summary: Statement of Deficiency - MHLCS Annual

raw_content:
PRINTED: 05/28/2019

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
MHL011-386 05/16/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
212 BALDWIN ROAD
LIVINGSTONE'S HOME
ARDEN, NC 28704
(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 5/16/19.
Deficiencies were cited.
This facility is licensed for the following service
categories:
10A NCAC 27G .5100 Community Respite
Services for Individuals of all Disability Groups
10A NCAC 27G Supervised Living for Individuals
of all Disability Groups-Alternative Family Living.
V 117| 27G .0209 (B) Medication Requirements V117

10A NCAC 27G .0209 MEDICATION
REQUIREMENTS

(b) Medication packaging and labeling:

(1) Non-prescription drug containers not
dispensed by a pharmacist shall retain the
manufacturer's label with expiration dates clearly
visible;

(2) Prescription medications, whether purchased
or obtained as samples, shall be dispensed in
tamper-resistant packaging that will minimize the
risk of accidental ingestion by children. Such
packaging includes plastic or glass bottles/vials
with tamper-resistant caps, or in the case of
unit-of-use packaged drugs, a zip-lock plastic bag
may be adequate;

(3) The packaging label of each prescription
drug dispensed must include the following:

(A) the client's name;

(B) the prescriber's name;

(C) the current dispensing date;

(D) clear directions for self-administration;

(E) the name, strength, quantity, and expiration
date of the prescribed drug; and

(F) the name, address, and phone number of the
pharmacy or dispensing location (e.g., mh/dd/sa
center), and the name of the dispensing
practitioner.

Division of Health Service Regulation

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

STATE FORM

TITLE

6808 9D1Z11

(X6) DATE

If continuation sheet 1 of 6

Division of Health Service Regulation

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

MHLO011-386

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
212 BALDWIN ROAD
ARDEN, NC 28704

LIVINGSTONE'S HOME

PRINTED: 05/28/2019

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

05/16/2019

(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 117] Continued From page 1 V117

This Rule is not met as evidenced by:

Based on record reviews, observation and
interviews, the facility staff failed to ensure
prescription medications contained the packaging
label for each prescription drug with the
information required: client's name, prescriber's
name,date medication was dispensed by
pharmacy, administration instructions, name,
strength, quantity, and expiration date of the
prescribed drug; and the name, address, and
phone number of the pharmacy or dispensing
location and dispensing practitioner/pharmacist.
The findings are:

Review on 5/13/19 of Client #2's record revealed:
-admission date of 8/17/16.

-diagnoses of Moderate Intellectual and
Developmental Disability, Hypothyroidism,
Obstructive Sleep Apnea, Allergic Rhinitis, High
Cholesterol, Depression Disorder, Speech
Impediment, Tracheotomy Implant,
Gastro-Esophageal Reflux Disease, Chronic
Obstructive Pulmonary Disease, and Parkinson's
Disease.

-Physician's orders included:

-1/24/19- Polyethylene Glycol 17 gram/dose
powder - 1 capful with any liquid daily, except
when having diarrhea

-3/22/19- Saline Bullets - use 1 vial via
nebulizer as needed.

Observation on 5/13/19 at approximately 2:30
p.m. of Client #2's medications revealed:

Division of Health Service Regulation
STATE FORM

6808 9D1Z11

If continuation sheet 2 of 6

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHLO011-386

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

212 BALDWIN ROAD
ARDEN, NC 28704

LIVINGSTONE'S HOME

PRINTED: 05/28/2019

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

05/16/2019

(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

V117

V 118)

Continued From page 2

-Polyethylene Glycol 17 gram/dose powder -
"Prescription Laxative" - with no prescription
label.

-AddiPak - 3 ML sterile 0.9% Na Cl Solution for
inhalation USP - unit dose vials - "RX only" - with
no prescription label.

Interview on 5/13/19 with the Alternative Family
Living provider revealed:

-the Polyethylene Glycol was Client #2's and the
label fell off; she could not provide the label for
the Polyethylene Glycol.

-she ordered the AddiPak (Saline Bullets) off the
Internet due to the pharmacy not having any
available.

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:

(A) client's name;

Division of Health Service Regulation
STATE FORM

V117

V 118

6809

If continuation sheet 3 of 6

Division of Health Service Regulation

PRINTED: 05/28/2019
FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
MHL011-386 05/16/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
. 212 BALDWIN ROAD
LIVINGSTONE'S HOME
ARDEN, NC 28704
(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 3

drug.

file followed up by appoint
with a physician.

order of a physician affecti

-admission date of 1/1/16.
Disorder, Mild Intellectual

Narcissistic Personality Di

30 ml two times a day.

MAR.
-Magnesium Citrate - 500
was initialed as started on

Division of Health Service Regulation
STATE FORM

(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

(5) Client requests for medication changes or
checks shall be recorded and kept with the MAR

This Rule is not met as evidenced by:
Based on record review and interview the facility
failed to administer medications on the written

(Clients #1 and #2). The findings are:

Review on 5/13/19 of Client #1's record revealed:
-diagnoses of Autism Disorder, Impulse Control
Disability, Unspecified BiPolar Disorder,

Anus, and Fecal Impaction.

-Physician's orders included:

-4/26/19 - Magnesium Hydroxide 400 mg/5 ml -
-5/3/19 - Magnesium Citrate - 500 mg - daily.
Review on 5/13/19 of Client #1's Medication
Administration Record (MAR) from March 2019
through May 2019 revealed:

-Magnesium Hydroxide 400 mg/5 ml - 30 ml two
times a day - discontinued hand-written on May

V 118

iment or consultation

ing two of two clients

and Developmental

isorder, Imperforated

mg - 1 tablet daily -
5/3/19 .

6808 9D1Z11

If continuation sheet 4 of 6

Division of Health Service Regulation

PRINTED: 05/28/2019

FORM APPROVED

Interview on 5/13/19 and 5/14/19 with the
Alternative Family Living (AFL) provider revealed:
-Magnesium Hydroxide was replaced with the
Magnesium Citrate but she could not locate the
physician's order.

-on 5/14/19 she provided a physician note to
discontinue the Magnesium Hydroxide and start
Magnesium Citrate 500 mg daily, however there
was no physician signature.

Review on 5/13/19 of Client #2's record revealed:
-admission date of 8/17/16.

-diagnoses of Moderate Intellectual and
Developmental Disability, Hypothyroidism,
Obstructive Sleep Apnea, Allergic Rhinitis, High
Cholesterol, Depression Disorder, Speech
Impediment, Tracheotomy Implant,
Gastro-Esophageal Reflux Disease, Chronic
Obstructive Pulmonary Disease, and Parkinson's
Disease.

-Physician's orders included:

-3/22/19- Saline Bullets - use 1 vial via
nebulizer as needed.

-4/4/18 - Fluticasone Propionate (Flonase) 50
mcg - activation nasal - 1 spray each nare daily.

-5/3/19 - Fluticasone Propionate 50 mcg - 1
spray each nare - changed to as needed.

-4/4/18 - olopatadine (Pataday) 0.2 %
ophthalmic solution - 1 drop both eyes daily for 30
days.

-5/3/19 - olopatadine 0.2% ophthalmic
solution - 1 drop both eyes - changed to as
needed.

Review on 5/13/19 of Client #2's MAR from
March 2019 through May 2019 revealed:

- Saline Bullets - use 1 vial via nebulizer as
needed - was not listed for March.
-Fluticasone Propionate (Flonase) 50 mcg -

Division of Health Service Regulation

STATE FORM

6808 9D1Z11

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL011-386 05/16/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
. 212 BALDWIN ROAD
LIVINGSTONE'S HOME
ARDEN, NC 28704
(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 4 Vv 118

If continuation sheet 5 of 6

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHLO011-386

212 BALDWIN ROAD
ARDEN, NC 28704

LIVINGSTONE'S HOME

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 05/28/2019

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

05/16/2019

activation nasal - 1 spray each nare daily - was
not listed on any of the MARs.

-Fluticasone Propionate 50 mcg - 1 spray each
nare - changed to as needed - was not listed on
the May MAR.

-olopatadine (Pataday) 0.2 % ophthalmic solution
- 1 drop both eyes daily for 30 days - was not
initialed as given for the remaining days in May
2019.

-olopatadine 0.2% ophthalmic solution - 1 drop
both eyes - changed to as needed - was not on
the May MAR.

Interview on 5/13/19 and 5/14/19 with the AFL
provider revealed:

-the Saline Bullets, Fluticasone Propionate and
olopatadine were not listed on the MARs as noted
above.

-on 5/14/19 she provided one page MARs with
the above medications listed for the missing
months.

-she stated she turned in the wrong MARs to the
office and found these at the facility.

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

Division of Health Service Regulation
STATE FORM

6809

9D1Z11

(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 5 Vv 118

If continuation sheet 6 of 6


state: NC

facility_name: Livingstone's Home

summary: Plan of Correction - MHLCS Annual

raw_content:
PRINTED: 09/06/2018

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION DHSR (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ALBUIEDING - Mental Hee MPHRTeED
MHL011-386 awing SEP 9.0 2018 0 i452018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Li
LiVINGSTONE'S HOME 212 BALDWIN ROAD Ic. & Cert. Section
ARDEN, NC 28704
(xa) 1D SUMMARY STATEMENT OF DEFICIENCIES Tp 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

Medication Requirements

let /15/18. . ae
se ie Sted 8/15/78 The RN will retrain Medication

| Administration specifically for this
| This facility is licensed for the following service home by 9/1/18. Competency testing

categories: il
10A NCAC 27G .5100 Community Respite will occur at the end of training. RN wi
Services for Individuals of all Disability Groups review all current medications and
10A NCAC 27G Supervised Living for Individuals =
of all Disability Groups-Alternative Family Living. related documentation for accuracy.

V 118| 27G .0209 (C) Medication Requirements ‘| v118 The QP will verity that the home has the

“How To” Quick Reference To
10A NCAC 27G .0209 MEDICATION a
the home by 9/1/18

REQUIREMENTS Medication in y 9/1/
(c) Medication administration: . ill piss
(1) Prescription or non-prescription drugs shall Monthly and ongoing, QP will compare:
only be administered to a client on the written prescription to medication bottle to
a a person authorized by law to prescribe MAR looking for inconsistency
(2) Medications shall be self-administered by . 4
clients only when authorized in writing by the Monthly and ongoing, the QP will
client's physician. ent the review of the
(3) Medications, including injections, shall be dcunien aa
administered only by licensed persons, or by prescription and medication bottle a
unlicensed persons trained by a registered nurse, MAR looking for inconsistency on the
pharmacist or other legally qualified person and 2
privileged to prepare and administer medications Home Inspection document
(4) A Medication Administration Record (MAR) of ;
all drugs administered to each client must be kept At a regional QP meeting Program
current. Medications administered shall be Managers will retrain all QPs on the
recorded immediately after administration. The oo ee =
MAR is to include the following: process for reviewing medications in
(A) client's name; the AFL homes, by 10/1/18

(B) name, strength, and quantity of the drug;
(C) instructions for administering the drug;

(D) date and time the drug is administered; and oo.
(E) name or initials of person administering the and related documentation in all AFL
drug. a. homes by 11/1/18

(5) Client requests for medication changes or
Division of Health Service Regulation

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

Was EATER

QPs will review all current medications

STATE FORM 58;

M6D211 If continuation sheet 1 of 9

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

PRINTED: 09/06/2018

(X1) PROVIDER/SUPPLIERI/CLIA
IDENTIFICATION NUMBER:

MHLO011-386

LIVINGSTONE'S HOME

STREET ADDRESS, CITY, STATE, ZIP CODE
212 BALDWIN ROAD

ARDEN, NC 28704

(X4) ID
PREFIX
TAG

V 118

FORM APPROVED
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
A. BUILDING. COMPLETED
BWI 08/45/2018

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

Continued From page 1

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 tc keep the MAR current and failed
to follow the written order of a physician affecting
2 of 2 clients (Client #1 and #2). The findings are:

Record review on 8/15/18 for Client #1 revealed:
-Admission date of 1/1/16 with diagnoses of Mild
Intellectual Disability, Impulse Control Disorder
and Oppositional Defiant Disorder.

-Physician order dated 5/22/18 for Fiber Powder 2
teaspoons 1-2 times daily.

Review on 8/14/18 of MARs for June-August
2018 revealed

-Fiber Powder not administered on 6/10/18,
6/14/18, 7/2/18, 7/3/18, 7/5/18, 7/6/18, 7/8/18,
7/20/18, 7/26/18, 7/27/18, 7/28/18, 7/30/18,
8/1/18-8/13/18.

Record review on 8/15/18 for Client #2 revealed:

| -Admission date of 8/17/16 with diagnoses of

Moderate Intellectual Disability, Hypothyroidism,
High Cholesterol, Parkinson's, COPD (Chronic
Obstructive Pulmonary Disease) and Major
Depressive Disorder.

-Physician order dated 6/6/18 for Loratadine

| 10mg once daily.
| Review on 8/14/18 of MARs for June-August

2018 revealed:

-Loratadine 10mg take 1 tab three times daily
(TID).

-Administered once daily except 7/28/18 when it

Division of Health Service Regulation
STATE FORM

i i)
| PREFIX
TAG

| a cee

Vv 118

899

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

(XS)
COMPLETE
DATE

Criminal History Records Check

Hiring process was reviewed and
amended. When and application is
reviewed and it is determined they
have not lived in the state for at least 5
years the HR Manager will have the
fingerprint document completed before
initiating other steps to complete the
background checks. This information
will be added to the New Hire Checklist.

M60211 If continuation sheet 2 of 9

PRINTED: 09/06/2018

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: COMPLETED
A. BUILDING:
MHL011-386 BAIN 08/15/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

212 BALDWIN ROAD

LIVINGSTONE'S HOME ARDEN, NC 28704

T 7 a
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES | ID PROVIDER'S PLAN OF CORRECTION 5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
|

V 118] Continued From page 2 v118

was administered twice.

Interview on 8/14/18 with AFL Caregiver revealed:
-She thought the Fiber Powder for Client #1 was
PRN (as needed) and had administered it that
way.

-She was not aware the order for Fiber Powder
was to give every day.

-She administered the Loratadine to Client #2
daily and did not know why she had documented
that it was given twice on 7/28/18. "That was 2
mistake."

| -She had not noticed the instructions on the MAR
were written incorrectly to give Loratadine TID.
-She got the monthly MARs from her QP

| (qualified professional)

Interview on 8/15/18 with the Qualified
Professional revealed:

-She began working for Licensee in November
2017.

-She was responsible for reviewing medications
and MARs at the facility.

-She had not noticed the MAR for Client #2 was |
written incorrectly for the administration of
Loratadine.

V 133] G.S. 122C-80 Criminal History Record Check V 133

G.S. §122C-80 CRIMINAL HISTORY RECORD
CHECK REQUIRED FOR CERTAIN |
APPLICANTS FOR EMPLOYMENT | |
(a) Definition. - As used in this section, the term
"provider" applies to an area authority/county |
program and any provider of mental health, |
developmental disability, and substance abuse
services that is licensable under Article 2 of this
Chapter.

(b) Requirement. - An offer of employment by a

—e
Division of Health Service Regulation
STATE FORM 8899 M6D211 If continuation sheet 3 of 9

PRINTED: 09/06/2018

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: COMPLETED
A. BUILDING:
MHL011-386 Be WING 08/15/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
212 BALDWIN ROAD
LIVINGSTONE'S HOME
ARDEN, NC 28704
(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION 8)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL | PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

V 133] Continued From page 3 V 133

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

| the applicant has been a resident of this State for
five years or more, then the offer is conditioned
on consent to a State criminal history record
check of the applicant. A provider shall not
employ an applicant who refuses to consent to a
criminal history record check required by this
section. Except as otherwise provided in this
subsection, within five business days of making
the conditional offer of employment, a provider
shall submit a request to the Department of
Justice under G.S. 114-19.10 to conduct a
criminal history record check required by this
section or shall submit a request to a private
entity to conduct a State criminal history record
check required by this section. Notwithstanding
G.S. 114-19.10, the Department of Justice shall
return the results of national criminal history
record checks for employment positions not
covered by Public Law 105-277 to the
Department of Health and Human Services,
Criminal Records Check Unit. Within five
business days of receipt of the national criminal
history of the person, the Department of Health
and Human Services, Criminal Records Check
Unit, shall notify the provider as to whether the
information received may affect the employability
of the applicant. In no case shall the results of the
national criminal history record check be shared

Division of Health Service Regulation
STATE FORM 6899 M6D211 If continuation sheet 4 of 9

PRINTED: 09/06/2018
FORM APPROVED

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

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

B. WING.

MHLO011-386 08/15/2018

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE
212 BALDWIN ROAD

LIVINGSTONE'S HOME ARDEN, NC 28704

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

| DEFICIENCY) |
]
V 133) Continued From page 4 V 133

with the provider. Providers shall make available
upon request verification that a criminal history |
check has been completed on any staff covered
by this section. A county that has adopted an
appropriate local ordinance and has access to
the Division of Criminal Information data bank
may conduct on behalf of a provider a State
criminal history record check required by this
section without the provider having to submit a
request to the Department of Justice. In such a
case, the county shall commence with the State
criminal history record check required by this
section within five business days of the
conditional offer of employment by the provider.
All criminal history information received by the
provider is confidential and may not be disclosed,
except to the applicant as provided in subsection
(c) of this section. For purposes of this
subsection, the term "private entity" means a
business regularly engaged in conducting
criminal history record checks utilizing public
records obtained from a State agency.

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

(1) The level and seriousness of the crime.

(2) The date of the crime.

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

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

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

(6) The prison, jail, probation, parole,
rehabilitation, and employment records of the

person since the date the crime was committed.

Division of Health Service Regulation
STATE FORM sa00 MeD211 If continuation sheet 5 of 9

PRINTED: 09/06/2018
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (41) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING.

(X3) DATE SURVEY
COMPLETED

MHL011-386 BEWING 08/15/2018

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

212 BALDWIN ROAD
ARDEN, NC 28704

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

LIVINGSTONE'S HOME

Continued From page 5

(7) The subsequent commission by the person of
a relevant offense. |
The fact of conviction of a relevant offense alone |
shall not be a bar to employment; however, the |
listed factors shall be considered by the provider. |
If the provider disqualifies an applicant after
consideration of the relevant factors, then the
provider may disclose information contained in
the criminal history record check that is relevant
to the disqualification, but may not provide a copy
of the criminal history record check.to the
applicant.

(d) Limited Immunity. - A provider and an officer
or employee of a provider that, in good faith,
complies with this section shall be immune from
civil liability for:

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

(e) Relevant Offense. - As used in this section,
"relevant offense" means a county, state, or
federal criminal history of conviction or pending
indictment of a crime, whether a misdemeanor or
felony, that bears upon an individual's fitness to
have responsibility for the safety and well-being of
persons needing mental health, developmental
disabilities, or substance abuse services. These
crimes include the criminal offenses set forth in
any of the following Articles of Chapter 14 of the
General Statutes: Article 5, Counterfeiting and
Issuing Monetary Substitutes; Article 5A,
Endangering Executive and Legislative Officers;
Article 6, Homicide; Article 7A, Rape and Other
Sex Offenses; Article 8, Assaults; Article 10,
Kidnapping and Abduction; Article 13, Malicious

Division of Health Service Regulation
STATE FORM 6299 MsD211 ifcontinuation sheet 6 of 9

PRINTED: 09/06/2018
FORM APPROVED

Division of Health Service Regulation

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(x3) DATE SURVEY
COMPLETED

B. WING

MHL011-386

08/15/2018

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

212 BALDWIN ROAD

LIVINGSTONE'S HOME ARDEN, NC 28704

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVEACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
PN
V 133) Continued From page 6 V 133

Injury or Damage by Use of Explosive or
Incendiary Device or Material; Article 14, Burglary
and Other Housebreakings; Article 15, Arson and
Other Burnings, Article 16, Larceny; Article 17, |
Robbery; Article 18, Embezzlement; Article 19,
False Pretenses and Cheats; Article 19A,
Obtaining Property or Services by False or
Fraudulent Use of Credit Device or Other Means;
Article 19B, Financial Transaction Card Crime
Act; Article 20, Frauds; Article 21, Forgery; Article
26, Offenses Against Public Morality and
Decency; Article 26A, Adult Establishments; |
Article 27, Prostitution; Article 28, Perjury; Article
29, Bribery; Article 31, Misconduct in Public |
Office; Article 35, Offenses Against the Public
Peace; Article 36A, Riots and Civil Disorders;
Article 39, Protection of Minors; Article 40,
Protection of the Family; Article 59, Public
Intoxication; and Article 60, Computer-Related
Crime. These crimes also include possession or
sale of drugs in violation of the North Carolina |
Controlled Substances Act, Article 5 of Chapter
90 of the General Statutes, and alcohol-related
offenses such as sale to underage persons in |
violation of G.S. 18B-302 or driving while
impaired in violation of G.S. 20-138.1 through
G.S. 20-138.5.
(f) Penalty for Furnishing False Information. - Any |
applicant for employment who willfully furnishes, |
| supplies, or otherwise gives false information on |
an employment application that is the basis fora |
criminal history record check under this section
shall be guilty of a Class A1 misdemeanor.
(g) Conditional Employment. - A provider may |
employ an applicant conditionally prior to
obtaining the results of a criminal history record
check regarding the applicant if both of the
| following requirements are met:
| (1) The provider shall not employ an applicant

Division of Health Service Regulation
STATE FORM 5899 M6D211 If continuation sheet 7 of 9

Division of Health Service Requlation

PRINTED: 09/06/2018
FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
MHL011-386 BF WING 08/15/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
212 BALDWIN ROAD
LIVINGSTONE'S HOME
iS ARDEN, NC 28704
(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 133} Continued From page 7 V 133

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

This Rule is not met as evidenced by:

Based on personnel record review and staff
interviews the facility failed to request a State
Bureau of Investigation (SBI) national criminal
background check within 5 days of making the
conditional offer of employment for 1 of 3
sampled staff (Qualified Professional (QP) who
had lived in North Carolina for less than 5 years
prior to employment. The findings are:

Record review on 8/15/18 for QP revealed:
-Date of Hire 11/1/17

-Criminal background check conducted 10/10/17
-SBI fingerprint check sent 11/22/17.

-Interview on 8/15/18 with QP revealed:
-She had previously lived in Florida and had not
been in NC for 5 years.

Interview on 8/15/18 with Human Resources
Manager revealed:

-The Licensee criminal background review
included a national check

-She was not aware a specific SBI check was
required as part of that.

Division of Health Service Regulation
STATE FORM

899 M6D211

If continuation sheet 8 of 9

PRINTED: 09/06/2018
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
MHLO011-386 BLMING' 08/15/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
212 BALDWIN ROAD
LIVINGSTONE'S HOME
ARDEN, NC 28704
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

Division of Health Service Regulation
STATE FORM 5399 M6D211 If continuation sheet 9 of 9

inspection_type: MHLCS Annual

document_type: Plan of Correction


facility_name: Asheville Detox Center

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

raw_content:
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

ASHEVILLE DETOX CENTER

(X4) ID
PREFIX
TAG

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHL011-436

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

INITIAL COMMENTS

An annual and follow up survey was completed
on 11/14/25. Deficiencies were cited.

This facility is licensed for the following service
categories:

410A NCAC 27G .3100 Non-hospital Medical
Detoxification-Individuals who are Substance
Abusers.

10A NCAC 27G .3400 Residential
Treatment-Individuals with Substance Abuse
Disorders.

This facility is licensed for 10 in the 3100 program
with a current census of 10 and licensed for 6 in
the 3400 program with a current census of 0.

The survey sample consisted of audits of 3
current clients.

27G .3102 Nonhospital Med. Detox. - Staff

JOA NCAC 27G .3102 = STAFF

(a) Aminimum of one direct care staff member
shall be on duty at all times for every nine or
fewer clients.

(b) The treatment of each client shall be under
the supervision of a physician.

(c) The services of a certified alcoholism
counselor, a certified drug abuse counselor or a
certified substance abuse counselor shall be
available to each client.

(d) Each facility shall have at least one staff
member on duty at all times trained in the
following areas:

(1) substance abuse withdrawal symptoms,
including delirium tremens; and

(2) symptoms of secondary complications
to substance abuse.

(e) Each direct care staff member shall receive
continuing education to include understanding of

Division of Health Service Regulation

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

STATE FORM

(X2} MULTIPLE CONSTRUCTION

A. BUILDING:

B. WING

0000

PRINTED: 11/17/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
11/14/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

25 CHOCTAW STREET
ASHEVILLE, NC 28801

PROVIDER'S PLAN OF CORRECTION

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

Bis

SW3P11

DEFICIENCY)

RECEIVED
DEC 01 2025
DHSR-MH Licensure Sect

TITLE

cp lictce Hur

(x6) DATE
1/24 /ao2s~

If continuation sheet 1 of 7

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA

AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

IDENTIFICATION NUMBER:

MHLO011-436

(X2) MULTIPLE CONSTRUCTION

A. BUILDING:

B. WING

25 CHOCTAW STREET

ASHEVILLE DETOX CENTER

(X4) ID
PREFIX
TAG

ASHEVILLE, NC 28801

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

Continued From page 2

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

10A NCAC 27E .0107 TRAINING ON
ALTERNATIVES TO RESTRICTIVE
INTERVENTIONS

(a) Facilities shall implement policies and
practices that emphasize the use of alternatives
to restrictive interventions.

(b) Prior to providing services to people with
disabilities, staff including service providers,
employees, students or volunteers, shall
demonstrate competence by successfully
completing training in communication skills and
other strategies for creating an environment in
which the likelihood of imminent danger of abuse
or injury to a person with disabilities or others or
property damage is prevented.

(c) Provider agencies shall establish training
based on state competencies, monitor for internal
compliance and demonstrate they acted on data
gathered.

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

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

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

(g) Staff shall demonstrate competence in the
following core areas:

(1) knowledge and understanding of the
people being served;

Division of Health Service Regulation
STATE FORM

5W3P 11

PRINTED: 11/17/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

PROVIDER'S PLAN OF CORRECTION

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R
11/14/2025

(x5)

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

DEFICIENCY)

If continuation sheet 3 of 7

PRINTED: 11/17/2025
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIERICLIA. (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED

R
MHL011-436 B. WING ________ 11/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
25 CHOCTAW STREET
ASHEVILLE, NC 28801

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE

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

ASHEVILLE DETOX CENTER

Continued From page 4

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

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

(4) The content of the instructor training the
service provider plans to employ shall be
approved by the Division of MH/DD/SAS pursuant
to Subparagraph (i)(5) of this Rule.

(5) Acceptable instructor training programs
shall include but are not limited to presentation of:
(A) understanding the adult learner;

(B) methods for teaching content of the
course;

(C} methods for evaluating trainee
performance; and

(D) documentation procedures.

(6) Trainers shall have coached experience
teaching a training program aimed at preventing,
reducing and eliminating the need for restrictive
interventions at least one time, with positive
review by the coach.

(7) Trainers shall teach a training program
aimed at preventing, reducing and eliminating the
need for restrictive interventions at least once
annually.

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

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

(1) Documentation shall include:

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

(B) when and where attended; and

(C) instructor's name.

Division of Health Service Regulation
STATE FORM 6899 5W3P11 If continuation sheet 5 of 7

PRINTED: 11/17/2025

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
MHLO11-436 B. WING 41/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
25 CHOCTAW STREET
ASHEVILLE, NC 28801

(X%4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE

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

ASHEVILLE DETOX CENTER

Continued From page 6

-Date of hire: 11/3/25.

-Job Title: Behavioral Health Technician (BHT).
-There was no documentation of training in
alternatives to restrictive intervention (North
Carolina Interventions Plus (NCI+) training).

Review on 11/13/25 of Counselor #1's record
revealed:

-Date of hire: 6/25/25.

-Job Title: BHT Clinical Intern.

-There was no documentation of training in
alternatives to restrictive intervention (North
Carolina Interventions Plus (NCI+) training).

Interview on 11/13/25 with Staff #1 revealed:
-Had just been employed at the facility for 2
weeks.

-Did not recall having NCI training.

Interview on 11/13/25 with Counselor #1
revealed:

-Had not had NCI training.

-Was now licensed and could complete an
attestation.

Interview on 14/13/25 with the Program Director
revealed:

-Had already discussed adding NCI to onboard
for new employees.

-Was not aware that licensed clinical staff could
complete an attestation in lieu of the NCI training.
-NCI training scheduled for 12/11/25.

-Had administrative turnover this past year and
was tightening up all training requirements.

Division of Health Service Regulation
STATE FORM 6899 5W3P11 If continuation sheet 7 of 7

inspection_type: MHLCS Annual and Follow-up


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

raw_content:
PRINTED: 11/17/2025
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
MHL011-436 B. WING _____ 11/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
25 CHOCTAW STREET
ASHEVILLE, NC 28801

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

DEFICIENCY)

ASHEVILLE DETOX CENTER

V 000} INITIAL COMMENTS Vv 000

An annual and follow up survey was completed
on 11/14/25. Deficiencies were cited.

This facility is licensed for the following service
categories:

10A NCAC 27G .3100 Non-hospital Medical
Detoxification-Individuals who are Substance
Abusers.

10A NCAC 27G .3400 Residential
Treatment-Individuals with Substance Abuse
Disorders.

This facility is licensed for 10 in the 3100 program
with a current census of 10 and licensed for 6 in
the 3400 program with a current census of 0.
The survey sample consisted of audits of 3
current clients.

V 219} 27G .3102 Nonhospital Med. Detox. - Staff Vv 219

10A NCAC 27G .3102 STAFF

(a) Aminimum of one direct care staff member
shall be on duty at all times for every nine or
fewer clients.

(b) The treatment of each client shall be under
the supervision of a physician.

(c) The services of a certified alcoholism
counselor, a certified drug abuse counselor or a
certified substance abuse counselor shall be
available to each client.

(d) Each facility shall have at least one staff
member on duty at all times trained in the
following areas:

(1) substance abuse withdrawal symptoms,
including delirium tremens; and

(2) symptoms of secondary complications
to substance abuse.

(e) Each direct care staff member shall receive
continuing education to include understanding of

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

STATE FORM 6899 5W3P11 If continuation sheet 1 of 7

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL011-436 B. WING

NAME OF PROVIDER OR SUPPLIER
25 CHOCTAW STREET

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 11/17/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
11/14/2025

the nature of addiction, the withdrawal syndrome,
group therapy, family therapy and other treatment
methodologies.

This Rule is not met as evidenced by:

Based on record reviews and interview, the
facility failed to ensure 1 of 3 audited staff (Nurse
#1) received continuing education to include
understanding of the nature of addiction, the
withdrawal syndrome, group therapy, family
therapy and other treatment methodologies. The
findings are:

Review on 11/14/25 of Nurse #1's record
revealed:

-Date of hire: 7/11/22.

-Job Title: Nursing Manager/Licensed Practical
Nurse.

-There was no documentation of continuing
education in annual required trainings since
9/22/23.

Interview on 11/14/25 with Nurse #1 revealed:
-Was up to date with training requirements.

Interview on 11/14/25 with the Program Director
revealed:

-Had been some turn over in administration for
the past year.

-Had included these specific trainings to
onboarding for new staff.

-Annual trainings were usually completed with our
supervising clinician.

-Will make sure these trainings are included in on
going annual trainings.

Division of Health Service Regulation

STATE FORM 6899

5W3P11

ASHEVILLE DETOX CENTER
ASHEVILLE, NC 28801
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 219] Continued From page 1 Vv 219

If continuation sheet 2 of 7

PRINTED: 11/17/2025

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL011-436 B. WING 11/14/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
25 CHOCTAW STREET
ASHEVILLE DETOX CENTER
ASHEVILLE, NC 28801
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (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 536} Continued From page 2 V 536
V 536] 27E .0107 Client Rights - Training on Alt to Rest. | V 536
Int.

10A NCAC 27E .0107 TRAINING ON
ALTERNATIVES TO RESTRICTIVE
INTERVENTIONS

(a) Facilities shall implement policies and
practices that emphasize the use of alternatives
to restrictive interventions.

(b) Prior to providing services to people with
disabilities, staff including service providers,
employees, students or volunteers, shall
demonstrate competence by successfully
completing training in communication skills and
other strategies for creating an environment in
which the likelihood of imminent danger of abuse
or injury to a person with disabilities or others or
property damage is prevented.

(c) Provider agencies shall establish training
based on state competencies, monitor for internal
compliance and demonstrate they acted on data
gathered.

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

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

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

(g) Staff shall demonstrate competence in the
following core areas:

(1) knowledge and understanding of the
people being served;

Division of Health Service Regulation
STATE FORM 6899 5W3P11 If continuation sheet 3 of 7

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL011-436 B. WING

NAME OF PROVIDER OR SUPPLIER

ASHEVILLE DETOX CENTER

(X2) MULTIPLE CONSTRUCTION

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

PRINTED: 11/17/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
11/14/2025

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

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

V 536} Continued From page 3 V 536

(2) recognizing and interpreting human
behavior;

(3) recognizing the effect of internal and
external stressors that may affect people with
disabilities;

(4) strategies for building positive
relationships with persons with disabilities;

(5) recognizing cultural, environmental and
organizational factors that may affect people with
disabilities;

(6) recognizing the importance of and
assisting in the person's involvement in making
decisions about their life;

(7) skills in assessing individual risk for
escalating behavior;
(8) communication strategies for defusing
and de-escalating potentially dangerous behavior;
and
(9) positive behavioral supports (providing
means for people with disabilities to choose
activities which directly oppose or replace
behaviors which are unsafe).

(h) Service providers 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;

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

(i) Instructor Qualifications and Training
Requirements:

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

(2) Trainers shall demonstrate competence

Division of Health Service Regulation

STATE FORM 6899 5W3P11 If continuation sheet 4 of 7

PRINTED: 11/17/2025

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL011-436 B. WING 11/14/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
25 CHOCTAW STREET
ASHEVILLE DETOX CENTER
ASHEVILLE, NC 28801
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (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 536} Continued From page 4 V 536

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

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

(4) The content of the instructor training the
service provider plans to employ shall be
approved by the Division of MH/DD/SAS pursuant
to Subparagraph (i)(5) of this Rule.

(5) Acceptable instructor training programs
shall include but are not limited to presentation of:
(A) understanding the adult learner;

(B) methods for teaching content of the
course;

(C) methods for evaluating trainee
performance; and

(D) documentation procedures.

(6) Trainers shall have coached experience

teaching a training program aimed at preventing,
reducing and eliminating the need for restrictive
interventions at least one time, with positive
review by the coach.
(7) Trainers shall teach a training program
aimed at preventing, reducing and eliminating the
need for restrictive interventions at least once
annually.
(8) Trainers shall complete a refresher
instructor training at least every two years.

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

(1) Documentation shall include:

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

(B) when and where attended; and

(C) instructor's name.

Division of Health Service Regulation
STATE FORM 6899 5W3P11 If continuation sheet 5 of 7

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL011-436 B. WING

NAME OF PROVIDER OR SUPPLIER

25 CHOCTAW STREET

ASHEVILLE DETOX CENTER ASHEVILLE, NC 28801

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 11/17/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
11/14/2025

(2) The Division of MH/DD/SAS may
request and review this documentation any time.
(k) Qualifications of Coaches:

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

(2) Coaches shall teach at least three times
the course which is being coached.

(3) Coaches shall demonstrate
competence by completion of coaching or
train-the-trainer instruction.

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

This Rule is not met as evidenced by:

Based on record reviews and interviews, the
facility failed to ensure 2 of 3 audited staff (Staff
#1, Counselor #1) received initial training in
alternatives to restrictive interventions prior to the
provision of services. The findings are:

Review on 11/13/25 of Staff #1's record revealed:
-Date of hire: 10/7/24.

-Job Title: Behavioral Health Technician.

-There was no documentation of training in
alternatives to restrictive intervention (North
Carolina Interventions Plus (NCI+) training).
-There was no documentation of training in
seclusion, physical restraint and isolation time-out
(North Carolina Interventions Plus (NCI+)
training).

Review on 11/13/25 of Staff #1's record revealed:
Division of Health Service Regulation

STATE FORM 6899

5W3P11

(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 536} Continued From page 5 V 536

If continuation sheet 6 of 7

PRINTED: 11/17/2025

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL011-436 B. WING 11/14/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
25 CHOCTAW STREET
ASHEVILLE DETOX CENTER
ASHEVILLE, NC 28801
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (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 536} Continued From page 6 V 536

-Date of hire: 11/3/25.

-Job Title: Behavioral Health Technician (BHT).
-There was no documentation of training in
alternatives to restrictive intervention (North
Carolina Interventions Plus (NCI+) training).

Review on 11/13/25 of Counselor #1's record
revealed:

-Date of hire: 6/25/25.

-Job Title: BHT Clinical Intern.

-There was no documentation of training in
alternatives to restrictive intervention (North
Carolina Interventions Plus (NCI+) training).

Interview on 11/13/25 with Staff #1 revealed:
-Had just been employed at the facility for 2
weeks.

-Did not recall having NCI training.

Interview on 11/13/25 with Counselor #1
revealed:

-Had not had NCI training.

-Was now licensed and could complete an
attestation.

Interview on 11/13/25 with the Program Director
revealed:

-Had already discussed adding NCI to onboard
for new employees.

-Was not aware that licensed clinical staff could
complete an attestation in lieu of the NCI training.
-NCI training scheduled for 12/11/25.

-Had administrative turnover this past year and
was tightening up all training requirements.

Division of Health Service Regulation

STATE FORM 6899

5W3P11

If continuation sheet 7 of 7

document_type: Statement of Deficiency


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

raw_content:
PRINTED: 11/21/2024
FORM APPROVED

Division of Health Service Regulation

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

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

R
11/05/2024

MHL011-436 BPMANG,

STREET ADDRESS, CITY, STATE, ZIP CODE

25 CHOCTAW STREET
ASHEVILLE, NC 28801

NAME OF PROVIDER OR SUPPLIER

ASHEVILLE DETOX CENTER

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

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

| DEFICIENCY)

V 000 INITIAL COMMENTS

An annual, complaint, and follow up survey was
completed on November 5, 2024. The complaint
was unsubstantiated (Intake# NC00222022). A
deficiency was cited.

This facility is licensed for the following service
category: 10A NCAC 27G .3100 Non-hospital
Medical Detoxification for Individuals who are
Substance Abusers.

This facility is licensed for 16 and has a current
| census of 11. The survey sample consisted of
audits of 2 current clients and 1 deceased client.

alt
V 114 27G .0207 Emergency Plans and Supplies vi1t4 FP \wose we Ad
ors
10A NCAC 27G .0207 EMERGENCY PLANS se & axe?
AND SUPPLIES \e A faa x
(a) Each facility shall develop a written fire plan Kot & wo
and a disaster plan and shall make a copy of ans ye
these plans available ™ yd
to the county emergency services agencies upon | ox “

| fequest. The plans shall include evacuation
procedures and routes. | gee
(b) The plans shall be made available to all staff
and evacuation procedures and routes shall be | |
posted in the |

“facility. RECEIVED |

(c) Fire and disaster drills in a 24-hour facility

shall be held at least quarterly and shall be DEC f 2 2024
| repeated for each shift. - |

Drills shall be conducted under conditions that DHSR-MH Licensure Sect

simulate the facility's response to fire

emergencies.
(d) Each facility shall have a first aid kit
_ accessible for use.

Division of Health Service Regulation = L
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE, J SO pe TME CCU (x6) DATE
e

Wpsrly

ee eee
STATE FORM 800 2KX811 {fcontinuation sheet 1 of 3

PRINTED: 11/21/2024
FORM APPROVED

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (K2) MULTIPLE CONSTRUCTION
AND PLAN OF CORRECTION IDENTIFICATION NUMBER.

(X3) DATE SURVEY
COMPLETED

A. BUILDING:
R
MHL011-436 5. WING 11/05/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
25 CHOCTAW STREET

ASHEVILLE DETOX CENTER
ASHEVILLE, NC 28801

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES | PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX | {EACH DEFICIENCY MUST BE PRECEDED BY FULL | pReFK | (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

This Rule is not met as evidenced by: |
Based on record review and interview, the facility
failed to ensure that fire and disaster drills were
conducted for each shift at least quarterly. The
findings are:

Review on 11/4/24 of the facility's fire and |
disaster drills from 2/12/24 to 11/4/24 revealed:
-No documentation of fire drills for the following
shifts and quarters:

-April 2024-June 2024: 1st and 3rd shifts.
-No documentation of disaster drills for the
following shifts and quarters:

-April 2024-June 2024:1st, 2nd, and 3rd
shifts.

-July 2024-September 2024: 2nd and 3rd |
shifts.

Interview on 11/1/24 with Client #1 revealed:
-had not been at the facility long enough to
| participate in a fire/disaster drill.

Interview on 11/4/24 with Client #2 revealed:
-had not been at the facility long enough to
participate in a fire/disaster drill. |
-knew that they would go outside in case of an |

emergency.

| Interview on 11/5/24 with Staff #2 revealed:

| -worked as a second shift behavioral health
technician (BHT) at the facility.
-second shift was from 3:30PM-12:00AM, third |
shift came in at 11:30PM and stayed till 8:00AM.
-completed a fire and disaster drill while on shift
-could not recall the date when this was
completed.

Division of Health Service Regulation
STATE FORM 6999 ZKX811 if continuation sheet 2 of 3

PRINTED: 11/21/2024
FORM APPROVED

Division of Health Service Regulation

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

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

R
11/05/2024

MHL011-436 EWING

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

ASHEVILLE DETOX CENTER
ILLE DETO: ASHEVILLE, NC 28801

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION 5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL | PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) | Tas CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

V 114) Continued From page 2

Interview on 11/4/24 with BHT Supervisor #1

| revealed:
-moved into a supervisory role in July 2024.
-typically worked 1st shift was at the facility by

| 8:00AM.
-worked with the Program Director (PD) to get fire
drills completed.

| -had not completed a disaster drill

| Interview on 11/4/24 and 11/5/24 with the PD
revealed: |
-clients were at the facility short term for |
detoxification. |
-became the PD of the facility in the summer of |
2024.

-worked to ensure that fire and disaster drills
were completed timely.

-could not respond to how the prior PD conducted |
fire and disaster drills.

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

Division of Health Service Regulation
STATE FORM 6399 2KX811 if continuation sheet 3 of 3

y y

ASHEVILLE

Plan of Correction for Asheville Detox Center

ID Prefix Tag V 114

On 11/25/24, the Chief Compliance Officer will provide training to the Facility Director at
Asheville Detox Center. The training shall include a review of the disaster plan at Asheville Detox
Center, a review of state rule 27G .0207, and a review of the evacuation routes and procedures.
CCO will have the Facility Director walk through a sample fire and disaster drill to ensure said
drills meet facility standards and adequately simulate an emergency situation. The Facility
Director will then provide the same training to all personnel that work at the facility, and will
complete the training by 12/2/24.

The Facility Director will designate one staff member on each shift that will be
responsible for completing, documenting and submitting drill reports in his absence, and will
provide additional training on the documentation procedure utilized by the facility to these staff
members. This training will be completed by 12/4/24.

Automated monthly email reminders will be utilized, and sent to the Facility Director, as
a reminder that fire and disaster drills must be completed. The Facility Director will have one
week from the date of the email reminder to facilitate, document and submit the drill report.
Email reminders will be sent on the first of each month, beginning December 1, 2024.

Drill report documentation will be monitored by the CCO on a monthly basis, beginning
eight days after the receipt of the automated email reminder. If the drill report has not been
completed and submitted, CCO will communicate with the Facility Director to identify why the
drill report has not been completed, and allow an addition 72 hours for the drill report to be
completed. If additional monitoring indicates the drill report has not been documented, CCO
will go to the facility and facilitate the fire/disaster drill, and complete documentation.

Authorized Representative Signature: ASL CLO

Date: il Jase 724

inspection_type: MHLCS Annual, Complaint, and Follow-up


raw_content:
Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL011-436

ASHEVILLE DETOX CENTER

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 11/21/2024

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

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

R
11/05/2024

(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 114

INITIAL COMMENTS

An annual, complaint, and follow up survey was
completed on November 5, 2024. The complaint
was unsubstantiated (Intake# NC00222022). A
deficiency was cited.

This facility is licensed for the following service
category: 10A NCAC 27G .3100 Non-hospital
Medical Detoxification for Individuals who are
Substance Abusers.

This facility is licensed for 16 and has a current
census of 11. The survey sample consisted of
audits of 2 current clients and 1 deceased client.

27G .0207 Emergency Plans and Supplies

10A NCAC 27G .0207 EMERGENCY PLANS
AND SUPPLIES

(a) Each facility shall develop a written fire plan
and a disaster plan and shall make a copy of
these plans available

to the county emergency services agencies upon
request. The plans shall include evacuation
procedures and routes.

(b) The plans 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 the facility's response to fire
emergencies.

(d) Each facility shall have a first aid kit
accessible for use.

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

STATE FORM

V 000

Vv 114

6899

TITLE

(X6) DATE

If continuation sheet 1 of 3

Division of Health Service Regulation

PRINTED: 11/21/2024
FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
R
MHL011-436 11/05/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
25 CHOCTAW STREET
ASHEVILLE DETOX CENTER
ASHEVILLE, NC 28801
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (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

findings are:

shifts.

shifts.

emergency.

completed.

Division of Health Service Regulation
STATE FORM

V 114] Continued From page 1 Vv 114

This Rule is not met as evidenced by:

Based on record review and interview, the facility
failed to ensure that fire and disaster drills were
conducted for each shift at least quarterly. The

Review on 11/4/24 of the facility's fire and
disaster drills from 2/12/24 to 11/4/24 revealed:
-No documentation of fire drills for the following
shifts and quarters:

-April 2024-June 2024: 1st and 3rd shifts.
-No documentation of disaster drills for the
following shifts and quarters:

-April 2024-June 2024:1st, 2nd, and 3rd

-July 2024-September 2024: 2nd and 3rd

Interview on 11/1/24 with Client #1 revealed:
-had not been at the facility long enough to
participate in a fire/disaster drill.

Interview on 11/4/24 with Client #2 revealed:
-had not been at the facility long enough to
participate in a fire/disaster drill.

-knew that they would go outside in case of an

Interview on 11/5/24 with Staff #2 revealed:
-worked as a second shift behavioral health
technician (BHT) at the facility.

-second shift was from 3:30PM-12:00AM, third
shift came in at 11:30PM and stayed till 8:00AM.
-completed a fire and disaster drill while on shift.
-could not recall the date when this was

6808 ZKX811

If continuation sheet 2 of 3

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL011-436

ASHEVILLE DETOX CENTER

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 11/21/2024

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

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

R
11/05/2024

Interview on 11/4/24 with BHT Supervisor #1
revealed:

-moved into a supervisory role in July 2024.
-typically worked ‘st shift was at the facility by
8:00AM.

-worked with the Program Director (PD) to get fire
drills completed.

-had not completed a disaster drill.

Interview on 11/4/24 and 11/5/24 with the PD
revealed:

-clients were at the facility short term for
detoxification.

-became the PD of the facility in the summer of
2024.

-worked to ensure that fire and disaster drills
were completed timely.

-could not respond to how the prior PD conducted
fire and disaster drills.

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

Division of Health Service Regulation
STATE FORM

6809

ZKX811

(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

If continuation sheet 3 of 3