two. The survey sample consisted of
two former clients.
Division of Health Service Regulation
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
STATE FORM 6899 2EU711 If continuation sheet 1 of 1

inspection_type: MHLCS Complaint


state: NC

facility_name: Falcon Crest Residential Care 3 Inc.

summary: Statement of Deficiency - MHLCS Annual

raw_content:
PRINTED: 10/23/2023

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL001-103 B. WING 10/20/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

3309-A NC HIGHWAY 49

FALCON CREST RESIDENTIAL CARE 3 INC BURLINGTON, NC 27217

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)
V 000} INITIAL COMMENTS V 000

An annual survey was completed on October 20,
2023. No deficiencies were cited.

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

This facility is licensed for 4 and currently has a
census of 1. The survey sample consisted of
audits of 1 client1.

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

STATE FORM 6899 P8EK11 If continuation sheet 1 of 1

inspection_type: MHLCS Annual

document_type: Statement of Deficiency


summary: Statement of Deficiency - MHLCS Annual

raw_content:
Division of Health Service Regulation

PRINTED: 03/24/2022
FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
MHLO001-103 03/24/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
3309-A NC HIGHWAY 49
FALCON CREST RESIDENTIAL CARE 3 INC
BURLINGTON, NC 27217
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000) INITIAL COMMENTS Vv 000

An annual survey was completed on 3/24/22. No
deficiencies were cited.

This facility is licensed for the following service
category:

10A NCAC 27G .1700 Residential Treatment
Staff Secure for Children or Adolescents.

This facility is licensed for 4 of licensed beds and
currently has a census of 2. The survey sample
consisted of audits of 2 clients

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

STATE FORM

6899

ZX5Z11

TITLE (X6) DATE

If continuation sheet 1 of 1


raw_content:
Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
MHLO001-103

PRINTED: 08/21/2020

STREET ADDRESS, CITY, STATE, ZIP CODE

3309-A NC HIGHWAY 49
BURLINGTON, NC 27217

FALCON CREST RESIDENTIAL CARE 3 INC

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

A. BUILDING: COMPLETED
B.WING 08/21/2020

(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 August 21,
2020. The complaint was unsubstantiated. No
deficiencies were cited. (Intake #NC00168440)
This facility is licensed for the following service
category:
10A NCAC 27G .1700 Residential Treatment
Staff Secure for Children or Adolescents.
Division of Health Service Regulation
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

STATE FORM

6899

TWN111 If continuation sheet 1 of 1


summary: Statement of Deficiency - MHLCS Annual

raw_content:
PRINTED: 02/14/2020

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL001-103 B. WING 02/13/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

3309-A NC HIGHWAY 49

FALCON CREST RESIDENTIAL CARE 3 INC BURLINGTON, NC 27217

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)
V 000} INITIAL COMMENTS V 000

An annual survey was completed on February 13,
2020. No deficiencies were cited.

This facility is licensed for the following service
category:

10A NCAC 27G .1700 Residential Treatment
Staff Secure for Children or Adolescents.

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

STATE FORM 6899 R8G211 If continuation sheet 1 of 1


summary: Statement of Deficiency - MHLCS Annual

raw_content:
Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

FALCON CREST RESIDENTIAL CARE 3 INC

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
MHLO001-103

B. WING

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 01/23/2019
FORM APPROVED

01/16/2019

STREET ADDRESS, CITY, STATE, ZIP CODE

3309-A NC HIGHWAY 49

BURLINGTON, NC 27217

(X3) DATE SURVEY
COMPLETED

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

DEFICIENCY)
V 000} INITIAL COMMENTS Vv 000
An annual survey was completed on January 16,
2019. No deficiencies were cited.
The facility is licensed for the following service
category:
10A NCAC 27G. 1700 Residential Treatment
Staff Secure for Children or Adolescents.
Division of Health Service Regulation
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
STATE FORM 6899 OWRD11 If continuation sheet 1 of 1


facility_name: Falcon Crest Residential Care 2

summary: Statement of Deficiency - MHLCS Annual

raw_content:
Division of Health Service Regulation

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

MHL001-141

NAME OF PROVIDER OR SUPPLIER

FALCON CREST RESIDENTAL CARE 2

STREET ADDRESS, CITY, STATE, ZIP CODE

723 NORTH FISHER STREET
BURLINGTON, NC 27217

PRINTED: 02/02/2026

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

A. BUILDING: COMPLETED
B.WING 01/29/2026

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

(X4) ID
PREFIX
TAG

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

(x5)
COMPLETE
DATE

V 000} INITIAL COMMENTS

An annual survey was completed on January 29,
2026. No deficiencies were cited.

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

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

Division of Health Service Regulation

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

V 000

TITLE (X6) DATE

STATE FORM

809

PD2M11 If continuation sheet 1 of 1


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

raw_content:
Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
MHL001-159

B. WING

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 02/04/2022
FORM APPROVED

02/03/2022
STREET ADDRESS, CITY, STATE, ZIP CODE

723 NORTH FISHER STREET
BURLINGTON, NC 27217

ALAMANCE ACADEMY, LLC

(X3) DATE SURVEY
COMPLETED

(X4) ID
PREFIX
TAG

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

ID
PREFIX
TAG

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

(x5)
COMPLETE
DATE

V 000

INITIAL COMMENTS

An annual and follow up survey was attempted on
2/3/22. According to the Program Director there
are no clients being served at the facility. The last
time clients were served at the facility was
4/15/21.

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

Observation of the facility on 2/3/22 at
approximately 9:40 AM revealed: The home
appeared to be empty. There were no staff and/or
clients present at the group home.

Interview with the Program Director on 2/3/22
revealed: The group home did not have any
clients living there. The group home had no
clients since around April 15, 2021. She just
recently submitted a change of licensure for the
group home about two weeks ago.

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

STATE FORM

V 000

6899

TITLE

(X6) DATE

MS5H011 If continuation sheet 1 of 1

inspection_type: MHLCS Annual and Follow-up


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

raw_content:
Division of Health Service Regulation

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

MHLO001-159

NAME OF PROVIDER OR SUPPLIER

PRINTED: 12/10/2021

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

STREET ADDRESS, CITY, STATE, ZIP CODE

723 NORTH FISHER STREET
BURLINGTON, NC 27217

ALAMANCE ACADEMY, LLC

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R-C
11/30/2021

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

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

TAG CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

(xs)
COMPLETE
DATE

V 000} INITIAL COMMENTS

A complaint and follow up survey was completed
on 11/30/21. The complaints were substantiated
(intake #NC00175826, NC00175831,
NC00175951 and NC00175980). Deficiencies
were cited.

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

The survey sample consisted of audits of 2
current clients, 1 former client, 1 deceased client.

V 114) 27G .0207 Emergency Plans and Supplies

10A NCAC 27G .0207 EMERGENCY PLANS
AND SUPPLIES

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

(b) The plan shall be made available to all staff
and evacuation procedures and routes shall be
posted in the facility.

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

This Rule is not met as evidenced by:

Based on record review and interviews, the
facility failed to conduct disaster drills under
conditions that simulate emergencies. The
findings are:

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

STATE FORM

V 000

Vv 114

TITLE

6808 W3NM11 It

(X6) DATE

continuation sheet 1 of 24

Division of Health Service Regulation

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

MHLO001-159

NAME OF PROVIDER OR SUPPLIER

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

723 NORTH FISHER STREET
BURLINGTON, NC 27217

ALAMANCE ACADEMY, LLC

PRINTED: 12/10/2021

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

R-C
11/30/2021

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL
TAG 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 114] Continued From page 1

Review of the facility's disaster drill log on 4/7/21
revealed:

-3/6/21-1st shift

-2/6/21-1st shift

-1/1/21-no shift indicated

-There were no disaster drills conducted for 2nd
and 3rd shift for the 1st quarter of 2021.

-There were no disaster drills conducted for 4th

quarter of 2020.

Interview with client #1 on 4/1/21 revealed:
-He lived at the group home for about a month.
-He was not sure if staff did any fire or disaster
drills with them.

Interview with client #2 on 4/1/21 revealed:

-He lived at the home for about three weeks.
-Staff had not done a fire and/or disaster drill with
them.

Interview on 4/7/21 with the Program Director
revealed:

-The group home had three separate staff shifts.
-She stopped taking referrals for a while. She did
not have clients from March 2020 until November
2020. She got a client November 27, 2020.

-Staff #5 was a compliance officer within the
agency and did the majority of the drills.

-She was a little surprised staff #5 did not
complete disaster drills for all shifts.

-She confirmed staff failed to conduct disaster
drills under conditions that simulate emergencies.

This deficiency constitutes a re-cited deficiency
and must be corrected within 30 days.

V 115| 27G .0208 Client Services

Vv 114

V 115

Division of Health Service Regulation
STATE FORM

6809

W3NM11

If continuation sheet 2 of 24

Division of Health Service Regulation

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

MHLO001-159

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 12/10/2021

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

723 NORTH FISHER STREET
BURLINGTON, NC 27217

ALAMANCE ACADEMY, LLC

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

R-C
11/30/2021

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 115] Continued From page 2 V 115

10A NCAC 27G .0208 CLIENT SERVICES

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

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

(2) activities are suitable for the ages, interests,
and treatment/habilitation needs of the clients
served; and

(3) clients participate in planning or determining
activities.

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

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

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

This Rule is not met as evidenced by:

Based on record reviews and interviews the
facility failed to provide supervision to ensure the
safety and welfare of one of one deceased client
(DC #4) and one of one former client (FC #3).
The findings are:

a. Review on 4/7/21 of DC #4's record revealed:

Division of Health Service Regulation
STATE FORM

6809

If

continuation sheet 3 of 24

Division of Health Service Regulation

PRINTED: 12/10/2021
FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
R-C
MHLO001-159 11/30/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
723 NORTH FISHER STREET
ALAMANCE ACADEMY, LLC
BURLINGTON, NC 27217
(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

V 115] Continued From page 3

Hyperactivity Disorder.
-DC #4 died on 3/28/21.
-DC #4 was 15 years old.

ideations.

report.

bag.

examiner on 11/18/21.

Division of Health Service Regulation
STATE FORM

-Admission date of 3/17/21.

-Diagnoses of Intermittent Explosive Disorder,
Depressive Disorder, Impulse Control Disorder,
Conduct Disorder and Attention Deficit

-"Comprehensive Clinical Assessment" dated
3/11/21 had the following:
marijuana use, though his mother expressed
concern that Facebook messages have been
found between [DC #4] and peers related to
marijuana." DC #4's biological parents had a
history of substance abuse. DC #4 had a history
of defiance, verbal and physical aggression,
property destruction, depression and suicidal

Review of facility records on 3/30/21 revealed:
-An incident report dated 3/28/21 indicated DC #4
cause of death was unknown. There was no
description of the incident included in this incident

Review of a police report on 4/7/21 revealed:
-The report was dated 4/2/21-The Program
Director believed drugs were found in a vacant
room at the group home. The Program Director
advised when she touched the bag her mouth
started tingling. An officer went to the home with
a "K9" partner and searched the location. The
dog came to a dresser in the vacant room and
stared at it. There was a book bag containing
white powder residue in one of the pockets of the

Review of the Report of Autopsy Examination on
11/30/21 for DC #4 revealed:
-The report was completed by the medical

V 115

"[DC #4] denied

6808 W3NM11

If continuation sheet 4 of 24

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHLO001-159

PRINTED: 12/10/2021

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

STREET ADDRESS, CITY, STATE, ZIP CODE

723 NORTH FISHER STREET
BURLINGTON, NC 27217

ALAMANCE ACADEMY, LLC

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R-C
11/30/2021

-The medical examiner determined DC #4's
cause of death was cocaine and fentanyl toxicity.
-There was no natural disease or physical injury
detected during the exam.

b. Review on 4/1/21 of FC #3's record revealed:
-Admission date 3/16/21.

-Diagnoses of Attention Deficit Hyperactivity
Disorder, Disruptive Mood Dysregulation Disorder
and Cannabis Abuse.

-FC #3 was discharged on 3/29/21.

-FC #3 was 14 years old.

-"Clinical Assessment" dated 3/16/21 had the
following: The previous placement was
concerned FC #3 would harm someone or be
seriously harmed due to his lack of regard for
others. He had a history of substance abuse,
storytelling, possible gang involvement, homicidal
ideations, elopement and assaultive behaviors.
-"Comprehensive Clinical Assessment" dated
1/22/21 had the following: "On 1/5/21 [FC #3's]
grandmother reported to the therapist that [FC
#3's] biological mother, from whose custody he
was removed due to substantiated reports of
neglect and substance use, had aided [FC #3] in
eloping from the home. It was reported that
biological mother had assisted [FC #3] in gaining
access to substances including marijuana. [FC
#3] reported during this period of elopement on or
around 1/5/21 he had access to
Methamphetamines and marijuana; [FC #3]
declined to provide details around the frequency
and severity of his substance use during this
time."

Interview on 4/1/21 with client #2 revealed:

-DC #4 did talk to him about wanting to get high a
few days before he passed away.

-On 3/27/21 "[DC #4 and FC #3] told him they
had some "Molly"

Division of Health Service Regulation

STATE FORM

6808 W3NM11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 115] Continued From page 4 V 115

If continuation sheet 5 of 24

Division of Health Service Regulation

PRINTED: 12/10/2021
FORM APPROVED

(Methylenedioxymethamphetamine). They tried to
peer pressure him into doing drugs with them."
He never saw the Molly they kept saying they
had. He was not even sure what Molly looked
like.

-He never saw DC #4 and/or FC #3 doing drugs
in the group home. He suspected they were doing
drugs because they kept talking about doing
drugs in the home on other occasions.

Interview on 4/8/21 with FC #3 revealed:

-On 3/28/21 around 10:00 am he noticed
something was wrong with DC #4.

-DC #4 was still laying in bed and his lips and
arms looked blue. He checked DC #4's pulse and
there was no pulse. When he touched DC #4 he
felt cold.

-He told staff #1 he thought something was wrong
with DC #4.

-Staff #1 made a phone call and police officers
and Emergency Medical Services (EMS) staff
came out to the group home.

-He was informed later the police officers found a
vape pen that belonged to him. He was told "the
vape pen may be laced with Molly." He brought
the vape pen with him when he was admitted to
the home. "He used the vape pen to smoke
tobacco, not Molly." "I don't understand how that
vape pen could contain Molly."

-He used drugs in the past, however he was
clean for about 80 days.

-In the past he used Molly, heroin, cocaine,
marijuana and other drugs.

-He never did any drugs at Alamance Academy.
He never did drugs with DC #4 and never saw DC
#4 doing any drugs.

Interview on 4/5/21 with staff #1 revealed:
-On 3/28/21 around 10:00 am FC #3 informed
him that something did not look right with DC #4.

Division of Health Service Regulation

STATE FORM

6808 W3NM11

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHLO001-159 11/30/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
723 NORTH FISHER STREET
ALAMANCE ACADEMY, LLC
BURLINGTON, NC 27217
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 115] Continued From page 5 V 115

If continuation sheet 6 of 24

PRINTED: 12/10/2021

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHLO001-159 11/30/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
723 NORTH FISHER STREET
ALAMANCE ACADEMY, LLC
BURLINGTON, NC 27217
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 115] Continued From page 6 V 115

-He let DC #4 and FC #8 sleep in later that
morning. Third shift staff informed him the clients
were up a little late the night before.

-He went into their bedroom and saw DC #4 lying
in bed. He called DC #4's name, tapped his leg
and noticed DC #4's body was stiff.

-DC #4 was unresponsive. DC #4's face, arms
and legs looked blue.

-He saw a yellowish, bloody, foamy like
substance coming from DC #4's mouth and nose.
-He called 911 and pulled DC #4 onto the floor
and started doing Cardiopulmonary Resuscitation
(CPR) with the dispatcher on the phone.

-EMS arrived, they took over and he left the
bedroom.

-Staff #3 was running a little late and arrived to
the home shortly after EMS arrived.

-He talked to FC #3 after he found DC #4
unresponsive. FC #3 said "he and [DC #4] were
taking Molly by using a vape pen." FC #3 did not
specify which day and time this occurred.

-FC #3 had a history of substance abuse. FC #3
would sometimes say he took substances in the
past.

Interview on 4/9/21 with staff #2 revealed:

-On 3/27/21 she worked 3rd shift with staff #4.
She arrived for her shift around 9:00 pm.

-The clients were in their rooms initially, they
came out to greet staff and went back into their
bedrooms.

-The clients were in their bedrooms playing music
and playing video games.

-DC #4 came to her a little later and told her that
client #1 was bothering him. He asked if it was ok
if he slept in the room with FC #3 for the night. FC
#3 did not have a roommate and there was an
empty bed in his room. She told DC #4 he could
sleep in the room with FC #3, but just for that one
night.

Division of Health Service Regulation

STATE FORM

e899 W3NM11 If continuation sheet 7 of 24

Division of Health Service Regulation

PRINTED: 12/10/2021
FORM APPROVED

-She thought the clients actually went to bed
around 11:00 pm on 3/27/21.

-Staff normally sit in the hallway once the clients
go to bed for the night. They sit outside of the
clients bedrooms so they can listen for anything
unusual with the clients.

-"Staff normally don't go into the bedrooms once
the clients go to bed for the night. Staff don't want
to disturb the clients while they are sleeping."
Staff are not required to do bed checks once the
clients go into their bedrooms.

-DC #4 came out of his room at least two times
after 12 am on 3/28/21 to use the bathroom. Staff
#4 asked DC #4 if he was he ok each time and
he replied he was ok. She didn't notice anything
out of the ordinary with DC #4.

-She left the group home around 8:00 am on
3/28/21 and the clients were all in bed.

Interview on 4/5/21 with staff #4 revealed:

-He and staff #2 were working the night prior to
DC #4 passing away. They worked 3rd shift and
their shift started at 9:00 pm on 3/27/21.

-He thought all of the clients were in their
bedrooms by 10:00 pm that night.

-When the clients are in their bedrooms they
check on them occasionally. They are not actually
required to do bed checks during 3rd shift.

-Staff normally just sit in the hallway in a chair
outside of the bedrooms.

-DC #4 did get up a couple of times during 3rd
shift. He asked DC #4 if he was ok and he replied
he was ok. He thought DC #4 got up for the last
time around 2:00 am.

-He left the home on 3/28/21 around 7:30 am and
all the clients were still in bed sleeping.

Interview with FC #3's Social Worker on 4/5/21
revealed:
-FC #3 had a history of substance abuse. FC #3

Division of Health Service Regulation

STATE FORM

6808 W3NM11

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHLO001-159 11/30/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
723 NORTH FISHER STREET
ALAMANCE ACADEMY, LLC
BURLINGTON, NC 27217
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 115] Continued From page 7 V 115

If continuation sheet 8 of 24

Division of Health Service Regulation

PRINTED: 12/10/2021
FORM APPROVED

was always talking about taking different drugs
and having gang affiliations.

-She was not sure if FC #3 was always being
truthful about some of the things he was saying.
-She thought FC #3 was clean for about two
months prior to his admission to Alamance
Academy.

-When FC #8 lived at another group home he had
an incident with another client. FC #3 eloped with
a 12 year old client. They went to a store and got
some over the counter medication. The 12 year
old took the medication and overdosed, but did
not die. It could not be determined if FC #3
coerced the 12 year old client into taking the over
the counter medication.

-She thought that overdose incident with the 12
year old happened about a year ago.

Interview with the Clinical Quality Clinician for
Managed Care Organization (MCO) on 3/30/21
revealed:

-She was looking into the death incident with DC
#4,

-She was informed there is a search warrant for
the group home. The police officers on the scene
suspected DC #4 passed away from a drug
overdose.

-She was informed the police officer found blood
and vomit on his bedding.

-It was suspected that FC #3 supplied DC #4 with
the drug Molly.

-FC #3 told the Qualified Professional he and DC
#4 were using a vape pen that may have been
laced with Molly the night before DC #4 passed
away.

-She was informed by a Department of Social
Services staff that FC #3 had a history of
coercing others to do things.

-FC #3 had a similar incident at another
placement. FC #3 persuaded a younger client to

Division of Health Service Regulation

STATE FORM

6808 W3NM11

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHLO001-159 11/30/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
723 NORTH FISHER STREET
ALAMANCE ACADEMY, LLC
BURLINGTON, NC 27217
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 115] Continued From page 8 V 115

If continuation sheet 9 of 24

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHLO001-159

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

723 NORTH FISHER STREET
BURLINGTON, NC 27217

ALAMANCE ACADEMY, LLC

PRINTED: 12/10/2021

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

R-C
11/30/2021

take drugs, that client overdosed but did not die.
-"She had her concerns about this facility
because [DC #4] was not found deceased on
3/28/21 until 10:00 am by [FC #3]. She was trying
to figure out why it took so long for anyone to
realize [DC #4] had passed away."

Interview with a Local Police Officer on 3/30/21
revealed:

-He responded to the incident with DC #4.

-His main priority was to secure the crime scene
once he arrived.

-When he arrived EMS staff were still on the
scene and had DC #4 on the floor. EMS staff
pronounced DC #4 had passed away within a
minute of his arrival. He heard one of EMS
workers say "rigor mortis had already started, so
[DC #4] was possibly dead for several hours."

Interviews with the Local Detective on 4/5/21 and
4/12/21 revealed:

-She was investigating the death of DC #4. They
did suspect DC #4 overdosed on drugs.

-She suspected DC #4 possibly used Molly,
Fentanyl and other drugs. They must wait on the
toxicology report to confirm which drugs were in
DC #4's system.

-This was an open investigation and she was not
allowed to give a lot of information related to that
incident.

-FC #3 was interviewed about the incident with
DC #4.

-FC #3 never admitted to them that he and/or DC
#4 were doing drugs at the group home.

Interview with the Qualified Professional on
4/9/21 revealed:

-He talked with FC #3 after he was informed
about the passing of DC #4.

-FC #3 said he and DC #4 smoked some tobacco

Division of Health Service Regulation
STATE FORM

6809

W3NM11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 115] Continued From page 9 V 115

If continuation sheet 10 of 24

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 12/10/2021
FORM APPROVED

(X3) DATE SURVEY

on 3/27/21. FC #3 said "they used a vape pen
and he thought the vape pen was laced with
Molly. FC #3 said this was his personal vape pen.
-FC #3 also said he had a bag in the home that
belonged to a friend. He said the bag possibly
had Molly in it. The police officers took that bag
and some other items out the home on the day of
the incident.

-FC #3 kept changing his story. He felt like FC #3
was trying to cover up something.

-Client #2 said FC #3 offered him Molly the day
before the incident.

Interviews with the Program Director on 4/5/21,
4/7/21, 4/12/21 and 11/30/21 revealed:

-Staff #1 called her on 3/28/21 and said DC #4
was unresponsive in his bedroom.

-She went to the group home and was informed
DC #4 had passed away.

-Staff #2 and staff #4 worked during 3rd shift and
left the home the morning of 3/28/21.

-Third shift staff said they didn't notice anything
out of the ordinary with any of the clients during
their shift.

-Staff are not required to check on the clients
during 3rd shift once they go to bed.

-She had staff take the clients to the main office
following the incident with DC #4.

-She talked with the clients about the incident with
DC #4. Client #2 said someone came to group
home and dropped drugs off to a bedroom
window for DC #4, however he was not specific
as to when that occurred. Client #2 also thought
FC #3 had the drugs on him about two days prior
to the incident with DC #4. Client #2 did not
specify how or where FC #3 got the drugs.
-Client #1 really did not give her any information
related to the incident with DC #4.

-FC #3 said he had a vape pen at the group
home. FC #3 said "the vape pen could have been

Division of Health Service Regulation

STATE FORM

6809

W3NM11

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHLO001-159 11/30/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
723 NORTH FISHER STREET
ALAMANCE ACADEMY, LLC
BURLINGTON, NC 27217
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 115) Continued From page 10 V 115

If continuation sheet 11 of 24

Division of Health Service Regulation

PRINTED: 12/10/2021
FORM APPROVED

laced with Molly. "She thought FC #3 and DC #4
possibly used the vape pen prior to DC #4's
death."

-She asked FC #3 why DC #4 died and not him
after using the vape pen. FC #3 told her "because
[DC #4] was not used to doing drugs like he was."
-She was aware FC #3 had a history of
substance abuse, however he had been clean.
She did not think FC #3 was still using drugs.
-She heard FC #3 possibly had the drugs on him
when he was admitted. She was informed about
that after the incident with DC #4.

-She decided FC #3 needed to be discharged
after that incident with DC #4. She contacted FC
#3's Social Worker to start the discharge process.
-When she told FC #3's Social Worker about the
incident, she said it seemed to be a pattern with
FC #3. She said at another facility FC #3 possibly
bullied a 12 year old client into doing drugs and
that client overdosed. The 12 year old did not die.
-"The week leading up to [DC #4's] death [client
#2] told her [DC #4] said he wanted to get high."
Client #2 said "he knew [DC #4] had access to
drugs."

-DC #4 did not have a history of substance
abuse. DC #4's mother said he would
occasionally smoke marijuana, but he did not
seem to have a substance abuse issue.

-It was suspected that DC #4 overdosed on
drugs. When she saw DC #4 he had a lot of fluid
coming from his mouth, it was a bloody
substance.

-The police officer said it looked a little
suspicious. The fact that FC #3 was in the same
bedroom and did not hear or see anything with
DC #4.

-DC #4 was not supposed to be in the room with
FC #3 the night prior to that incident. Staff #2
allowed DC #4 to sleep in the room with FC #3.
DC #4 told staff #2 he wanted to sleep in the

Division of Health Service Regulation

STATE FORM

6808 W3NM11

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHLO001-159 11/30/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
723 NORTH FISHER STREET
ALAMANCE ACADEMY, LLC
BURLINGTON, NC 27217
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 115) Continued From page 11 V 115

If continuation sheet 12 of 24

Division of Health Service Regulation

PRINTED: 12/10/2021
FORM APPROVED

room with FC #3 because client #1 was bothering
him. Staff #2 told DC #4 he could sleep in the
room with FC #3 just for that one night.

-"Now when she think about it, she feels like [DC
#4] was trying to get in that room with [FC #3] so
he could do drugs."

-She thought FC #3 admitted to the police he had
Molly in the group home and gave some to DC #4
on 3/27/21.

-The police said "they possibly found residue from
Molly in [FC #3's] book bag, however it had to be
tested."

-She had a cleaning service come into the home
after the incident. The cleaning crew found
something in a bag that looked like drugs. She
informed the police and they sent someone out in
order to take a look at the substance. The police
told her it was something you use to cut drugs.
-She was informed about a month ago that the
white liquid substance she found in the empty
bedroom was actually drugs. A police officer
informed her the substance in the bag found in
the empty room was Fentanyl.

-The officer also informed her DC #4's toxicology
report indicated he had drugs in his system at the
time of death.

Review on 11/30/21 of a Plan of Protection written
by the Program Director dated 11/30/21 revealed:
What will you immediately do to correct the above
rule violations in order to protect clients from
further risk or additional harm?: "Room checks
hours and will ensure compliance through the
video monitoring and checklist. Search policy
document searches of new consumers. If
consumer leave group home consumer will be
searched when they return. After bedtime, door
will be partially closed to ensure privacy and staff
will check hourly. Group home staff will be trained
on monitoring and PCP (Person Centered Plan)

Division of Health Service Regulation

STATE FORM

6808 W3NM11

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHLO001-159 11/30/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
723 NORTH FISHER STREET
ALAMANCE ACADEMY, LLC
BURLINGTON, NC 27217
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 115) Continued From page 12 V 115

If continuation sheet 13 of 24

Division of Health Service Regulation

PRINTED: 12/10/2021
FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
R-C
MHLO001-159 11/30/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
723 NORTH FISHER STREET
ALAMANCE ACADEMY, LLC
BURLINGTON, NC 27217
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE, DATE

DEFICIENCY)

V 115) Continued From page 13

service definition of Level Il and monitoring and
grief/loss. Substance Abuse and triggers training
will be done by Licensed Counselor in Substance
Abuse. All consumer with a substance abuse
diagnosis will have a SA (Substance Abuse)
assessment."

Describe your plans to make sure the above
happens. " Agency will ensure that staff monitor
through video monitoring and room check
checklist. Agency will review documented
checklist of consumer personal items at
admission and complete search of consumer's
pockets, bookbags, suitcase, etc. Agency will
maintain documentation of staff trainings. Agency
QP (Qualified Professional) will complete
Admission Assessment and ensure that
appropriate assessments and clinical services
are in place."

The facility served clients with diagnoses that
included Substance Abuse, Attention Deficit
Hyperactivity Disorder, Intermittent Explosive
Disorder, Depressive Disorder, Impulse Control
Disorder, Conduct Disorder and Disruptive Mood
Dysregulation Disorder. The clients age ranged
between 14 and 16 years of age. FC #3 and DC
#4 lived at the group home for about two weeks.
According to the Program Director client #2
informed her DC #4 said he wanted to get high
about a week before he passed away. DC #4's
mother told Program Director he would
occasionally smoke marijuana. FC #3 had a
history of substance abuse and group staff were
all aware. Third shift staff were not required to do
any additional monitoring of clients once they go
into their bedrooms. DC #4 talked staff #2 into
letting him sleep in the bedroom with FC #3. It
was reported to staff #1 by FC #3 on 10/28/21
around 10:00 am that DC #4 was unresponsive.
Staff #1 called EMS and attempted CPR on DC.

Division of Health Service Regulation
STATE FORM

V 115

6808 W3NM11

If continuation sheet 14 of 24

Division of Health Service Regulation

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

MHLO001-159

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 12/10/2021

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

723 NORTH FISHER STREET
BURLINGTON, NC 27217

ALAMANCE ACADEMY, LLC

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R-C
11/30/2021

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

ID
PREFIX
TAG

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

(x)
COMPLETE
DATE

V 115) Continued From page 14

#4. EMS staff pronounced DC #4 was deceased
and saw signs of rigor mortis. FC #3 informed the
Qualified Professional he and DC #4 were
smoking tobacco with a vape pen on 3/27/21. He
informed the Qualified Professional the vape pen
was possibly laced with "Molly." The autopsy
revealed DC #4 passed away as a result of
cocaine and fentanyl toxicity.

This deficiency constitutes a Type A1 rule
violation for serious harm and neglect and must
be corrected within 23 days. An administrative
penalty of $10,000 is imposed. If the violation is
not corrected within 23 days, an additional
administrative penalty of $500.00 per day will be
imposed for each day the facility is out of
compliance beyond the 23rd day.

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

10A NCAC 27G .0209 MEDICATION
REQUIREMENTS

(c) Medication administration:

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

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

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

Division of Health Service Regulation
STATE FORM

V 115

V 118

6809

If continuation sheet 15 of 24

Division of Health Service Regulation

PRINTED: 12/10/2021
FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
R-C
MHLO001-159 11/30/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
723 NORTH FISHER STREET
ALAMANCE ACADEMY, LLC
BURLINGTON, NC 27217
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

V 118] Continued From page 15

(A) client's name;

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

(C) instructions for administering the drug;

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

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

This Rule is not met as evidenced by:

Based on record review and interviews, the
facility failed to keep the MAR current and failed
to ensure staff followed the physician's order
affecting one of one deceased client (DC #4).
The findings are:

The following is evidence the facility failed to keep
the MAR current.

Review on 4/7/21 of DC #4's record revealed:
-Admission date of 3/17/21.

-Diagnoses of Intermittent Explosive Disorder,
Depressive Disorder, Impulse Control Disorder,
Conduct Disorder and Attention Deficit
Hyperactivity Disorder.

-DC #4 died on 3/28/21.

-DC #4 was 15 years old.

Review of physician's orders on 4/9/21 for DC #4
revealed:

-Order dated 3/26/21 for Guanfacine 1 milligram
(mg), one tablet in the morning and Risperidone

Division of Health Service Regulation
STATE FORM

V 118

6808 W3NM11

If continuation sheet 16 of 24

Division of Health Service Regulation

PRINTED: 12/10/2021
FORM APPROVED

0.5 mg, take % tablet at bedtime.

Review on 4/9/21 of a Medication Administration
Record (MAR) for DC #4 revealed:

-March 2021-Guanfacine 1 mg was not listed.
Staff documented the Risperidone 0.5 mg am
dose was administered on 3/27. There was a
blank box on 3/27 pm dose for the Risperidone
0.5 mg.

"Due to the failure to accurately document
medication administration it could not be
determined if

clients received their medications as ordered by
the physician"

The following is evidence the facility failed to
follow the physician's order.

Review of physician's orders on 4/9/21 for DC #4
revealed:

-Order dated 3/26/21 for Guanfacine 1 mg one
tablet in the morning and Risperidone 0.5 mg,
take % tablet at bedtime.

Review on 4/9/21 of a MAR for DC #4 revealed:
-March 2021-The morning dose of Guanfacine 1
mg and was not administered to DC #4 on 3/27.
The bedtime dose of Risperidone 0.5 mg was not
administered to DC #4 on 3/27.

Interview with staff #1 on 4/12/21 revealed:
-He did administer DC #4's medications on the
morning and evening of 3/27/21.

-He found out on the evening of 3/27/21 that DC
#4 had changes to his morning medication.

-DC #4 said his morning medication made him
sleepy, the doctor changed it so he could take
that medication at bedtime.

-He saw a sticky note that staff left in DC #4's

Division of Health Service Regulation

STATE FORM

6808 W3NM11

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHLO001-159 11/30/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
723 NORTH FISHER STREET
ALAMANCE ACADEMY, LLC
BURLINGTON, NC 27217
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118) Continued From page 16 Vv 118

If continuation sheet 17 of 24

Division of Health Service Regulation

PRINTED: 12/10/2021
FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
R-C
MHLO001-159 11/30/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
723 NORTH FISHER STREET
ALAMANCE ACADEMY, LLC
BURLINGTON, NC 27217
(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

V 118) Continued From page 17

current for DC #4.

medication for DC #4.

at bedtime only.

medication.

emergency.

current for DC #4.

revealed:

March 2021 MAR.

Division of Health Service Regulation
STATE FORM

record which indicated there was a medication
change. He has already given the medication
when he saw the sticky note left by staff.

-He confirmed staff failed to keep the MAR

-He confirmed facility staff failed to follow the
physician's order for DC #4.

Interview with staff #3 on 4/12/21 revealed:
-He took DC #4 to see his physician on 3/26/21.
-The physician made a change to the Risperidone

-DC #4 told the physician the medication was
making him sleepy during the day. The physician
changed the Risperidone medication to be given

-He thought another medication was added,
however he could not remember the name of that

-The order was faxed over to pharmacy by the
physician's office. When he went to the pharmacy
the order was not filled, he did not get the
Risperidone medication for DC #4.

-When he returned to the group home he did not
change MAR because he had no medication.

-He left a sticky note for staff on some documents
in the pocket of DC #4's record book.

-He was not sure if he verbally told staff about the
change to DC #4's medications.

-He was in a rush because he had a family

-He confirmed staff failed to keep the MAR

-He confirmed facility staff failed to follow the
physician's order for DC #4.

Interview with the Program Director on 4/12/21

-There were some medication errors with DC #4's

V 118

6808 W3NM11

If continuation sheet 18 of 24

Division of Health Service Regulation

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

MHLO001-159

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 12/10/2021

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

723 NORTH FISHER STREET
BURLINGTON, NC 27217

ALAMANCE ACADEMY, LLC

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R-C
11/30/2021

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

ID
PREFIX
TAG

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

(x)
COMPLETE
DATE

V 118) Continued From page 18

-Staff #3 took DC #4 to see his physician on
3/26/21. DC #4 had some changes to his
medication.

-She was told DC #4 was no longer taking
morning medications.

-The March MAR did not reflect the recent
medication changes for DC #4. Staff did not add
the Guanfacine medication to the March MAR.
-Staff #1 told her he gave DC #4 his morning
medications on 3/27/21. Staff #1 said he was not
aware of any medication changes.

-Staff #3 said he told staff #1 about the
medication changes for DC #4 on the evening of
3/27/21.

-She was not sure why staff didn't document they
gave DC #4 the Risperidone on 3/27/21.

-She confirmed staff failed to keep the MAR
current for DC #4.

-She confirmed facility staff failed to follow the
physician's order for DC #4.

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
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

Division of Health Service Regulation
STATE FORM

V 118

V 367

6809

If continuation sheet 19 of 24

Division of Health Service Regulation

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

MHLO001-159

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 12/10/2021

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

723 NORTH FISHER STREET
BURLINGTON, NC 27217

ALAMANCE ACADEMY, LLC

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R-C
11/30/2021

(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 19 V 367

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
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

Division of Health Service Regulation
STATE FORM

6809

If continuation sheet 20 of 24

Division of Health Service Regulation

PRINTED: 12/10/2021
FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
R-C
MHLO001-159 11/30/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
723 NORTH FISHER STREET
ALAMANCE ACADEMY, LLC
BURLINGTON, NC 27217
(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 20

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 record review and interview facility staff
failed to include the required documentation for
Level Ill incidents. The findings are:

Review of facility records on 3/30/21 revealed:
-There was an incident report dated 3/28/21 for
deceased client (DC #4). Staff wrote DC #4's

Division of Health Service Regulation
STATE FORM

V 367

6808 W3NM11

If continuation sheet 21 of 24

Division of Health Service Regulation

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

MHLO001-159

NAME OF PROVIDER OR SUPPLIER

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

723 NORTH FISHER STREET
BURLINGTON, NC 27217

ALAMANCE ACADEMY, LLC

PRINTED: 12/10/2021
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R-C
11/30/2021

STREET ADDRESS, CITY, STATE, ZIP CODE

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

ID
PREFIX
TAG

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

CROSS-REFERENCED TO THE APPROPRIATE, DATE
DEFICIENCY)

V 367| Continued From page 21

cause of death was unknown.

-The incident report had no description of the
incident.

-The incident report had no status of the effort to
determine the cause of the incident.

Interview with the Program Director on 11/30/21
revealed:

-She did not realize the incident report for DC #4
did not include all of the required information.
-The Qualified Professional and another staff
were responsible for completing the incident
report in the Incident Response Improvement
System (IRIS) for DC #4.

-She knew staff #1 wrote up the incident after DC
#4 died. She thought the Qualified Professional
added that information into the IRIS system.

V 736] 27G .0303(c) Facility and Grounds Maintenance

10A NCAC 27G .0303 LOCATION AND
EXTERIOR REQUIREMENTS

(c) Each facility and its grounds shall be
maintained in a safe, clean, attractive and orderly
manner and shall be kept free from offensive
odor.

This Rule is not met as evidenced by:

Based on observation and interviews, the facility
failed to ensure facility grounds were maintained
in a safe, clean, attractive and orderly manner.
The findings are:

Observation on 4/1/21 at approximately 10:15 am
of the facility revealed:

Division of Health Service Regulation
STATE FORM

V 367

V 736

6809

W3NM11

If continuation sheet 22 of 24

Division of Health Service Regulation

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

MHLO001-159

NAME OF PROVIDER OR SUPPLIER

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

723 NORTH FISHER STREET
BURLINGTON, NC 27217

ALAMANCE ACADEMY, LLC

PRINTED: 12/10/2021

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

R-C
11/30/2021

(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 736 | Continued From page 22 V 736

-Den area-The storm door had approximately 12
inches of black tape over it.

-The empty bedroom-The blinds were broken.
The outer double pane window had shattered
glass and inner portion of the window had
approximately 7 pieces of tape on it.

-Kitchen area-Walls had food debris and grease
stains. The handle to refrigerator was loose and
had tape around it.

-Client #1's bedroom-There was a dime sized
crack in the bedroom door. The bedroom door
had peeling paint and the frame of the door was
cracked. The closet door had a hole about the
size of a grapefruit size.

-Client #2's bedroom-The blinds were broken.
The walls were stained . The bedroom door
broken would not close properly.

-Th hallway area-The walls were stained and had
dark markings.

-Bathroom-There was a white putty like
substance on the wall.

Interview with staff #5 on 4/1/21 revealed:

-He did a lot of the maintenance repairs for the
home. He was aware of most of the maintenance
issues with the home.

-He knew the window and doors had to be
replaced throughout the home. The windows and
doors were already ordered, they were just late
arriving.

-He confirmed the facility failed to ensure facility
grounds were maintained in a safe, clean,
attractive and orderly manner.

Interview with staff #6 on 4/1/21 revealed:
-Management was aware of most of the
maintenance issues with the home.

-The window in the empty bedroom just broke a
few days ago, no one was residing in that room
when the window broke.

Division of Health Service Regulation
STATE FORM

6809

W3NM11

If continuation sheet 23 of 24

Division of Health Service Re

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

NAME OF PROVIDER OR SUPPLIER

MHLO001-159

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

723 NORTH FISHER STREET
BURLINGTON, NC 27217

ALAMANCE ACADEMY, LLC

PRINTED: 12/10/2021

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

R-C
11/30/2021

-The front door was taped because a basketball
hit it about a week ago.

-He confirmed the facility failed to ensure facility
grounds were maintained in a safe, clean,
attractive and orderly manner.

Interview with the Program Director on 4/5/21
revealed:

-Staff #5 would normally take care of any
maintenance issues with the group home.

-She visited the group home on a regular basis.
She was aware the group home needed some
repairs.

-She confirmed the facility failed to ensure facility
grounds were maintained in a safe, clean,
attractive and orderly manner.

This deficiency constitutes a re-cited deficiency
and must be corrected within 30 days.

Division of Health Service Regulation
STATE FORM

6809

W3NM11

(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 736 | Continued From page 23 V 736

If continuation sheet 24 of 24

inspection_type: MHLCS Complaint and Follow-up


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

raw_content:
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES

(X1) PROVIDER/SUPPLIER/CLIA

(X2) MULTIPLE CONSTRUCTION

PRINTED: 02/07/2020
FORM APPROVED

(X3) DATE SURVEY

10A NCAC 27G .0207 EMERGENCY PLANS
AND SUPPLIES

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

(b) The plan shall be made available to all staff
and evacuation procedures and routes shall be
posted in the facility.

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

This Rule is not met as evidenced by:

Based on record review and interview, the facility
failed to conduct fire and disaster drills under
conditions that simulate emergencies quarterly
and for each shift. The findings are:

Review on 2/4/20 of the facility's fire drill log
revealed the following:
-1/23/20- 2nd shift.

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

STATE FORM

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL001-159 B. WING 02/04/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
723 NORTH FISHER STREET
ALAMANCE ACADEMY, LLC BURLINGTON, NC 27217
(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 February 4, 2020. The complaint
was substantiated (intake #NC00160331).
Deficiencies were cited.
This facility is licensed for the following service
category: 10A NCAC 27G .1300 Residential
Treatment for Children or Adolescents.
V 114) 27G .0207 Emergency Plans and Supplies Vv 114

5809 49WE11

TITLE (X6) DATE

If continuation sheet 1 of 6

PRINTED: 02/07/2020

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL001-159 B. WING 02/04/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
723 NORTH FISHER STREET
ALAMANCE ACADEMY, LLC
BURLINGTON, NC 27217
(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 114] Continued From page 1 Vv 114

-1/13/20- 3rd shift.
-1/6/20- 1st shift.
-12/30/19- 3rd shift.
-12/10/19- 2nd shift.
-12/4/19- 3rd shift.
-11/30/19- 3rd shift.
-10/4/19- 3rd shift.
-9/18/19- 3rd shift.
-9/12/19- 2nd shift.
-9/1/19- 1st shift.
-8/13/19- 3rd shift.
-8/10/19- 3rd shift.
-8/2/19- 2nd shift.
-7/25/19- 3rd shift.
-6/29/19- 3rd shift.
~6/21/19- 2nd shift.
~6/14/19- 2nd shift.
-6/5/19- 3rd shift.
-5/26/19- 3rd shift.
-There were no fire drills performed on first shift
for the fourth quarter of 2019.

-There were no fire drills performed on first shift
for the second quarter of 2019.

Review on 2/4/20 of the facility's disaster drill log
revealed the following:

-1/17/20- 2nd shift

-12/20/19- 1st shift.

-11/5/19- 2nd shift.

-10/8/19- 2nd shift.

-9/28/19- 1st shift.

-8/26/19- 2nd shift.

-7/4/19- 2nd shift.

-6/27/19- 1st shift.

-5/18/19- 1st shift.

-4/19/19- 1st shift.

-There were no disaster drills performed on the
third shift for the fourth quarter of 2019.

-There were no disaster drills performed on the
third shift for the third quarter of 2019.

Division of Health Service Regulation

STATE FORM 6899 49WE11 If continuation sheet 2 of 6

PRINTED: 02/07/2020
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
R
MHLO001-159 B. WING ____ 02/04/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

723 NORTH FISHER STREET

ALAMANCE ACADEMY, LLC BURLINGTON, NC 27217

(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 114| Continued From page 2 Vv 114

-There were no disaster drills performed on the
second and third shift for the second quarter of
2019.

Interview on 2/4/20 with the Home Manager
revealed:

-First shift was from 8:00 am to 3:00 pm.
-Second shift was from 3:00 pm to 11:00 pm.
-Third shift was from 11:00 pm to 8:00 am.
-She was unaware that some fire and disaster
drills for some of the quarters had not been done
for all shifts.

-She confirmed the facility failed to conduct fire
disaster drills under conditions that simulate
emergencies quarterly and for each shift

This deficiency constitutes a re-cited deficiency
and must be corrected within 30 days.

V 736| 27G .0303(c) Facility and Grounds Maintenance | V 736

10A NCAC 27G .0303 LOCATION AND
EXTERIOR REQUIREMENTS

(c) Each facility and its grounds shall be
maintained in a safe, clean, attractive and orderly
manner and shall be kept free from offensive
odor.

This Rule is not met as evidenced by:

Based on observation and interview, the facility
failed to ensure facility grounds were maintained
in a clean, safe and attractive manner. The
findings are:

Observation on 2/4/20 at about 11:17 am of the
hallway bathroom revealed:

Division of Health Service Regulation
STATE FORM 6899 49WE11 If continuation sheet 3 of 6

PRINTED: 02/07/2020

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
MHLO001-159 B. WING ____ 02/04/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

723 NORTH FISHER STREET

ALAMANCE ACADEMY, LLC BURLINGTON, NC 27217

(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 736 | Continued From page 3 V 736

-There were holes on the wall from where a
former towel rack used to be.
-Walls were dirty/stained. .

Observation on 2/4/20 at about 11:20 am of
bedroom located in front of bathroom revealed:
-There was a hole about two inched long next to
the closet.

-There was an electric panel door that was
partially painted.

-Entrance door to room was broken at the bottom
and would not close fully.

Observation on 2/4/20 at about 11:23 am of
bedroom located behind the kitchen area
revealed:

-There was a hole about two inches long next to
the left side closet.

Observation on 2/4/20 at about 11:26 am of
bedroom located next to the living area revealed:
-There were numerous grease stains all
throughout the walls.

Interview on 2/4/20 with the Home Manager
revealed:

-Landlord was in charge of making needed
repairs, but agency was responsible for minor
things such as painting and repairing walls.
-Holes on the walls had been recently made by
the residents.

-Agency had partially painted the home, but had
not finished yet.

-She confirmed the facility failed to ensure facility
grounds were maintained in a clean, safe and
attractive manner.

V 752} 27G .0304(b)(4) Hot Water Temperatures V 752

Division of Health Service Regulation
STATE FORM 6899 49WE11 If continuation sheet 4 of 6

PRINTED: 02/07/2020
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
R
MHLO001-159 B. WING ____ 02/04/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

723 NORTH FISHER STREET

ALAMANCE ACADEMY, LLC BURLINGTON, NC 27217

(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 752} Continued From page 4 V 752
10A NCAC 27G .0304 FACILITY DESIGN AND
EQUIPMENT

(b) Safety: Each facility shall be designed,
constructed and equipped in a manner that
ensures the physical safety of clients, staff and
visitors.

(4) In areas of the facility where clients are
exposed to hot water, the temperature of the
water shall be maintained between 100-116
degrees Fahrenheit.

This Rule is not met as evidenced by:

Based on observation and interviews the facility
failed to maintain the facility water temperature
between 100-116 degrees Fahrenheit. The
findings are:

Observation of the facility on 2/4/20 at
approximately 11:15 AM revealed :

-The kitchen sink water temperature was 119
degrees Fahrenheit.

-Bathroom water temperature was 119 degrees
Fahrenheit.

Observation of the facility on 2/4/20 at
approximately 2:00 PM revealed:

-The kitchen sink water temperature was 119
degrees Fahrenheit.

-Bathroom water temperature was 119 degrees
Fahrenheit.

Observation on 2/4/20 of staff measuring water
temperature revealed:
-Staff was using a food thermometer.

Interview on 2/4/20 with the Home Manager
revealed:

-She did not realize the water temperature was
over 116 degrees.

Division of Health Service Regulation

STATE FORM 6899 49WE11 If continuation sheet 5 of 6

PRINTED: 02/07/2020

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL001-159 B. WING 02/04/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
723 NORTH FISHER STREET
ALAMANCE ACADEMY, LLC BURLINGTON, NC 27217
(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 752} Continued From page 5 V 752
-She confirmed the facility failed to maintain the
facility water temperature between 100-116
degrees Fahrenheit.
Interview on 2/4/20 with the Director revealed:
-Facility had been tracking water temperatures
and had not been high before.
-Facility had recently undergone inspection and
had passed.
-She would have water heater adjusted to
measure below 116 degrees Fahrenheit.
-She confirmed the facility failed to maintain the
facility water temperature between 100-116
degrees Fahrenheit.
Division of Health Service Regulation
STATE FORM 6899 49WE11 If continuation sheet 6 of 6

inspection_type: MHLCS Annual, Complaint, and Follow-up


summary: Statement of Deficiency - MHLCS Annual

raw_content:
Division of Health Service Regulation

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

MHLO001-159

NAME OF PROVIDER OR SUPPLIER

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

723 NORTH FISHER STREET
BURLINGTON, NC 27217

ALAMANCE ACADEMY, LLC

PRINTED: 04/08/2019

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

04/03/2019

(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 000} INITIAL COMMENTS V 000
An annual survey was completed on April 3,
2019. There was a deficiency cited.
This facility is licensed for the following service
category: 10A NCAC 27G. 1300
Residential Treatment for Children or Adolescents
V 114| 27G .0207 Emergency Plans and Supplies Vv 114

10A NCAC 27G .0207 EMERGENCY PLANS
AND SUPPLIES

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

(b) The plan shall be made available to all staff
and evacuation procedures and routes shall be
posted in the facility.

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

This Rule is not met as evidenced by:

Based on record review and interview the facility
failed to conduct fire and disaster drills on each
shift at least quarterly. The findings are:

Review on 4/3/19 of the facility's fire and disaster
drills record revealed:
-Fire drills were conducted on the following dates
and shifts:

-1/16/19 - 2nd

-1/29/19 - 1st

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

STATE FORM

6808 YOEL11

TITLE

(X6) DATE

If continuation sheet 1 of 2

Division of Health Service Re

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

NAME OF PROVIDER OR SUPPLIER

MHLO001-159

ALAMANCE ACADEMY, LLC

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 04/08/2019

STREET ADDRESS, CITY, STATE, ZIP CODE
723 NORTH FISHER STREET
BURLINGTON, NC 27217

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

04/03/2019

-2/1/19 - 2nd

-2/14/19 - 1st

-3/11/19 - 2nd
-Disaster drills were conducted on the following
dates and shifts:

-1/15/19 - 2nd

-3/8/19 - 2nd
-There were no fire and disaster drills conducted
on 3rd shift.
-There were no fire and disaster drills conducted
on each shift at least quarterly.

Interview on 4/3/19 with the Director revealed:
-She confirmed drills were not conducted on each
shift at least quarterly.

-A new document for drills would be implemented.
-She would discuss drills with staff to ensure
compliance.

Division of Health Service Regulation
STATE FORM

6809

(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 114] Continued From page 1 Vv 114

If continuation sheet 2 of 2


summary: Statement of Deficieny - MHLCS Follow-up

raw_content:
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
MHL001-159

NAME OF PROVIDER OR SUPPLIER

ALAMANCE ACADEMY, LLC

STREET ADDRESS, CITY, STATE, ZIP CODE

723 NORTH FISHER STREET
BURLINGTON, NC 27217

PRINTED: 06/18/2018

FORM APPROVED
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
A. BUILDING: COMPLETED
R
B.WING 06/13/2018

(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}
A follow up survey was completed on June 13,
2018. No deficiencies were cited.
This facility is licensed for the following service
category: 10A NCAC 27G. 1300 Residential
Treatment for Children or Adolescents
Division of Health Service Regulation
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
6899 FF9O12 If continuation sheet 1 of 1

STATE FORM

inspection_type: MHLCS Follow-up

document_type: Statement of Deficieny