raw_content:
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
MHL001-149
NAME OF PROVIDER OR SUPPLIER
1710 SYKI

JUST IN TIME YOUTH SERVICES

PRINTED: 05/20/2019

STREET ADDRESS, CITY, STATE, ZIP CODE
ES STREET

BURLINGTON, NC 27215

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

A. BUILDING: COMPLETED
B.WING 05/10/2019

Assessment/Treatment/Habilitation Plan

10A NCAC 27G .0205 ASSESSMENT AND
TREATMENT/HABILITATION OR SERVICE
PLAN

(c) The plan shall be developed based on the
assessment, and in partnership with the client or
legally responsible person or both, within 30 days
of admission for clients who are expected to
receive services beyond 30 days.

(d) The plan shall include:

(1) client outcome(s) that are anticipated to be
achieved by provision of the service and a
projected date of achievement;

(2) strategies;

(3) staff responsible;

(4) a schedule for review of the plan at least
annually in consultation with the client or legally
responsible person or both;

(5) basis for evaluation or assessment of
outcome achievement; and

(6) written consent or agreement by the client or
responsible party, or a written statement by the
provider stating why such consent could not be
obtained.

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

STATE FORM

6899

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000) INITIAL COMMENTS V 000
An annual and complaint survey was completed
on 5/10/19. The complaint was unsubstantiated
(intake #NC00151036). Deficiencies were cited.
This facility is licensed for the following service
10A NCAC 27G.1700 Residential Treatment Staff
Secure for Children and Adolescents.
V 112] 27G .0205 (C-D) v112

TITLE

(X6) DATE

Ewsu11 If continuation sheet 1 of 25

PRINTED: 05/20/2019
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: . COMPLETED
A. BUILDING:
MHL001-149 B. WING ____ 05/10/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

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

DEFICIENCY)
V 112| Continued From page 1 Vv 112

This Rule is not met as evidenced by:

Based on record review and interviews, the
acility failed to implement strategies to address
he needs and behaviors for one of three clients
(#1). The findings are:

Review on 5/9/19 of client #1's record revealed:
-Admission date of 10/31/18.

-Diagnoses of Autism Spectrum Disorder, Major
Depressive Disorder, Conduct Disorder, Attention
Deficit Hyperactivity Disorder and Generalized
Anxiety Disorder.

-17 years old.

-Comprehensive Clinical Assessment dated
3/26/19-Client #1 had a history of walking away
rom placements, sexually aggressive behaviors,
destruction of property and physical aggression.
-Person Centered Plan dated 11/1/18 for client #1
had no strategies to address elopement from the
acility.

Review of facility records on 5/8/19 revealed:
-Incident reports for client #1 had the following
information:

(1). 5/10/19"Staff was reading [client #1]
academic sheet and observed [client #1] made
several inappropriate remarks at school, staff
asked [client #1] what did he say that was
disrespectful and [client #1] stated he made a
comment about porn but he didn't direct the
comment at no one. Staff informed [client #1] he
was going to call teacher and investigate incident.
[Client #1] replied why, you don't believe me , I'm
tired of you f******g people I'm gone, staff
prompted [client #1] not to go out facility and
[client #1] ran out door, staff followed [client #1]
and called non-emergency number to inform of
[client #1] absent and give description of [client
Division of Health Service Regulation

STATE FORM 6899 Ewsu11 If continuation sheet 2 of 25

PRINTED: 05/20/2019

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
MHL001-149 B. WING 05/10/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1710 SYKES STREET
JUST IN TIME YOUTH SERVICES
BURLINGTON, NC 27215
(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

V 112| Continued From page 2 Vv 112

#1] dress. Staff notified [supervisor of client]
unauthorized leave, staff remain on call in case of
[client #1] return."

(2). 4/29/19-"Staff was on shift after previous
unexplained absence from [Client #1], when local
law enforcement return [client #1] to facility. Staff
notified parent and immediate supervisor of
[Client #1] return and was instructed to transport
[client #1] to [Local Hospital] to be evaluated due
to absence and lack of medication being
administered due to client being out of facility.
[Client #1] had been off his medications for 48
hours. Staff transported [client #1] to Hospital for
assessment and [client #1] was admitted for
urther observation. [Client #1] remained in
Hospital until 4-28-19 when [House Manager]
picked him up from hospital and returned [client
#1] to facility with discharge instructions. Staff
ransported [client #1] to [Local behavioral health
agency] on 4-29-19 for follow up appointment with
[License Professional]. [Client #1] was seen and
ransported to school without further incident."

(3). 4/26/19-"Staff monitored [client #1] return
rom being AWOL (away without leave) from
acility and his return by Police. [Client #1] stated
soon as he takes a shower he is leaving and
here is nothing staff can do to stop him. [Local
Police] informed client if he keeps running away
he can be arrested , [client #1] replied | turn 18 in
2 months and you have to release me so do what
you got to do, I'm good. Staff attempted to
de-escalate the situation by encouraging [client
#1] to comply with treatment and medication
management, staff informed him being off his
medications is dangerous. Staff prompted [client
#1] to not exit facility and [client #1] walked out
the door stating catch me if you can, staff called
local law enforcement, [clients guardian], and
Division of Health Service Regulation

STATE FORM 6899 Ewsu11 If continuation sheet 3 of 25

PRINTED: 05/20/2019
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: . COMPLETED
A. BUILDING:
MHL001-149 B. WING ____ 05/10/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

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

DEFICIENCY)
V 112| Continued From page 3 Vv 112

[supervisor]. Staff feels [client #1] needs to be
assessed to determine mental stability at this time
due to not taking medication while absent from
facility, [client #1] has not returned at this time."

(4). 4/25/19-"Staff informed [client #1] of recent
home visit events that he cannot go home due to
violent outburst with guardian and destruction of
property. Staff prompted [client #1] to decrease
his aggressive behaviors. [Client #1] stated he
has nothing to lose he is leaving facility, staff
attempt to de-escalate situation by speaking in
low non-threatening tone. [Client #1] walked out
back door, staff followed still encouraging [client
#1] to rethink his actions. Staff notified [Director],
[guardian for client #] , and local law enforcement
of [client #1] actions. [Client #1] is still AWOL
(away without leave) from facility at this time,
local law enforcement are still looking for [client
#1] and [client #1] is still listed as missing."

(5). 4/23/19-"Staff prompted [client #1] to clean
out van and [client #1] refused stating he tired of
his place he is leaving. Staff redirected [client #1]
io focus and think situation through more
carefully, before reacting off impulse. [Client #1]
stated he is leaving and there is nothing staff can
do to stop me but call police. [Client #1] ran out
he door and down the street towards park. Staff
called non-emergency number and reported client
(o authorities. [Local Police] called staff at
11:45pm to inform staff [client #1] was at [local
restaurant] in [Name of city], staff went to [local
restaurant] and transported [client #1] back to
acility. [Client #1] came in and went to bed
without further report."

Review of facility records on 5/10/19 revealed:
-There were police reports that responded with all
of the above episodes of elopement for client #1.
Division of Health Service Regulation

STATE FORM 6899 Ewsu11 If continuation sheet 4 of 25

PRINTED: 05/20/2019
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: . COMPLETED
A. BUILDING:
MHL001-149 B. WING ____ 05/10/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

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

DEFICIENCY)
V 112| Continued From page 4 Vv 112

Interview with client #1 on 5/8/19 revealed:

-He eloped from the home several times in April
2019.

-About a week or two ago towards the end of April
he ran about 3-4 times in one day.

-He would sometimes visit family in the area or
just hang out.
-He just recently ran with a client from another
home.
-They walked to a local restaurant and decided to
call the police after they arrived.

-He did not have a good feeling about being at
that local restaurant.
-The police had located him several times while
he was out in the community.
-Towards the end of April he went to the hospital
after eloping from the home.
-He was not sure how many days he was in the
hospital and/or the reason he was in the hospital.

Interview with the House Manager on 5/10/19
revealed:

-He thought client #1 ran away from the home
about three times.

‘When he had the elopement episode towards
the end of April 2019 he ran several times in one
day.

Client #1 would elope, return to the home and
elope again.

-He thought he stayed out overnight during that
elopement episode.

He did go to the hospital after that incident for
about two days.

He thought he went to the hospital because he
was not taking his medication due to the
elopement.

-Client #1 would normally tell them he was
leaving and just walk out the door.

-Staff were required to call the police each time
Division of Health Service Regulation

STATE FORM 6899 Ewsu11 If continuation sheet 5 of 25

PRINTED: 05/20/2019
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: . COMPLETED
A. BUILDING:
MHL001-149 B. WING ____ 05/10/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

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

DEFICIENCY)
V 112| Continued From page 5 Vv 112

client #1 elopes from the facility.
-He confirmed client #1 had no strategies to
address his elopement from the facility.

Interview with the Program Director on 5/8/19 and
5/10/19 revealed:

He thought client #1 started running away from
he home in April, 2019.

He thought client #1 eloped from the home about
hree times.

The police department was called each time
client #1 walked away.

During one of client #1's elopement incidents
staff took him to the hospital after he returned.

He thought client #1 possibly went to the hospital
because he was not taking his medication.

-He thought client #1 was gone for a day or two
during that elopement incident.

-Client #1 actually called the police himself during
one of his elopement incidents.

-Client #1 had eloped with another client and they
went to a local restaurant.

-Client #1 called the police and the police
department informed staff of client #1's
whereabouts.

-Staff went to Hooters and returned client #1 to
the group home.

-Client #1 got in trouble at school on 5/9/19.
-Client #1 left the group home on 5/9/19 after
school around 6:00 PM.

-The police department was contacted on 5/9/19
and informed client #1 had eloped from the
facility.

-As of 5/10/19 client #1 remains on the run and
the police officers had not located him.

-Client #1 would normally tell staff he was leaving.
-Client #1 would just walk out the door.

-He confirmed client #1 had no strategies to
address his elopement from the facility.

Division of Health Service Regulation
STATE FORM 6899 Ewsu11 If continuation sheet 6 of 25

PRINTED: 05/20/2019
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: . COMPLETED
A. BUILDING:
MHL001-149 B. WING ____ 05/10/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 112| Continued From page 6 Vv 112

Interview with the Licensee on 5/9/19 revealed:
-Client #1 was previously at her group home.
-Client #1 left her group home because he
required a higher level of care.

-Client #1 went to a Psychiatric Residential
Treatment Facility (PRTF) due to the incidents of
elopement.

-Client #1 contacted her after he was discharged
from the PRTF and wanted to return to her
facility.

-Client #1 begin to elope again in April 2019.
-She thought client #1 had eloped from the home
about 2-3 times.

-Staff were required to call the police each time
client #1 eloped.

-The police department had an issue with them
calling each time a client eloped.

-The police department felt like they should
"restrain" clients if they try to leave the facility.
-She had told the police department staff can't put
heir hands on a client if they wanted to elope.
-She confirmed client #1 had no strategies to
address his elopement from the facility.

Review on 5/10/19 of a Plan of Protection written
by the Program Director dated 5/10/19 revealed:
What will you immediately do to correct the above
rule violations in order to protect clients from
urther risk or additional harm? "[Program
Director] will contact [Licensed Professional] to
provide a safety plan for [client #1] to address
issues of [client #1] running away from facility."
Describe your plans to make sure the above
happens: "Treatment Team will address additional
strategies and goals to put in treatment plan to
help [client #1] develop positive strategies to
decrease/eliminate running away from facility as
a option when frustrated or upset."

Client #1 had a history of elopement from
Division of Health Service Regulation
STATE FORM 6899 Ewsu11 If continuation sheet 7 of 25

PRINTED: 05/20/2019
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: . COMPLETED
A. BUILDING:
MHL001-149 B. WING ____ 05/10/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

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

DEFICIENCY)
V 112| Continued From page 7 Vv 112

facilities. There were four documented incidents
of elopement involving client #1 between April
and May 2019. Client #1 ran away from the home
as recently as 5/9/19 and his whereabouts are
still unknown. The police department were
contacted each time client #1 eloped from the
facility. The Licensee indicated client #1 was
discharged from her facility previously due to
consistent episodes of elopement. Although the
Licensee was aware of client #1's elopement
history she failed to have strategies in his
treatment plan to address Client #1's elopements.
This deficiency constitutes a Type A1 rule
violation for serious neglect and must be
corrected within 23 days. An administrative
penalty of $2000.00 is imposed. If the violation is
not corrected within 23 days, an additional
administrative penalty of $500 per day will be
imposed each day the facility is out of compliance
beyond the 23rd day.

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

10A NCAC 27G .0209 MEDICATION
REQUIREMENTS

(c) Medication administration:

(1) Prescription or non-prescription drugs shall
only be administered to a client on the written
order of a person authorized by law to prescribe
drugs.
(2) Medications shall be self-administered by
clients only when authorized in writing by the
client's physician.

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

Division of Health Service Regulation
STATE FORM 6899 Ewsu11 If continuation sheet 8 of 25

PRINTED: 05/20/2019
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: . COMPLETED
A. BUILDING:
MHL001-149 B. WING ____ 05/10/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

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

DEFICIENCY)
V 118| Continued From page 8 V 118

all drugs administered to each client must be kept
current. Medications administered shall be
recorded immediately after administration. The
MAR is to include the following:

(A) client's name;

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

(C) instructions for administering the drug;

(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 reviews and interviews, the
facility failed to follow the physician's orders for
three of four current clients (#1, #2 and #3) and
one of one former client (FC #5). The findings
are:

a. Review on 5/8/19 of client #1's record
revealed:

-Admission date of 10/31/18.

-Diagnoses of Autism Spectrum Disorder, Major
Depressive Disorder, Conduct Disorder, Attention
Deficit Hyperactivity Disorder and Generalized
Anxiety Disorder.

-Admission Assessment dated 11/1/18 indicated
client #1 had lost several family members and
exhibited signs of grief. He had issues managing
anger and history of assaultive behaviors.
-Physician's order dated 2/6/19 for Zyprexa 10
mg, one tablet two times daily. Zyprexa used to
treat Schizophrenia and manic episodes of
Division of Health Service Regulation

STATE FORM 6899 Ewsu11 If continuation sheet 9 of 25

PRINTED: 05/20/2019
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: . COMPLETED
A. BUILDING:
MHL001-149 B. WING ____ 05/10/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

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

DEFICIENCY)
V 118| Continued From page 9 V 118

Bipolar Disorder.

-Physician's order dated 2/6/19 for Claritin 10 mg,
one tablet daily. Claritin used to treat allergy
symptoms.
-Physician's order dated 1/9/19 for Melatonin 3
mg, two tablets at bedtime. Melatonin used for
sleep and other sleep disorders.

-Physician's order dated 1/9/19 for Kapvay ER 0.1
mg, two tablets once daily at bedtime. Kapvay
used to treat symptoms of Attention Deficit
Hyperactivity Disorder.

-Physician's order dated 12/17/18 for Minocycline
100 mg, one capsule two times daily. Minocycline
used to treat infections.

-The April 2019 MAR indicated the following
medications were not administered to client #1:
Claritin 10 mg on 4/16 and Melatonin 3 mg on 4/1
through 4/4.
-The March 2019 MAR indicated the following
medications were not administered to client #1:
Claritin 10 mg on 3/28; Zyprexa 10 mg on 3/28
and 3/29 AM doses and 3/27,3/28 PM doses;
Minocycline 100 mg on 3/23 through 3/29 AM
doses and 3/23 through 3/28 PM doses;
Melatonin 3 mg on 3/22 through 3/28.
-The February 2019 MAR indicated the following
medications were not administered to client #1:
Zyprexa 10 mg on 2/23 through 2/25 AM doses
and 2/23, 2/24 PM doses.
-The January 2019 MAR indicated the following
medications were not administered to client #1:
Kapvay ER 0.1 mg on 1/1 and 1/2; Zyprexa 10
mg on 1/18 through 1/24 AM doses and 1/18
through 1/23 PM doses; Minocycline 100 mg on
1/16 through 1/21 AM doses and 1/16 through
1/20 PM doses.

b. Review on 5/8/19 of client #2's record
revealed:

-Admission date of 11/7/18.

Division of Health Service Regulation

STATE FORM 6899 Ewsu11 If continuation sheet 10 of 25

PRINTED: 05/20/2019
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: . COMPLETED
A. BUILDING:
MHL001-149 B. WING ____ 05/10/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

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

DEFICIENCY)
V 118| Continued From page 10 V 118

-Diagnoses of Oppositional Defiant Disorder,
Attention Deficit Hyperactivity Disorder, Reactive
Attachment Disorder-inhibited type and
Cone-Rod Dystrophy.

-Admission Assessment dated 11/7/18 indicated
client #2 exhibits verbal and physical aggression.
He has poor impulse control, poor insight and
poor judgement.
-Physician's order dated 2/6/19 for Zoloft 100 mg,
one tablet two times daily. Zoloft used to treat
depression, Obsessive Compulsive Disorder,
Panic Disorder and Post Traumatic Stress
Disorder.
-Physician's order dated 2/6/19 for Risperdal 1
mg, one tablet two times daily. Risperdal used to
teat Schizophrenia, Bipolar Disorder and
irritability associated with Autism.

-Physician's order dated 2/6/19 for Catapres 0.2
mg, one tablet two times daily. Catapres used to
eat anxiety.
-Physician's order dated 1/15/19 for Melatonin 5
mg, two tablets at bedtime. Melatonin used for
sleep and other sleep disorders.

-Physician's order dated 12/13/18 for Doxycycline
Hyclate 100 mg, one tablet daily. Doxycycline
Hyclate used to treat and prevent infections.
-Physician's order dated 11/7/18 for Wellbutrin 75
mg, one tablet two times daily. Wellbutrin used to
reat depression.
-Physician's order dated 11/17/18 for Cogentin
0.5 mg, one tablet two times daily. Cogentin used
io treat symptoms of involuntary movements due
io side effects of certain psychiatric drugs.

-The March 2019 MAR indicated the following
medications were not administered to client #2:
Melatonin 5 mg on 3/22 through 3/29;
Doxycycline Hyclate 100 mg on 3/17 and 3/18;
Cogentin 0.5 mg on 3/17 through 3/28 AM doses
and 3/16 through 3/26 PM doses; Catapres 0.2
mg on 3/12 through 3/15 AM doses and 3/11
Division of Health Service Regulation

STATE FORM 6899 Ewsu11 If continuation sheet 11 of 25

g

g

PRINTED: 05/20/2019
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: . COMPLETED
A. BUILDING:
MHL001-149 B. WING ____ 05/10/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118| Continued From page 11 V 118

through 3/15 PM doses.

-The February 2019 MAR indicated the following
medications were not administered to client #2:
Cogentin 0.5 mg on 2/10 through 2/12 AM and
PM doses; Catapres 0.2 mg on 2/3 through 2/9
AM doses and 2/2 through 2/7 PM doses; Zoloft
100 mg on 2/21 through 2/28 AM doses and 2/21
through 2/27 PM doses; Risperdal 1 mg on 2/11,
2/12 AM doses and 2/11 PM dose; Melatonin 5
mg on 2/18.

-The January 2019 MAR indicated the following
medications were not administered to client #2:
Zoloft 100 mg on 1/20, 1/21 AM doses and 1/19,
1/20 PM doses; Cogentin 0.5 mg on 1/5 through
1/10 AM doses and 1/5 through 1/9 PM dose;
Wellbutrin 75 mg on 1/1 through 1/9 AM doses
and 1/1 through 1/8 PM doses.

c. Review on 5/8/19 of client #3's record revealed:
-Admission date of 7/10/18.

-Diagnoses of Post Traumatic Stress Disorder,
Disruptive Mood Dysregulation Disorder,
Oppositional Defiant Disorder and Attention
Deficit Hyperactivity Disorder.

-Admission Assessment dated 7/10/18 indicated
client #3 had a history of property destruction,
running away, aggression, stealing and being
impulsive.

-Physician's order dated 2/4/19 for Vyvanse 70
mg, one capsule in the morning. Vyvanse used to
treat Attention Deficit Hyperactivity Disorder.
-Physician's order dated 2/4/19 for Lithium
Carbonate ER 450 mg, one tablet two times daily.
Lithium Carbonate ER used to treat Manic
Depressive Disorder.

-Physician's order dated 2/4/19 for Seroquel 25
mg, one tablet at bedtime. Seroquel used to treat
Schizophrenia, Bipolar Disorder and Depression.
-The March 2019 MAR indicated the following
medications were not administered to client #3:
Division of Health Service Regulation

STATE FORM 6899 Ewsu11 If continuation sheet 12 of 25

PRINTED: 05/20/2019

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
MHL001-149 B. WING 05/10/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1710 SYKES STREET
JUST IN TIME YOUTH SERVICES
BURLINGTON, NC 27215
(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

V 118] Continued From page 12 V 118

Vyvanse 70 mg on 3/7 through 3/11; Lithium
Carbonate ER 450 mg on 3/7 through 3/11 AM
doses and 3/6 through 3/11 PM doses; Seroquel
on 3/9 and 3/10.

d. Review on 5/8/19 of FC #5's record revealed:
‘Admission date of 4/29/16.

Diagnoses of Mild Intellectual Disability, Post
Traumatic Stress Disorder, Disruptive Mood
Dysregulation Disorder, Bipolar Disorder and
Attention Deficit Hyperactivity Disorder.
-Discharged from home March 2019.

‘Admission Assessment dated 4/29/16 indicated
FC #5 had a history of physical and verbal
aggression, self harm and property destruction.
-Physician's order dated 2/20/19 for Flonase
0.05% nasal spray, one spray per nostril daily.
Flonase used to relieve seasonal and year round
allergic and non-allergic nasal symptoms.
-Physician's order dated 2/19/19 for Remeron 45
mg, one tablet at bedtime. Remeron used to treat
Depression.
-Physician's order dated 8/18/17 for Haldol 10
mg, one tablet three times daily. Haldol used to
reat Psychotic Disorders.

-The March 2019 MAR indicated the following
medications were not administered to FC #5:
Remeron 45 mg on 3/6 and 3/7; Haldol 10 mg on
2/6-8AM/2PM doses and 2/5 8 PM dose.

-The February 2019 MAR indicated the following
medication was not administered to FC #5:
Flonase 0.05% nasal spray on 2/5 through 2/16.

nterview with client #1 on 5/8/19 revealed:

-He ran out of medication a couple of times.
-Staff had to get a doctor's order to get a refill on
his medication.

-He also missed medications sometimes if he
was on the run.

-He gave no specifics on the type of medications
Division of Health Service Regulation

STATE FORM 6899 Ewsu11 If continuation sheet 13 of 25

PRINTED: 05/20/2019
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: . COMPLETED
A. BUILDING:
MHL001-149 B. WING ____ 05/10/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118| Continued From page 13 V 118

and how may times the issue occurred.

Interview with client #2 on 5/8/19 revealed:

-He did run out of medication a few times.

-He ran out of medication because staff failed to
get his medications refilled.

-He gave no specifics on the type of medications
and how many times the issue occurred.

Interview with the House Manager on 5/8/19 and
5/10/19 revealed:

-Clients' #1, #2, #3 and FC #5 ran out of
medications between January and April 2019.

-A preauthorization by the physician was required
by the pharmacy in order to refill the medications
-Sometimes there was a delay by staff getting a
client's physician to send the preauthorization to
the pharmacy.

-He confirmed staff failed to follow the physician's
orders for clients' #1, #2, #3 and FC #5.

Interview with the Program Director on 5/8/19 and
5/10/19 revealed:

- Staff did not consistently administer medications
to clients' #1, #2, #3 and FC #5.

-Clients' #1, #2, #3 and FC #5 ran out of
medications.

-Some of the clients had a medication
management agency "that could be difficult to
deal with."

-Staff would often have difficulty getting
medications refilled.

-Most of the time staff had to wait for the
physician to send a preauthorization to the
pharmacy.

-Clients were running out of medications due to
delay of the preauthorization being sent to the
pharmacy.

-He confirmed staff failed to follow the physician's
orders for clients' #1, #2, #3 and FC #5.

Division of Health Service Regulation

STATE FORM 6899 Ewsu11 If continuation sheet 14 of 25

PRINTED: 05/20/2019

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
MHL001-149 B. WING 05/10/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1710 SYKES STREET
JUST IN TIME YOUTH SERVICES
BURLINGTON, NC 27215
(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

V 118| Continued From page 14 V 118

Interview with the Licensee on 5/9/19 revealed:
-She knew that staff were having issues getting
preauthorizations for medications.

-She was not aware clients were running out of
medications.

-The House Manager was the person responsible
for making sure medication orders were refilled
properly.

-She confirmed staff failed to follow the
physician's orders for clients' #1, #2, #3 and FC
#5.

Review on 5/10/19 of a Plan of Protection written
by the House Manager dated 5/10/19 revealed:
What will you immediately do to correct the above
rule violations in order to protect clients from
urther risk or additional harm? "Staff will
implement medication management strategy of
contacting all doctors, therapist or any individual
hat writes prescriptions for client at start of order
and re-order 14 day in advance or request 3
month supply of all med (medications) with
exception of control drugs."

Describe your plans to make sure the above
happens: "All medications will be logged and
check on daily shift change, and sign off with
each staff coming on shift or off shift. All orders
will be ordered in timely manner. Staff will
document medications well before getting low
and reorder according to control policy."

Staff consistently failed to ensure prescribed
medications were refilled for clients' #1, #2, #3
and FC #5 within a timely manner and as
ordered. There was a delay with staff requesting
a preauthorization by a clients physician in order
for the pharmacy to refill the prescribed
medications. Clients' #1, #2, #3 and FC #5 ran
out of medications between the months of
Division of Health Service Regulation

STATE FORM 6899 Ewsu11 If continuation sheet 15 of 25

PRINTED: 05/20/2019
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: . COMPLETED
A. BUILDING:
MHL001-149 B. WING ____ 05/10/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

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

DEFICIENCY)
V 118| Continued From page 15 V 118

January 2019 and April 2019. The majority of the
medications prescribed for clients' #1, #2, #3 and
FC #5 were to help manage their behaviors and
mental health symptoms. This deficiency
constitutes a Type A2 rule violation for substantial
risk of serious harm and must be corrected within
23 days. No administrative penalty has been
assessed. If the violation is not corrected within
23 days, an administrative penalty of $500 per
day will be imposed each day the facility is out of
compliance beyond the 23rd day.

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

Division of Health Service Regulation
STATE FORM 6899 Ewsu11 If continuation sheet 16 of 25

PRINTED: 05/20/2019
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: . COMPLETED
A. BUILDING:
MHL001-149 B. WING ____ 05/10/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

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

DEFICIENCY)
V 536 | Continued From page 16 V 536
course.

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

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

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

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

(2) recognizing and interpreting human
behavior;

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

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

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

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

(7) skills in assessing individual risk for
escalating behavior;

(8) communication strategies for defusing
and de-escalating potentially dangerous behavior;
and

(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

Division of Health Service Regulation
STATE FORM 6899 Ewsu11 If continuation sheet 17 of 25

PRINTED: 05/20/2019

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
MHL001-149 B. WING 05/10/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1710 SYKES STREET
JUST IN TIME YOUTH SERVICES
BURLINGTON, NC 27215
(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 536 | Continued From page 17 V 536
outcomes (pass/fail);
(B) when and where they attended; and
(C) instructor's name;
(2) The Division of MH/DD/SAS may

review/request this documentation at any time.

(i) Instructor Qualifications and Training
Requirements:

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

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

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

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

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

(B) methods for teaching content of the
course;

(C) methods for evaluating trainee
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

Division of Health Service Regulation
STATE FORM 6899 Ewsu11 If continuation sheet 18 of 25

PRINTED: 05/20/2019
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: . COMPLETED
A. BUILDING:
MHL001-149 B. WING ____ 05/10/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

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

DEFICIENCY)
V 536 | Continued From page 18 V 536
need for restrictive interventions at least once
annually.
(8) Trainers shall complete a refresher

instructor training at least every two years.

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

(1) Documentation shall include:

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

(B) when and where attended; and

(C) instructor's name.

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

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

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

(3) Coaches shall demonstrate

competence by completion of coaching or
train-the-trainer instruction.

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

This Rule is not met as evidenced by:

Based on record review and interview, the facility
failed to ensure one of six audited staff (The
Qualified Professional) had training on the use of
alternatives to restrictive interventions prior to
providing services. The findings are:

Review on 5/10/19 of the facility's personnel files
revealed:

Division of Health Service Regulation

STATE FORM 6899 Ewsu11 If continuation sheet 19 of 25

PRINTED: 05/20/2019

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
MHL001-149 B. WING 05/10/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1710 SYKES STREET
JUST IN TIME YOUTH SERVICES
BURLINGTON, NC 27215
(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

V 536 | Continued From page 19 V 536

-The Qualified Professional had a hire date of
11/1/14.

-The Qualified Professional had a North Carolina
Interventions Core Training Part A certificate that
expired on 9/30/18.

-There was no documentation that the Qualified
Professional had current training on the use of
alternatives to restrictive interventions.

Interview with the Licensee on 5/10/19 revealed:
-Her agency uses North Carolina Interventions
Plus training on the use of alternatives to
restrictive interventions.

-The Qualified Professional works for another
agency and received her training with that
agency.

-She thought the Qualified Professional had the
"ProACT" training on the use of alternatives to
restrictive interventions.

-She did not have the Qualified Professional
rained in North Carolina Interventions Plus.
-She did not realize all staff were required to have
he same type of training on the use of
alternatives to restrictive interventions.

-She confirmed there was no documentation of
raining on the use of alternative to restrictive
intervention for the Qualified Professional.

V 537| 27E .0108 Client Rights - Training in Sec Rest & | V 537
TO

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

(a) Seclusion, physical restraint and isolation
ime-out may be employed only by staff who have
been trained and have demonstrated
competence in the proper use of and alternatives
io these procedures. Facilities shall ensure that

Division of Health Service Regulation
STATE FORM 6899 Ewsu11 If continuation sheet 20 of 25

PRINTED: 05/20/2019
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: . COMPLETED
A. BUILDING:
MHL001-149 B. WING ____ 05/10/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

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

DEFICIENCY)
V 537 | Continued From page 20 V 537

staff authorized to employ and terminate these
procedures are retrained and have demonstrated
competence at least annually.

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

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

(d) The training shall be competency-based,
include measurable learning objectives,
measurable testing (written and by observation of
behavior) on those objectives and measurable
methods to determine passing or failing the
course.
(e) Formal refresher training must be completed
by each service provider periodically (minimum
annually).
(f) Content of the training that the service
provider plans to employ must be approved by
the Division of MH/DD/SAS pursuant to
Paragraph (g) of this Rule.

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

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

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

(3) emphasis on safety and respect for the

rights and dignity of all persons involved (using
concepts of least restrictive interventions and

Division of Health Service Regulation
STATE FORM 6899 Ewsu11 If continuation sheet 21 of 25

PRINTED: 05/20/2019
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: . COMPLETED
A. BUILDING:
MHL001-149 B. WING ____ 05/10/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

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

DEFICIENCY)
V 537 | Continued From page 21 V 537
incremental steps in an intervention);
(4) strategies for the safe implementation
of restrictive interventions;
(5) the use of emergency safety

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

(6) prohibited procedures;

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

(8) documentation methods/procedures.

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

(1) Documentation shall include:

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

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

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

review/request this documentation at any time.

(i) Instructor Qualification and Training
Requirements:

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

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

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

(4) The training shall be
competency-based, include measurable learning
objectives, measurable testing (written and by

Division of Health Service Regulation
STATE FORM 6899 Ewsu11 If continuation sheet 22 of 25

PRINTED: 05/20/2019

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
MHL001-149 B. WING 05/10/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1710 SYKES STREET
JUST IN TIME YOUTH SERVICES
BURLINGTON, NC 27215
(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

V 537 | Continued From page 22 V 537

observation of behavior) on those objectives and
measurable methods to determine passing or
failing the course.

(5) The content of the instructor training the
service provider plans to employ shall be
approved by the Division of MH/DD/SAS pursuant
to Subparagraph (j)(6) of this Rule.

(6) Acceptable instructor training programs
shall include, but not be limited to, presentation
of:

(A) understanding the adult learner;

(B) methods for teaching content of the
course;

(C) evaluation of trainee performance; and
(D) documentation procedures.

(7) Trainers shall be retrained at least

annually and demonstrate competence in the use
of seclusion, physical restraint and isolation
time-out, as specified in Paragraph (a) of this

Rule.

(8) Trainers shall be currently trained in
CPR.

(9) Trainers shall have coached experience

in teaching the use of restrictive interventions at
least two times with a positive review by the
coach.
(10) Trainers shall teach a program on the
use of restrictive interventions at least once
annually.
(11) Trainers shall complete a refresher
instructor training at least every two years.

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

(1) Documentation shall include:

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

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

Division of Health Service Regulation
STATE FORM 6899 Ewsu11 If continuation sheet 23 of 25

PRINTED: 05/20/2019
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: . COMPLETED
A. BUILDING:
MHL001-149 B. WING ____ 05/10/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

BURLINGTON, NC 27215
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE

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

JUST IN TIME YOUTH SERVICES

V 537 | Continued From page 23 V 537

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

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

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

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

This Rule is not met as evidenced by:

Based on record review and interview, the facility
ailed to ensure one of six audited staff (The
Qualified Professional) had training in the use of
seclusion, physical restraints and isolation
ime-out. The findings are:

Review on 5/10/19 of the facility's personnel files
revealed:

-The Qualified Professional had a hire date of
11/1/14.

-The Qualified Professional had a North Carolina
nterventions Core Training Part B certificate that
expired on 9/30/18.

-There was no documentation that the Qualified
Professional had training in the use of seclusion,
physical restraints and isolation time-out.

nterview with the Licensee on 5/10/19 revealed:
-Her agency uses North Carolina Interventions
Plus training in the use of seclusion, physical
restraints and isolation time-out.

-The Qualified Professional works for another
agency and received her training with that
Division of Health Service Regulation

STATE FORM 6899 Ewsu11 If continuation sheet 24 of 25

PRINTED: 05/20/2019

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
MHL001-149 B. WING 05/10/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1710 SYKES STREET
JUST IN TIME YOUTH SERVICES
BURLINGTON, NC 27215
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 537 | Continued From page 24 V 537

agency.
-She thought the Qualified Professional had the
"ProACT" training in the use of seclusion,
physical restraints and isolation time-out.

-She did not have the Qualified Professional
trained in North Carolina Interventions Plus.

-She did not realize all staff were required to have
the same type of training in the use of seclusion,
physical restraints and isolation time-out.

- She confirmed there was no documentation of
training in the use of seclusion, physical restraints
and isolation time-out for the Qualified
Professional.

Division of Health Service Regulation
STATE FORM 6899 Ewsu11 If continuation sheet 25 of 25


state: NC

facility_name: Just In Time Youth Services

summary: Statement of Deficiency - MHLCS Complaint

raw_content:
Division of Health Service Regulation

PRINTED: 03/04/2019
FORM APPROVED

Acomplaint survey was completed on February
21, 2019. The complaint was unsubstantiated
(Intake #NC00148112). 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 Level lil.

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

STATE FORM

6899

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
Cc
MHL001-149 02/21/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1710 SYKES STREET
JUST IN TIME YOUTH SERVICES
BURLINGTON, NC 27215
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000) INITIAL COMMENTS Vv 000

Ov9611

TITLE (X6) DATE

If continuation sheet 1 of 1

inspection_type: MHLCS Complaint

document_type: Statement of Deficiency


raw_content:
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

MHL001-149

1710 SYK'

JUST IN TIME YOUTH SERVICES

B. WING

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 09/21/2018
FORM APPROVED

09/07/2018

STREET ADDRESS, CITY, STATE, ZIP CODE
ES STREET

BURLINGTON, NC 27215

(X3) DATE SURVEY
COMPLETED

Allegations, & Protection

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

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

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

c. Misappropriation of the property of a
healthcare facility.

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

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

Facilities must have evidence that all alleged

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

STATE FORM

6899

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000) INITIAL COMMENTS V 000
Acomplaint survey was completed on September
7, 2018. The complaint was unsubstantiated
(Intake #NC00142337). A deficiency was cited.
This facility is licensed for the following service
category:
10A NCAC 27G .1700 Residential Treatment
Staff Secure For Children or Adolescents Level
Il.
V 132) G.S. 131E-256(G) HCPR-Notification, V 132

TITLE

68CM11

(X6) DATE

If continuation sheet 1 of 3

PRINTED: 09/21/2018

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL001-149 B. WING ____ 09/07/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 132] Continued From page 1 V 132

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

This Rule is not met as evidenced by:

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

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

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

-- Age 11 years old.

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

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

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

STATE FORM 6899 68CM11 If continuation sheet 2 of 3

PRINTED: 09/21/2018

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL001-149 B. WING ____ 09/07/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1710 SYKES STREET
JUST IN TIME YOUTH SERVICES
BURLINGTON, NC 27215
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 132] Continued From page 2 V 132

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

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

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

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

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


summary: Plan of Correction - MHLCS Complaint

raw_content:
Division of Health Service Regulation

PRINTED: 09/21/201

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

MHLOO01-149)

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

NAME OF PROVIDER OR SUPPLIER

JUST IN TIME Y~UTH SERVICES

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

BURLINGTON, NC 27215

[RECEIVED

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

Notification, Allegations, & Protection

GS. §131E-256 HEALTH CARE
PERSONNEL REGISTRY

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

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

c. Misappropriation of the property of

a healthcare facility.

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

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

Facilities must have evidence that all alleged

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

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
he facility was unaware that they
V 000) INITIAL COMMENTS V 000 ’
needed to notify/report to NC IRIS or
A complaint survey was completed on September INC Healthcare Registry when they
7, 201 8. The complaint was unsubstantiated earned of allegations abuse against
(Intake #NC00142337). A deficiency was cited. healthcare personnel on
This facility is licensed for the following 11712018, which is when the facility
service category: as informed of compliant through
10A NCAC 27G .1700 Residential Treatment (Guildford County DSS initiation of
Staff Secure For Children or Adolescents investigation. Johanna Edwards,
Level Ill. RN (Nurse Consultant) for NC
Department of Health and Human
V 132) G.S. 131E-256(G) HCPR- V 132

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

TITLE

(x6) DATE

STATE FORM

6899

68CM11

If continuation sheet 1 of 3

PRINTED: 09/21/201
FORM APPROVED
Division of Health Service Regulation

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

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

1710 SYKES STREET
JUST IN TIME Y~UTH SERVICES

BURLINGTON, NC 27215
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE

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

DEFICIENCY)

V 132 | Continued From page 1 V 132

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

This Rule is not met as evidenced by:

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

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

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

-- Age 11 years old.

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

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

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

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

PRINTED: 09/21/201
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE + CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUI COMPLETED
LDING:
MHLOO1-149) 09/07/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET
BURLINGTON, NC 27215

JUST IN TIME Y~UTH SERVICES

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

DEFICIENCY)
V 132 | Continued From page 2 Vv 132

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

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

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

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

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

County Name: ail

Social Worker Name:
Children:

Date Report Received:

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

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

CO Child has limited or no readily accessible support network.

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

Part B. CURRENT INDICATORS OF SAFI/TY

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

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

Serious injury or abuse to the child other than accidental.

Caretaker fears he/she jvill maltreat the child.

Threat to cause harm ot retaliate against the child.

Substantial or unreason ble use of physical force.

Drug-exposed infant/child

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

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

DO Death of a child.

\
oo00000

Comments:

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

© Parent;
Other caretaker; OR

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

Comments:

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

GC 1305 Initials

NORTH CAROLINA
_ SAFETY ASSESSMENT
Page 2 of 8

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

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

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

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

Com

access to the child.

iments:

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

|

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

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

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

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

Com

contradictions.

iments:

5)
)

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

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

ete.

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

O Caretaker’s whereabouts are unknown

aD 7 mal } lf ,

Comments: } Va t “
1. Wills J Kk ,°

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

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

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

vo A

“ro

ey /il «nch on

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

Comments:

DSS-5231 Revised 01/17
Child Welfare Services

iF
wnials 7 C ey ho ff

Initials

t Yes re)

9. Yes {No,

4

10. Yes | No

NORTH CAROLINA

| SAFETY ASSESSMENT
Page 3 of 8

Caretaker does not meet thd

(suicidal/homicidal). |

|

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

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

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

Child is suicidal and parents will not take protective action.

Child is homicidal and parents will not take protective action.

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

ooog

Comments:

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

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

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

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

Open/broken/ missing }vindows.

Exposed electrical wires.

Excessive garbage or riitted or spoiled food that threatens health.

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

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

OH000000 0 ao

Comments:

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

© The caretaker is currenily high on drugs or alcohol.

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

Comments:

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

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

Comments:

Ly 44, ”

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

Initials

“Wh teas, pile

12% Yes.) No

NORTH CAROLINA
SAFETY ASSESSMENT

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

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

Caretaker repeatedly cy rses and/or puts child down.

Caretaker repeatedly scapegoats a particular child in the family.

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

OoH000 a

Comments:

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

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

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

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

OO oo0

Comments:

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

Initials

oO000000

NORTH CAROLINA
SAFETY ASSESSMENT

Page 5 of 8

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

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

Prior death of a child.

Prior serious harm to aty child.

Termination of parental rights.

Prior removal of any ckild.

Prior CPS substantiatian or services needed finding.

Prior threat of serious arm to child.

Caretaker failed to beni(fit from previous professional help.

Comments:___

oOo
Oo

Oo

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

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

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

Comments:

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

Initials

Initials

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

INTER /ENTION/SAFETY AGREEMENT.

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

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

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

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

CPS Social Worker’s Name: Phone Number:

Email Address:

CPS Supervisor’s Name:

| Phone Number: Email Address:

DSS-5231 Revised 01/17
Child Welfare Services

aa DSS-5231 Revised 01/17 Initials.

NORTH CAROLINA
SAFETY ASSESSMENT

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

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

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

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

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

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

PART D: SAFETY DECISION

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

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

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

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

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

Safe with a Plan, Complete

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

the safety indicators identified in Part B?

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

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

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

Child Welfare Services
Initials

SOSIAIS SIEJTOM PIO
LI/TO Postaoy TETS-SSA

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) ) )

TEMPORARY PARENTAL SAFETY AGREEMENT
Page 8 of 8

STANDING AND AGREEMENT

PARENT OR CARETAKER INITIALS

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

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

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

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

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

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

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

TEMPORARY SAFETY PROVIDER

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

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

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

i wae court interv ntion.

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

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

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

s about thi

t iffcircumstances change, if | have questions about CPS involy

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

| {EmaibAddress: 2 {éo

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

_ Phon¢ Numb:

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

byl dWhi

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

Signed: Date:

DSS-5231 Revised 01/17
Child Welfare Services

NC DEPARTMENT OF ROY COOPER - Governor

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

September 18, 2018

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

Dear Mr. Pinnix:

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

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

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

Sincerely,

oO Leten,
|

Joi B. Deberry

HCPI Investigator

Health Care Personnel Investigations

PO Box 13761

Durham, NC 27709

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

NA-09-0181-18

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

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

AN EQUAL OPPORTUNITY / AFFIRMATIVE ACTION EMPLOYER

document_type: Plan of Correction


facility_name: Haw River Group Home

summary: Statement of Deficiency - MHLCS Annual

raw_content:
PRINTED: 06/27/2025

FORM APPROVED
Division of Health Service Re
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHLO001-086 06/26/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2150 HAW RIVER-HOPEDALE ROAD
HAW RIVER GROUP HOME
HAW RIVER, NC 27258
(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 June 26,
2025. No deficiencies were cited.

This facility is licensed for the following service
category: 10A NCAC 27G. 5600C. Supervised

Living for Adults with Developmental Disabilities .

This facility is licensed for 6 and currently has a
census of 4. The survey sample consisted of
audits of 2 current clients, 1 former client.

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

STATE FORM

6899

V7XT11

TITLE (X6) DATE

If continuation sheet 1 of 1

inspection_type: MHLCS Annual


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

raw_content:
PRINTED: 12/23/2024

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL001-086 B. WING 12/16/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

2150 HAW RIVER-HOPEDALE ROAD

HAW RIVER, NC 27258

(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)

HAW RIVER GROUP HOME

V 000} INITIAL COMMENTS Vv 000

Acomplaint and follow up survey was completed
on December 16, 2024. The complaints were
unsubstantiated (Intake #NC00223830 and
#NC00224526). No deficiencies were cited.

This facility is licensed for the following service:
10A NCAC 27G. 5600C Supervised Living for
Adults with Developmental Disabilities.

This facility is licensed for six and has a current
census of four. The survey sample consisted of
two current clients and one former client.

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

STATE FORM 6899 4VMD11 If continuation sheet 1 of 1

inspection_type: MHLCS Complaint and Follow-up