raw_content:
PRINTED: 07/16/2025
FORM APPROVED

‘STATEMENT OF DEFICIENCIES.
AND PLAN OF CORRECTION

(Xt) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

R
07/15/2025

MHLO0411-443 B. WING

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

882 ELIADA HOME ROAD

LIAD, ENTE!
E A TREATMENT C1 R ASHEVILLE, NC 28806

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

INITIAL COMMENTS.

An annual, follow up and complaint survey was
completed on July 15, 2025. The complaint were
substantiated (Intake #NC00232481).
Deficiencies were cited.

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

This facility is licensed for 8 and has a current
census of 8. The survey sample consisted of
audits of 3 current clients.

G.S. 131E-256(G) HCPR-Notification,
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.

Division of Health Service Regulation

LABORATORY DIRECTOR'S

STATE FORM

OVIDER/SUPPYIER REPRESENTATIVE'S SIGNATURE

werttt

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

Correct: The HCPR required reports
shall be submitted by the CCO in regard
to this staff member.

Prevent: The PQI Investigations
Procedure Form will include a check box
for HCPR Required Reports and denote
all allegations against a staff must be
reported.

Prevent: The COO will retrain
residential staff on the timeline and
process for reporting allegations to PQI
and DSS.

Monitor: Upon completion of a PQ!
Investigation, the entire PQI team shall
review the completed form which shall
denote the completion of the HCPR
required report.

RECEIVED
nov 19 2025
DHSR-MH Licensure Sect

715/25

9/12/25

07/30/25

9/42/25

If continuation sheet 4 of 11

Division of Health Service Regulation

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

MHL011-443

PRINTED: 07/16/2025
FORM APPROVED

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

R
B. WING 07/15/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

ELIADA TREATMENT CENTER

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

Continued From page 1

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
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 record reviews and interviews, the

facility failed to report an allegation of abuse to
the Health Care Personnel Registry (HCPR)
affecting 1 of 3 audited staff (Staff #1). The
findings are:

Review on 7/14/25 of Staff #1's record revealed:
-Title: Youth Mentor.
-Date of Hire: 3/31/25.

Review on 7/14/15 of the facility incident reports
revealed:

-No documentation of a report to the HCPR for
allegation of abuse reported the local Department
of Social Services (DSS) 7/8/25.

Review on 7/14/25 of the Licensee Internal
Investigation completed by the Performance and
Quality Improvement (PQI) team dated 6/23/25
revealed:

-Date of incident: 6/16/25-6/17/25.

-There were no listed allegations of abuse.

Interview on 7/15/25 with the local DSS worker
revealed:

-Confirmed allegation of abuse against Staff #1
involving Client #1 and Client #2 reported 7/8/25.

Division of Health Service Regulation
STATE FORM

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

ese werttt ifcontinuation sheet 2 of 1

PRINTED: 07/16/2025

FORM APPROVED

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES {X1) PROVIDER/SUPPLIER/CLIA (<2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED

R
MHLO11-443 8. WING _____ 07/45/2025

NAME OF PROVIDER OR SUPPLIER ‘STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

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

ELIADA TREATMENT CENTER

Continued From page 2

Interview on 7/15/25 with the Quality Assurance
Manager revealed:

-Was a member of the PQI team.

-PQI team was responsible for reporting to the
HCPR for allegations of abuse against
employees.

-Was not aware of an allegation of abuse prior to
7/8/25.

-HCPR was not completed for allegation of abuse
against Staff #1 reported to the local DSS on
718/25.

-HCPR was not completed due to "a series of
miscommunications, (PQI) did not communicate
effectively as a team."

-Aware of the requirement for HCPR reporting,
",..we dropped the ball honestly (not reporting to
the HCPR for allegation of abuse against Staff #1
reported 7/8/25)."

Interview on 7/15/25 with the Chief Compliance
Officer revealed:

-Was a member of the PQI team.

-PQI team was responsible for reporting to the
HCPR for allegations of abuse against
employees.

-Was not aware of an allegation of abuse prior to
7/8/25.

-HCPR was not completed for allegation of abuse
against Staff #1 reported to the local DSS on
718/25.

~"...was rushing (completing internal investigation)
since the incident had already been delayed."
-Will make sure to use her checklist for
processing incidents moving forward to ensure
required departments are notified of any
allegation of abuse upon being made aware.
-Will update the incident investigation form to
include to refer back to incident processing
checklist to ensure all steps are taken.

Division of Health Service Regulation
STATE FORM e290 wert (fcontinuation sheet 3 of 11

NAME OF PROVIDER OR SUPPLIER

Division of Health Service Regulation

‘STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDERISUPPLIER/CLIA
IDENTIFICATION NUMBER:

MHL011-443

(X2) MULTIPLE CONSTRUCTION

PRINTED: 07/16/2025
FORM APPROVED

(X3) DATE SURVEY

COMPLETED

07/15/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

882 ELIADA HOME ROAD

ELIADA TREATMENT CENTER

Division of Health Service Regulation

STATE FORM

ASHEVILLE, NC 28806

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

Continued From page 3

Interview on 7/15/25 with the Chief Operating
Officer revealed:

-PQI team responsible for notifying the HCPR for
allegations of abuse against employees.

-Will ensure clear systematic overview of who is
following up and the step by step process
reviewing the incidents and processes involved.

27G .1701 Residential Tx. Child/Adol - Scope

10A NCAC 27G .1701 SCOPE

(a) Aresidential treatment staff secure facility for
children or adolescents is one that is a
free-standing residential facility that provides
intensive, active therapeutic treatment and
interventions within a system of care approach. it
shall not be the primary residence of an individual
who is not a client of the facility.

(b) Staff secure means staff are required to be
awake during client sleep hours and supervision
shall be continuous as set forth in Rule .1704 of
this Section.

(c) The population served shall be children or
adolescents who have a primary diagnosis of
mental illness, emotional disturbance or
substance-related disorders; and may also have
co-occurring disorders including developmental
disabilities. These children or adolescents shall
not meet criteria for inpatient psychiatric services.
(d) The children or adolescents served shall
require the following:

(1) removal from home to a
community-based residential setting in order to
facilitate treatment; and

(2) treatment in a staff secure setting.

(e) Services shall be designed to:

(1) include individualized supervision and
structure of daily living;

(2) minimize the occurrence of behaviors

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

Correction: The guardian shall be
notified in regard to the allegation by
the CCO.

Prevention: The PQI Investigation
Procedure Form shall be updated to
include a step to inform all guardians of

Monitor: The PQI Investigation
Procedure Form shall be shared with
the entire PQI team upon its
completion and shall denote that
guardian notification has been
completed

all students involved in an investigation.

7/9125

9/12/25

9/12/25

wert I continuation sheet 4 of 11

PRINTED: 07/16/2025
FORM APPROVED
Division of Health Service Requlation
‘STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A.BUILDING: COMPLETED

R
MHLO11-443 B.WING______ 07/15/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

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

DEFICIENCY)

ELIADA TREATMENT CENTER

Continued From page 4

related to functional deficits;

(3) ensure safety and deescalate out of
control behaviors including frequent crisis
management with or without physical restraint;
(4) assist the child or adolescent in the
acquisition of adaptive functioning in self-control,
communication, social and recreational skills; and
(5) support the child or adolescent in
gaining the skills needed to step-down to a less
intensive treatment setting.

(f} The residential treatment staff secure facility
shall coordinate with other individuals and
agencies within the child or adolescent's system
of care.

This Rule is not met as evidenced by:

Based on record reviews and interviews, the
facility failed to coordinate with individuals within
the client's system of care for 1 of 3 current
clients (Client #1). The findings are:

Review on 7/14/25 of Client #1's record revealed:

Age: 12.

-Date of admission: 6/5/25.

-Diagnoses: Personality Disorder, Major

Depressive Disorder, and Anxiety Disorder.

-No documentation of facility notification to

guardian for incident on 6/16/25 and 6/17/25.

-Child Family Team meeting dated 7/7/25:
-Guardian was not notified of incident dated

Division of Health Service Regulation

STATE FORM e098 vsti If continuation sheet 5 of 11

PRINTED: 07/16/2025
FORM APPROVED

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

MHLO011-443 B. WING,

NAME OF PROVIDER OR SUPPLIER. STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ASHEVILLE, NC 28806
‘SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION
(EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE

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

ELIADA TREATMENT CENTER

Continued From page 5
6/16/25 and 6/17/25.

Review on 7/14/25 of the Licensee Internal
Investigation completed by the Performance and
Quality Improvement (PQI) team dated 6/23/25
revealed:

-Date of incident: 6/16/25-6/17/25.

-There were no listed allegations of abuse.

Interview on 7/15/25 with the local DSS Worker
revealed:

Confirmed allegation of abuse against Staff #1
involving Client #1 reported 7/8/25.

Interview on 7/15/25 with Client #1's guardian
revealed:

-Was first informed by Client #1 while on a home
visit on 7/7/25 of the allegation of abuse.

Interview on 7/15/25 with Therapist #1 revealed:
Did not notify Client #1's guardian of incident
dated 6/16/25 and 6/17/25.

Interview on 7/15/25 with the Quality Assurance
Manager revealed:

-Was not sure why Client #1's guardian was not
made aware of the allegation of abuse.

-"| thought she (Client #1) had been made aware
(of allegation of abuse), assumption that she was
made aware."

Interview on 7/15/25 with the Chief Compliance
Officer revealed:

~"I should of notified [Client #1's] guardian, didn't
use my checklist of processing incidents.”

| -“..was rushing (completing internal investigation)
since the incident had already been delayed.”
-Will make sure to use her checklist for
processing incidents moving forward to ensure
required departments are notified of any

Division of Health Service Regulation
STATE FORM sss9 wettt Mfcontinuation sheet 6 of 11

PRINTED: 07/16/2025
FORM APPROVED

‘STATEMENT OF DEFICIENCIES: (X1) PROVIDER/SUPPLIER/CLIA {X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED

R
MHL011-443 BWING, 07/15/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

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

ELIADA TREATMENT CENTER

Continued From page 6

allegation of abuse upon being made aware.
-Will update the incident investigation form to
include to refer back to incident processing
checklist to ensure all steps are taken.

Interview on 7/15/25 with the Chief Operating
Officer revealed:

-The staff an allegation of abuse was reported to
would notify the Client's therapist and the PQI
team.

-No one told Client #1's therapist or their guardian
about the allegation of abuse.

-Will ensure clear systematic overview of who is
following up and the step by step process
reviewing the incidents and processes involved.

27G .0604 Incident Reporting Requirements

40A NCAC 27G .0604 = INCIDENT
REPORTING REQUIREMENTS FOR Correct: IRIS reports for all students
CATEGORY AAND B PROVIDERS involved in this investigation shall be
(a) Category A and B providers shall report all completed and submitted by the QAM.
level II incidents, except deaths, that occur during
the provision of billable services or while the
consumer is on the providers premises or level III
incidents and level II deaths involving the clients
to whom the provider rendered any service within
90 days prior to the incident to the LME
responsible for the catchment area where
services are provided within 72 hours of
becoming aware of the incident. The report shall
be submitted on a form provided by the
Secretary. The report may be submitted via mail,
in person, facsimile or encrypted electronic

i A Monitor: Upon completion of an
means. The report shall include the following investigation, the completed form shall 9192125

be shared with the entire PQI team and
1 reportin vider contact and
A andhass Weeeretlons denote that the IRIS reports have been
(2) client identification information; completed.

7/15/25

Prevent: The PQI Investigation
Procedure Form shall be updated to
include a step for completing all required
IRIS reports.

9/12/25

Prevent: The COO will retrain
residential staff on the timeline and
process for reporting allegations to PQI
and DSS.

7130/25

Division of Health Service Regulation
STATE FORM baad wert If continuation sheet 7 of 11

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

MHL011-443

NAME OF PROVIDER OR SUPPLIER

PRINTED: 07/16/2025
FORM APPROVED

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

COMPLETED

R
07/15/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

882 ELIADA HOME ROAD

ELIADA TREATMENT CENTER

ASHEVILLE, NC 28806

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

Continued From page 7

(3) type of incident;

(4) description of incident;

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

(6) other individuals or authorities notified
or responding.

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

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

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

(1) hospital records including confidential
information;

(2) reports by other authorities; and

(3) the provider's response to the incident.
(d) Category A and B providers shall send a copy
of all level til incident reports to the Division of
Mental Health, Developmental Disabilities and
Substance Abuse Services within 72 hours of
becoming aware of the incident. Category A
providers shall send a copy of all tevel II!
incidents involving a client death to the Division of
Health Service Regulation within 72 hours of
becoming aware of the incident. In cases of
client death within seven days of use of seclusion
or restraint, the provider shall report the death
immediately, as required by 10A NCAC 26C
0300 and 10A NCAC 27E .0104(e)(18).

({e) Category A and B providers shall send a
report quarterly to the LME responsible for the

Division of Health Service Regulation
STATE FORM

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

waTtt If continuation sheet 8 of 11

PRINTED: 07/16/2025
FORM APPROVED

‘STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A.BUILDING: COMPLETED

R
MHL011-443 BWING, 07/15/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION
PREFIX {EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE

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

ELIADA TREATMENT CENTER

Continued From page 8

catchment area where services are provided.
The report shall be submitted on a form provided
by the Secretary via electronic means and shall
include summary information as follows:

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

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

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

(5) the total number of level Ii and level Ill
incidents that occurred; and

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

This Rule is not met as evidenced by:

Based on record reviews and interviews, the
facility failed to report tevel II incidents in the
Incident Response Improvement System (IRIS)
within 72 hours of becoming aware of the
incident. The findings are:

Review on 7/14/25 of Client #1's record revealed:
-Age: 12.

-Date of admission: 6/5/25.

-Diagnoses: Personality Disorder, Major
Depressive Disorder, and Anxiety Disorder.

Division of Health Service Regulation
STATE FORM badd wertt IFeontinuation sheet 9 of 11

PRINTED: 07/16/2025
FORM APPROVED
Division of Health Service Regulation

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

R
MHLO11-443 8. WING —______. 07/15/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

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

ELIADA TREATMENT CENTER

Continued From page 9

Review on 7/14/25 of Client #2's record revealed:
Age: 16.

-Date of admission: 2/25/25.

-Diagnoses: Disruptive Mood Dysregulation
Disorder, and Attention Deficit Hyperactivity
Disorder, combined type.

Review on 7/14/25 of IRIS revealed:

-No documentation of level I! IRIS report for
allegation of abuse reported to the local
Department of Social Services (DSS) on 7/8/25
involving Client #1 and #2.

Review on 7/14/25 of the Licensee Internal
Investigation completed by the Performance and
Quality Improvement (PQI) team dated 6/23/25
revealed:

-Date of incident: 6/16/25-6/17/25.

-There were no listed allegations of abuse.

Interview on 7/15/25 with the local DSS Worker
revealed:

-Confirmed allegation of abuse against Staff #1
involving Client #1 and Client #2 reported 7/8/25.

Interview on 7/15/25 with the Quality Assurance
Manager revealed:

-Was a member of the PQI team.

-PQI team was responsible for reporting level II
incidents in IRIS.

-Was not aware of an allegation of abuse prior to
7/8/25.

-Level Il incident was not completed in IRIS for
the allegation of abuse against Staff #1 reported
to the local DSS on 7/8/25.

-Level II incident was not completed in IRIS for
the allegation of abuse against Staff #1 involving
Client #1 and Client #2 due to “a series of
miscommunications, (PQI) did not communicate
effectively as a team.”

Division of Health Service Regulation
STATE FORM 890 wert If continuation sheet 10 of 11

PRINTED: 07/16/2025

FORM APPROVED

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA {X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED

R
MHLO011-443 B, WING —_____. 07/15/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

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

ELIADA TREATMENT CENTER

Continued From page 10

-Aware of the requirement for incident reporting in
IRIS, "...we dropped the ball honestly (Level II
incident was not completed in IRIS for the
allegation of abuse against Staff #1 involving
Client #1 and Client #2)."

Interview on 7/15/25 with the Chief Compliance
Officer revealed:

-Was a member of the PQI team,

-PQI team was responsible for reporting level II
incidents in IRIS.

-Was not aware of an allegation of abuse prior to
7/8/25.

-Level II incident was not completed in IRIS for
the allegation of abuse against Staff #1 involving
Client #1 and Client #2 reported to the local DSS
on 7/8/25.

-"...was rushing {completing internal investigation)
since the incident had already been delayed.”
-Will make sure to use her checklist for
processing incidents moving forward to ensure
required departments are notified of any
allegation of abuse upon being made aware.
-Will update the incident investigation form to
include to refer back to incident processing
checklist to ensure all steps are taken.

Interview on 7/15/25 with the Chief Operating
Officer revealed:

-PQI team responsible for reporting level {I
incidents in IRIS for allegations of abuse against
employees.

-Level Il incident was not completed in IRIS for
the allegation of abuse against Staff #1 involving
Client #1 and Client #2 reported to the local DSS
on 7/8/25.

-Will ensure clear systematic overview of who is
following up and the step by step process
reviewing the incidents and processes involved.

Division of Health Service Regulation
STATE FORM 6899 weit If continuation sheet 11 of 11


state: NC

facility_name: Eliada Treatment Center

summary: Statement of Deficiency - MHLCS Complaint

raw_content:
PRINTED: 09/23/2024

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
Cc
MHL011-443 B. WING 09/20/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ELIADA TREATMENT CENTER
ASHEVILLE, NC 28806
(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 9/20/24.
The complaint was substantiated
(NC#00222112). 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.

This facility is licensed for 8 and currently has a
census of 7. The survey sample consisted of
audits of 3 current clients.

V 296] 27G .1704 Residential Tx. Child/Adol - Min. V 296
Staffing

410A NCAC 27G .1704 MINIMUM STAFFING
REQUIREMENTS

(a) A qualified professional shall be available by
telephone or page. A direct care staff shall be
able to reach the facility within 30 minutes at all
times.

(b) The minimum number of direct care staff
required when children or adolescents are
present and awake is as follows:

(1) wo direct care staff shall be present for
one, two, three or four children or adolescents;
(2) hree direct care staff shall be present

for five, six, seven or eight children or
adolescents; and

(3) ‘our direct care staff shall be present for
nine, ten, eleven or twelve children or
adolescents.

(c) The minimum number of direct care staff
during child or adolescent sleep hours is as
follows:
(1) wo direct care staff shall be present
and one shall be awake for one through four
children or adolescents;

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

STATE FORM 6899 ZCCM11 If continuation sheet 1 of 5

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL011-443 B. WING

NAME OF PROVIDER OR SUPPLIER
882 ELIADA HOME ROAD

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 09/23/2024
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
09/20/2024

(2) two direct care staff shall be present
and both shall be awake for five through eight
children or adolescents; and

(3) three direct care staff shall be present
of which two shall be awake and the third may be
asleep for nine, ten, eleven or twelve children or
adolescents.

(d) In addition to the minimum number of direct
care staff set forth in Paragraphs (a)-(c) of this
Rule, more direct care staff shall be required in
the facility based on the child or adolescent's
individual needs as specified in the treatment
plan.

(e) Each facility shall be responsible for ensuring
supervision of children or adolescents when they
are away from the facility in accordance with the
child or adolescent's individual strengths and
needs as specified in the treatment plan.

This Rule is not met as evidenced by:

Based on record reviews and interviews, the
facility failed to have the minimum number of
direct care staff required when children or
adolescents are present and awake. The findings
are:

Review on 9/19/24 of incident report dated
9/15/24 regarding Client #4 revealed:
-"Incident type: Consumer behavior-self injury."
-"...leaving the weight barn with the rest of the
cottage, she (Client #4) emptied her pockets of
items such as sticks and broken plastic ...upon
Division of Health Service Regulation

STATE FORM

6899 ZCCM11

ELIADA TREATMENT CENTER
ASHEVILLE, NC 28806
(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 296 | Continued From page 1 V 296

If continuation sheet 2 of 5

PRINTED: 09/23/2024
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA. (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
c
MHL011-443 B. WING _____ 09/20/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

882 ELIADA HOME ROAD

ELIADA TREATMENT CENTER
ASHEVILLE, NC 28806
(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 296} Continued From page 2 V 296

attempting to enter the cottage,[Client #4] would
not hand anything over to staff and could not
commit to being safe in the cottage, so she
stayed in the courtyard with staff ...when a code
occurred in another cottage, [Client #4] sat with
staff and peers in the courtyard, during which
time she was not self-harming. After [Client #4]
spent a substantial amount of time in the
courtyard conversing with staff and peers, she
stated that she was ready to transition back into
the cottage. Staff informed [Client #4] that we
could transition back inside as soon as she
handed over whatever she had been hiding

... Shortly after trying to get [Client #4] to give up
what she had been hiding, she stood up and
started walking away from the cottage. Staff
followed [Client #4] ...and called a code 1 for
additional staff to respond ...staff followed [Client
#4] ...to the edge of Eliada's property ...[Client #4]
and peer stayed outside despite staff prompts ..."

Interview on 9/20/24 with Client #1 revealed:
-Had been there 6 days short of 3 months.

-3 staff worked. "If they (staff) get called to other
cottages we have to stay in common area."

-He had just returned Sunday (9/15/24) afternoon
when Client #4 ran. "There were only a few kids
in the cottage. One staff 'sat central’. We hadn't
eaten yet and had to stand near the kitchen so
they could see us."

Interview on 9/20/24 with Client #2 revealed:
-"Code 1 means need extra staff to come to our
cottage."

-"Kids run in opposite directions ...other staff
come help follow kids."

-"l ran once, stayed on campus. Staff followed
me, let me breathe then tried to talk to me."

-"5 second rule ...we have 5 seconds to drop
everything and go into our rooms so extra staff
Division of Health Service Regulation

STATE FORM 6899 ZCCM11 If continuation sheet 3 of 5

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL011-443 B. WING

NAME OF PROVIDER OR SUPPLIER
882 ELIADA HOME ROAD

ELIADA TREATMENT CENTER ASHEVILLE, NC 28806

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 09/23/2024
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
09/20/2024

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

(X4) ID
PREFIX
TAG

ID
PREFIX
TAG

CROSS-REFERENCED TO THE APPROPRIATE

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

(x5)
COMPLETE
DATE

DEFICIENCY)

V 296} Continued From page 3 V 296

can go with the person that ran and so we stay
safe ...had 1 staff left with us for about an hour
...we all stayed in the common area so staff could
keep an eye on us ...| think this was Sunday
(9/15/24). Had just gotten back from physical
activity block around 5pm; dinner had to wait;
staff made us a little snack and we had to stand
around the kitchen. | went to bed right after."

Interview on 9/20/24 with Client #3 revealed:
-Had been there since July 10.

-Usually had 3-4 cottage staff ...3 staff on
weekends.

-"Sometimes 1 staff; sitting central when kids
run."

-"Last weekend had 1 staff from end of activity to
bedtime ...[Client #4] and [Client #5] ran together;
don't know where they went."

-"[Staff #3] stayed with us."

Interview on 9/20/24 with Staff #3 revealed:
-Worked Sunday to Wednesday but picked up
extra shifts.

-Usually had 3 staff on the floor and 1 support
staff.

-On Sunday 9/15/24, "1 student (Client #4) ran; 2
staff were with her,1 student was off task (not
sticking to schedule) in the courtyard. Both
students refused to comply."

-"| had one other staff member with me in the
cottage, can't remember who."

-"| was alone with them about 45 minutes; 3-4
students. We watched TV; they were all calm;
had a snack and [other cottage staff] came over
to prepare dinner."

-"Never left alone with kids in the cottage; never
happened before in my 6 months here."

Interview on 9/20/24 with the Executive Director
revealed:

Division of Health Service Regulation

STATE FORM

6899 ZCCM11

If continuation sheet 4 of 5

PRINTED: 09/23/2024
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
Cc
MHL011-443 B. WING 09/20/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ELIADA TREATMENT CENTER
ASHEVILLE, NC 28806
(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 296} Continued From page 4 V 296

-"We guard against having inappropriate staffing
and take it pretty seriously."

Division of Health Service Regulation
STATE FORM 6899 ZCCM11 If continuation sheet 5 of 5

inspection_type: MHLCS Complaint

document_type: Statement of Deficiency


summary: Plan of Correction - MHLCS Complaint

raw_content:
NAME OF PROVIDER OR SUPPLIER

ELIADA TREATMENT CENTER

(X4) 1D
PREFIX |
TAG

|
Vv 000)

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

PRINTED: 09/11/2024
FORM APPROVED

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

MHL011-443

(X2) MULTIPLE CONSTRUCTION
A BUILDING:

B. WING

STREET ADDRESS, CITY, STATE, ZIP CODE

882 ELIADA HOME ROAD

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

ASHEVILLE, NC 28806

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

(X3) DATE SURVEY
COMPLETED

09/10/2024

(XS)
COMPLETE
DATE

INITIAL COMMENTS

Acomplaint survey was completed on 9/10/24.
The complaint was unsubstantiated
(NC#00221599). 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.

This facility is licensed for 8 and currently has a
census of 8. The survey sample consisted of
audits of 3 current clients.

27G .0209 (H) Medication Requirements

10A NCAC 27G .0209 MEDICATION
REQUIREMENTS

(h) Medication errors. Drug administration errors
and significant adverse drug reactions shall be

| reported immediately to a physician or

pharmacist. An entry of the drug administered
and the drug reaction shall be properly recorded
in the drug record. A client's refusal of a drug
shall be charted.

This Rule is not met as evidenced by:

Based on record reviews and interviews, the
facility failed to ensure all medication
administration errors were immediately reported
to a pharmacist or physician affecting 1 of 3
audited clients (#3). The findings are:

Record review on 9/9/24 for Client #3 revealed:

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

DHSR-MH Licensure Sect

Correct - Medication Administration
trained staff will complete medication
error reports in the Electronic Health
Record. These will include consultation
with the MD and notification to the
Legally Responsible Person.

Prevent - All Medication Administration
trained staff will complete retraining on
medication error procedures. A guide
for medication errors will be given to
staff for reference as well.

Monitor - The Chief Compliance Officer
will review daily summary emails from
medication administration staff. Any
denoted refusals will prompt the CCO
to view the EHR for the Med Error
report. If a Med Error Report is not in
place, the CCO will work with the staff
member to have it completed.

Monitor - The PQ! Department will
review MARs monthly in comparison to
Medication Error Reports to ensure all

TITLE

11/5/2024

11/5/2024

11/5/2024

11/5/2024

(x6) DATE

STATE FORM

base Q2Z811

If continuation sheet 1 of 3

PRINTED: 09/11/2024

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED
MHL011-443 8. WING ____________4H4H 09/10/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ELIADA TREATMENT CENTER
ASHEVILLE, NC 28806
(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 123) Continued From page 1 V 123 Med Error Reports are completed

-Date of admission: 6/11/24. |
-Age: 14 years |
-Diagnoses: Disruptive Mood Dysregulation |
Disorder, Post Traumatic Stress Disorder, Anxiety
Disorder.
-Physician ordered medications dated 6/11/24
included:

-Clonidine 0.1mg (milligram) (sleep) 1 tablet
daily at bedtime.

-Metformin ER (extended release) (diabetes
prevention) 750mg 1 tablet daily at 6pm.

-Omeprazole 20mg (heartburn) 1 capsule
twice daily.

-Sucralfate 1 gram (stomach acid) 1 tablet |
before meals and at bedtime.

-Ziprasidone 60mg (mood) 1 capsule twice |
daily. |

Review on 9/9/24 of MARs (medication
administration record) from 7/1/24-9/8/24
revealed:

-Clonidine was documented as refused on
8/17/24 and 8/24/24.

-Metformin was documented as refused on |
716/24.

-Omeprazole was documented as refused on
8/17/24 (pm dose) and 8/24/24 (pm dose). |

-Sucralfate was documented as refused on |
7/16/24 (5:30pm dose), 8/17/24 (12pm dose and |
8pm dose), 8/24/24 (8pm dose), 8/26/24 (12pm__ |
dose) and 9/1/24 (8am dose).

-Ziprasidone was documented as refused on |
8/17/24 (pm dose) and 8/24/24 (pm dose).

Review on 9/9/24 of medication error reports from |
7/1/24-9/8/24 revealed:
-There were no reports for the above dates of
refusals nor documentation that a physician or |
pharmacist was immediately contacted regarding
the refused medications. |
Division of Health Service Regulation
STATE FORM 099 Q2ze11 Hf continuation sheet 2 of 3

PRINTED: 09/11/2024

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED
MHL011-443 B. WING _—______ 09/10/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ELIADA TREATMENT CENTER
Ti ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x8)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
| DEFICIENCY)
V 123 Continued From page 2 | ¥ 123

Interview on 9/10/24 with the Chief Compliance
Officer revealed:

-Staff involved with passing medications were
required to complete the medication error reports
when a student refused medications.

-Several medical/medically trained staff resigned
after administration increased compliance
standards.

-Anurse, who was also a former employee, had
recently returned to manage the nursing
department and was in process of bringing the
medication requirements back into compliance.

Division of Health Service Regulation
STATE FORM see Q2Z811 If continuation sheet 3 of 3

document_type: Plan of Correction


raw_content:
PRINTED: 09/11/2024
FORM APPROVED
Division of Health Service Regulation

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

MHL011-443 B. WING _____ 09/10/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

(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)

ELIADA TREATMENT CENTER

V 000} INITIAL COMMENTS Vv 000

Acomplaint survey was completed on 9/10/24.
The complaint was unsubstantiated
(NC#00221599). 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.

This facility is licensed for 8 and currently has a
census of 8. The survey sample consisted of
audits of 3 current clients.

V 123} 27G .0209 (H) Medication Requirements V 123

10A NCAC 27G .0209 MEDICATION
REQUIREMENTS

(h) Medication errors. Drug administration errors
and significant adverse drug reactions shall be
reported immediately to a physician or
pharmacist. An entry of the drug administered
and the drug reaction shall be properly recorded
in the drug record. A client's refusal of a drug
shall be charted.

This Rule is not met as evidenced by:

Based on record reviews and interviews, the
facility failed to ensure all medication
administration errors were immediately reported
to a pharmacist or physician affecting 1 of 3
audited clients (#3). The findings are:

Record review on 9/9/24 for Client #3 revealed:

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

STATE FORM 6899 Q2Z811 If continuation sheet 1 of 3

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL011-443 B. WING

NAME OF PROVIDER OR SUPPLIER
882 ELIADA HOME ROAD

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 09/11/2024
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

09/10/2024

-Date of admission: 6/11/24.
-Age: 14 years
-Diagnoses: Disruptive Mood Dysregulation
Disorder, Post Traumatic Stress Disorder, Anxiety
Disorder.
-Physician ordered medications dated 6/11/24
included:

-Clonidine 0.1mg (milligram) (sleep) 1 tablet
daily at bedtime.

-Metformin ER (extended release) (diabetes
prevention) 750mg 1 tablet daily at 6pm.

-Omeprazole 20mg (heartburn) 1 capsule
twice daily.

-Sucralfate 1 gram (stomach acid) 1 tablet
before meals and at bedtime.

-Ziprasidone 60mg (mood) 1 capsule twice
daily.

Review on 9/9/24 of MARs (medication
administration record) from 7/1/24-9/8/24
revealed:

-Clonidine was documented as refused on
8/17/24 and 8/24/24.

-Metformin was documented as refused on
716/24.

-Omeprazole was documented as refused on
8/17/24 (pm dose) and 8/24/24 (pm dose).

-Sucralfate was documented as refused on
7/16/24 (5:30pm dose), 8/17/24 (12pm dose and
8pm dose), 8/24/24 (8pm dose), 8/26/24 (12pm
dose) and 9/1/24 (8am dose).

-Ziprasidone was documented as refused on
8/17/24 (pm dose) and 8/24/24 (pm dose).

Review on 9/9/24 of medication error reports from
7/1/24-9/8/24 revealed:

-There were no reports for the above dates of
refusals nor documentation that a physician or
pharmacist was immediately contacted regarding
the refused medications.

Division of Health Service Regulation

STATE FORM

6899 Q2Z811

ELIADA TREATMENT CENTER
ASHEVILLE, NC 28806
(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 123] Continued From page 1 V 123

If continuation sheet 2 of 3

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION

PRINTED: 09/11/2024
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL011-443 B. WING 09/10/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ELIADA TREATMENT CENTER
ASHEVILLE, NC 28806
(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 123} Continued From page 2 V 123

Interview on 9/10/24 with the Chief Compliance
Officer revealed:
-Staff involved with passing medications were
required to complete the medication error reports
when a student refused medications.
-Several medical/medically trained staff resigned
after administration increased compliance
standards.
-A nurse, who was also a former employee, had
recently returned to manage the nursing
department and was in process of bringing the
medication requirements back into compliance.

Division of Health Service Regulation

STATE FORM ad Q2z811 If continuation sheet 3 of 3


summary: Statement of Deficiency - MHLCS Annual

raw_content:
Division of Health Service Regulation

PRINTED: 05/15/2024

FORM APPROVED

10A NCAC 27G .0207 EMERGENCY PLANS
AND SUPPLIES

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

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

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

This Rule is not met as evidenced by:

Based on record reviews and interviews, the
facility failed to hold fire and disaster drills at least
quarterly for each shift. The findings are:

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

STATE FORM

6899

D7F611

TITLE

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
MHL011-443 05/13/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ELIADA TREATMENT CENTER
ASHEVILLE, NC 28806
(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 May 13,
2024. Deficiencies were cited.
The facility is licensed for the following service
category: 10A NCAC 27G .1700 Residential
Treatment Staff Secure for Children and
Adolescents.
This facility is licensed for 8 and has a current
census of 4. The survey sample consisted of
audits of 2 current clients and 1 former client.
V 114| 27G .0207 Emergency Plans and Supplies Vv 114

(X6) DATE

If continuation sheet 1 of 3

Division of Health Service Regulation

AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

ELIADA TREATMENT CENTER

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION

IDENTIFICATION NUMBER: A. BUILDING

MHL011-443

STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

PRINTED: 05/15/2024
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

05/13/2024

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

(xs)

V 114] Continued From page 1

2024 (January-March).

revealed:

Officer revealed:

fire and disaster drill logs.

Manager revealed:

completing the fire drills.

Verification

G.S. §131E-256 HEALTH
REGISTRY

Division of Health Service Regulation
STATE FORM

Review on 5/7/24 and 5/8/24 of the facility's fire
and disaster drill log revealed:

-No documentation of fire drills on first shift for
third quarter 2023 (July-September).

-No documentation of fire drills on first shift for
fourth quarter 2023 (October-December).

-No documentation of fire drills on first shift for
first quarter 2024 (January-March).

-No documentation the clients were present for
disaster drills on first shift for third and fourth
quarter 2023 (July-December) and first quarter

Interview on 5/13/24 with the Residential Director
-"| make sure they (fire drills) are done."
-"Documenting that it (disaster drills) is happening
on campus but not necessarily in the cottage."
Interview on 5/13/24 with the Chief Compliance
-Was the responsibility of the Residential Director
to make sure drills were completed correctly.
-The Quality Assurance Manager would check the
Interview on 5/13/24 with the Quality Assurance
-Disaster drills were completed even if no clients

were present in the facility.
-Would alternate who was responsible for

V 131] G.S. 131E-256 (D2) HCPR - Prior Employment Vv 131

(d2) Before hiring health care personnel into a

Vv 114

CARE PERSONNEL

6808 D7F611

If continuation sheet 2 of 3

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL011-443

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

882 ELIADA HOME ROAD

PRINTED: 05/15/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

05/13/2024

health care facility or service, every employer at a
health care facility shall access the Health Care
Personnel Registry and shall note each incident
of access in the appropriate business files.

This Rule is not met as evidenced by:

Based on record review and interview the facility
failed to complete the Health Care Personnel
Registry (HCPR) check prior to hire. The findings
are:

Review on 5/9/24-5/10/24 of Former Staff (FS)
#2's record revealed:

-Date of Hire: 1/8/24.

-Date of HCPR check: 5/7/24.

Interview on 5/13/24 with the Chief Compliance
Officer revealed:

-Human Resources was responsible for
completing and filing the HCPR checks.
-HCPR checks had been completed for other
staff hired the same day as FS #2.

Division of Health Service Regulation
STATE FORM

6809

D7F611

ELIADA TREATMENT CENTER
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 131] Continued From page 2 Vv 131

If continuation sheet 3 of 3

inspection_type: MHLCS Annual


summary: Plan of Correction - MHLCS Annual

raw_content:
Division of Health Service Regulation

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

MHL011-443

A. BUIL!

(X2) MULTIPLE CONSTRUCTION

B. WING

PRINTED: 05/15/2024
FORM APPROVED

(X3) DATE SURVEY

DING: COMPLETED

05/13/2024

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

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

ee
V000 INITIAL COMMENTS

An annual survey was completed on May 13,
2024. Deficiencies were cited.

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

This facility is licensed for 8 and has a current
census of 4. The survey sample consisted of
audits of 2 current clients and 1 former client.

V 114 27G .0207 Emergency Plans and Supplies

10A NCAC 27G .0207 EMERGENCY PLANS.
AND SUPPLIES

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

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

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

This Rule is not met as evidenced by:

Based on record reviews and interviews, the

facility failed to hold fire and disaster drills at least
| quarterly for each shift. The findings are:

iD

PREFIX
TAG

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

(xs)
COMPLETE
DATE

—

Vv 000

v114

|
V114 - Correction - Residential Director
will initiate fire and disaster drills in the |
current quarter during each shift.

V114 - Prevention - Quality Assurance
Manager will create a calendar with
automated reminders prompting fire and
disaster drills with a minimum of once
per shift per quarter.

V114 - Monitoring - Quality Assurance
Manager will have reminders from the
automated calendar system to review
that a fire or disaster drill was
completed. Additionally, once per
quarter, the Quality Assurance Manager
will complete an audit of the record of
fire and disaster drills. Any deficiencies
found in internal monitoring will be
followed-up with a plan of correction.

V131 - Correction - PQ! Department
Staff will complete an audit of staff files
and HR Staff will complete registries for |
any found to be deficient.

V131 - Prevention - Chief Compliance |
Officer will create a process map of the |
hiring/onboarding process with the HR
Recruiter with the registries included as |
a step. Training will be completed by
the PQI and HR department heads to
ensure the HR Recruiter understands |
the process for running registries and |
documenting results in HR files. A
checklist of file requirements will be
created by CCO showing registries as a
required document that will be signed

off for each new hire.

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

TITLE (x6) DATE

STATE FORM

809

O7F611 If continuation sheet 1 of 3

RECEIVED
JUL 08 2024

DHSR-MH Licensure Sect

Division of Health Service Regulation

PRINTED: 05/15/2024
FORM APPROVED

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

MHL011-443

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

B. WING

(x3) DATE SURVEY
COMPLETED

05/13/2024

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD

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

| GS. §131E-256 HEALTH CARE PERSONNEL
REGISTRY
| (d2) Before hiring health care personnel into a

Division of Health Service Regulation
STATE FORM

6209

O7F611

ELIADA TREATMENT CENTER ASHEVILLE, NC 28806
(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)

M4) Contatied From babe: Nas | ¥1314 - Monitoring - HR Director will
Review on 5/7/24 and 5/8/24 of the facility's fire conduct regular checks of new hire HR
and disaster drill log revealed: files. This process will include
-No documentation of fire drills on first shift for checking that registries have been run
third quarter 2023 (July-September). in each file. Additionally, once per
-No documentation of fire drills on first shift for quarter, the PQI RISE intern will
fourth quarter 2023 (October-December). complete an audit of a sample of HR
-No documentation of fire drills on first shift for files which will include new hires, staff
first quarter 2024 (January-March). who had a work anniversary in the last
-No documentation the clients were present for quarter, and staff terminated in the last
disaster drills on first shift for third and fourth quarter. Any deficiencies found in
quarter 2023 (July-December) and first quarter internal monitoring will be followed-up
2024 (January-March). with a plan of correction.

Interview on 5/13/24 with the Residential Director
revealed:
-"| make sure they (fire drills) are done."
-"Documenting that it (disaster drills) is happening
on campus but not necessarily in the cottage."
Interview on 5/13/24 with the Chief Compliance
Officer revealed:
-Was the responsibility of the Residential Director |
to make sure drills were completed correctly.
-The Quality Assurance Manager would check the
| fire and disaster drill logs.
|
Interview on 5/13/24 with the Quality Assurance |
| Manager revealed:
| -Disaster drills were completed even if no clients |
were present in the facility. |
-Would alternate who was responsible for |
completing the fire drills. |
| |
Vv 134 |

If continuation sheet 2 of 3

PRINTED: 05/15/2024

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: _ COMPLETED
A. BUILDING:
MHLO11-443 B.WING, 05/13/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
ELIADA TREATMENT CENTER 882 ELIADA HOME ROAD
ASHEVILLE, NC 28806
(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) | Tac CROSS-REFERENCED TO THE APPROPRIATE, DATE

DEFICIENCY)

V 131) Continued From page 2 V 131 |

health care facility or service, every employer at a
health care facility shall access the Health Care |

| Personnel Registry and shall note each incident
of access in the appropriate business files.

This Rule is not met as evidenced by:

Based on record review and interview the facility
failed to complete the Health Care Personnel
Registry (HCPR) check prior to hire. The findings
are:

Review on 5/9/24-5/10/24 of Former Staff (FS)
#2's record revealed:

-Date of Hire: 1/8/24.

-Date of HCPR check: 5/7/24.

Interview on 5/13/24 with the Chief Compliance |
Officer revealed:
-Human Resources was responsible for |
completing and filing the HCPR checks.
-HCPR checks had been completed for other
staff hired the same day as FS #2.

Division of Health Service Regulation
STATE FORM 6e09 D7F611 If continuation sheet 3 of 3


summary: Statement of Deficiency - MHLCS Annual

raw_content:
PRINTED: 05/15/2024
FORM APPROVED
Division of Health Service Regulation

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

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

COMPLETED

A. BUILDING:

MHLO011-443 05/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4 ¢
882 ELIADA HOME ROAD ‘6

ELIADA TREATMENT CENTER
ASHEVILLE, NC 28806
ein | SUMMARY STATEMENT OF DEFICIENCIES i PROVID! le) (x5)
PREFIX | (EACH DEFICIENCY MUST B& PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) T™G (CROSS-REFERENCED TO THE APPROPRIATE | DATE

DEFICIENCY)

T
V114 - Correction - Residential Director |
will initiate fire and disaster drills in the
| An annual survey was completed on May 13, current quarter during each shift. |
| 2024. Deficiencies were cited. |

V000 INITIAL COMMENTS

|
V114 - Prevention - Quality Assurance |

| The facility is licensed for the following service Manager will create a calendar with

| category: 10A NCAC 27G .1700 Residential automated reminders prompting fire and

| Treatment Staff Secure for Children and disaster drills with a minimum of once

| Adolescents. per shift per quarter. |

| This facility is licensed for 8 and has a current V114 - Monitoring - Quality Assurance
census of 4. The survey sample consisted of Manager will have reminders from the
audits of 2 current clients and 1 former client. automated calendar system to review |

that a fire or disaster drill was |
V 114 27G .0207 Emergency Plans and Supplies Vv 114 completed. Additionally, once per

| quarter, the Quality Assurance Manager|

| 10A NCAC 27 .0207 EMERGENCY PLANS will complete an audit of the record of
AND SUPPLIES fire and disaster drills. Any deficiencies

| (a) Awritten fire plan for each facility and found in internal monitoring will be
area-wide disaster plan shall be developed and | followed-up with a plan of correction.
shall be approved by the appropriate local
authority. V131 - Correction - PQ!| Department

| (b) The plan shall be made available to all staff Staff will complete an audit of staff files |
and evacuation procedures and routes shall be and HR Staff will complete registries for |
posted in the facility. any found to be deficient.
(c) Fire and disaster drills in a 24-hour facility
shall be held at least quarterly and shall be 131 - Prevention - Chief Compliance
repeated for each shift. Drills shall be conducted Officer will create a process map of the |

under conditions that simulate fire emergencies.
(d) Each facility shall have basic first aid supplies
accessible for use.

hiring/onboarding process with the HR
Recruiter with the registries included as
a step. Training will be completed by |
the PQI and HR department heads to
ensure the HR Recruiter understands
the process for running registries and
documenting results in HR files. A
checklist of file requirements will be |
created by CCO showing registries as a
required document that will be signed
off for each new hire

This Rule is not met as evidenced by:
Based on record reviews and interviews, the
facility failed to hold fire and disaster drills at least
quarterly for each shift. The findings are:

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

If Continuation sheet 1 of 3

STATE FORM

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

MHL011-443

NAME OF PROVIDER OR SUPPLIER

ELIADA TREATMENT CENTER

(X2) MULTIPLE CONSTRUCTION

A, BUILD|

8B. WING

ING:

ASHEVILLE, NC 28806

PRINTED: 05/15/2024
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

05/13/2024

STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES
PREFIX | (EACH DEFICIENCY MUST BE PRECEDED BY FULL

Tas | REGULATORY OR LSC IDENTIFYING INFORMATION)

| ID

PREFIX

TAG

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

CROSS-REFERENCED TO THE APPROPRIATE. DATE
DEFICIENCY)

V 114 Continued From page 1

Review on 5/7/24 and 5/8/24 of the facility's fire
_ and disaster drill log revealed:

-No documentation of fire drills on first shift for
third quarter 2023 (July-September).

-No documentation of fire drills on first shift for
fourth quarter 2023 (October-December).

-No documentation of fire drills on first shift for
first quarter 2024 (January-March).

-No documentation the clients were present for
disaster drills on first shift for third and fourth
quarter 2023 (July-December) and first quarter
2024 (January-March).

revealed:
-"| make sure they (fire drills) are done.”

| on campus but not necessarily in the cottage.”

Interview on 5/13/24 with the Chief Compliance
Officer revealed:

to make sure drills were completed correctly.
fire and disaster drill logs.

Interview on 5/13/24 with the Quality Assurance
Manager revealed:

were present in the facility.
-Would alternate who was responsible for
| completing the fire drills.

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

| Verification

| GS. §131E-256 HEALTH CARE PERSONNEL
REGISTRY
(d2) Before hiring health care personnel into a

Interview on 5/13/24 with the Residential Director

-"Documenting that it (disaster drills) is happening

-Was the responsibility of the Residential Director

-The Quality Assurance Manager would check the

-Disaster drills were completed even if no clients

v1i4

V 131

—T

| in each file. Additionally, once per

V131 - Monitoring - HR Director will
conduct regular checks of new hire HR
files. This process will include
checking that registries have been run

quarter, the PQI RISE intern will
complete an audit of a sample of HR
files which will include new hires, staff
who had a work anniversary in the last
quarter, and staff terminated in the last |
quarter. Any deficiencies found in
internal monitoring will be followed-up
with a plan of correction.

Division of Health Service Regulation
STATE FORM

D7F611

If continuation sheet 2 of 3

PRINTED: 05/15/2024
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: COMPLETED
A.BUILDING:
MHLO011-443 B. WING 05/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD

ELIADA TREATMENT CENTER
ASHEVILLE, NC 28806

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

DEFICIENCY)

V 131) Continued From page 2 V 131

health care facility or service, every employer at a
health care facility shall access the Health Care
Personnel Registry and shall note each incident
of access in the appropriate business files.

This Rule is not met as evidenced by:

Based on record review and interview the facility
| failed to complete the Health Care Personnel
Registry (HCPR) check prior to hire. The findings
are:

Review on 5/9/24-5/10/24 of Former Staff (FS) |
#2's record revealed:
-Date of Hire: 1/8/24.
| -Date of HCPR check: 5/7/24,

Interview on 5/13/24 with the Chief Compliance
Officer revealed:

-Human Resources was responsible for
completing and filing the HCPR checks.
-HCPR checks had been completed for other
staff hired the same day as FS #2.

Division of Health Service Regulation
STATE FORM Laid D7F611 If continuation sheet 3 of 3

PRINTED: 05/15/2024
FORM APPROVED

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

B. WING

MHLO011-203 05/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
111 COMPTON DRIVE
ASHEVILLE, NC 28806

REUTER COTTAGE

(xa) 1D SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION | x5)
PREFIX (BACH 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 V114 - Correction - Residential

Director will initiate fire and disaster

An annual and complaint survey was completed drills in the current quarter during
| on May 13, 2024. The complaint was | each shift |
substantiated (Intake 4NC00216640). A
| deficiency was cited. V114 - Prevention - Quality Assurance
Manager will create a calendar with

| This facility is licensed for the following service automated reminders prompting fire |
| category: 10A NCAC 27G .1700 Residential and disaster drills with a minimum of |
| Treatment Staff Secure for Children or once per shift per quarter |

Adolescents,

This facility is licensed for 6 and has a current Mshage ait tan eal the
ivi consisted oF automated calendar system to review
| . that a fire or disaster drill was |
completed. Additionally, once per |

V 114 276 .0207 Emergency Plans and Supplies Vv 114 | quarter, the Quality Assurance
Manager will complete an audit of the

| 10A NCAC 27G .0207 EMERGENCY PLANS | record of fire and disaster drills. Any
| AND SUPPLIES 7 deficiencies found in internal

(a) Awritten fire plan for each facility and monitoring will be followed-up with a
| area-wide disaster plan shall be developed and plan of correction.
| shall be approved by the appropriate local
| authority. |

(b) The plan shall be made available to all staff
and evacuation procedures and routes shall be |
posted in the facility.
(c) Fire and disaster drills in a 24-hour facility |
shall be held at least quarterly and shall be

| repeated for each shift. Drills shall be conducted

| under conditions that simulate fire emergencies.

| (d) Each facility shall have basic first aid supplies
accessible for use.

| This Rule is not met as evidenced by:
Based on interviews and record reviews, the
facility failed to hold fire and disaster drills at least

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

(X6) DATE

if dontinuation sheet 1 of 2

STATE FORM ba SPU611

PRINTED: 05/15/2024
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: COMPLETED

A, BUILDING:

MHL011-203 BEWING 05/13/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
111 COMPTON DRIVE
REUTER COTTAGE
ASHEVILLE, NC 28806
(x4) ID | SUMMARY STATEMENT OF DEFICIENCIES | 10 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)
_—_|__- a
V 114 Continued From page 1 v114

quarterly for each shift. The findings are: |

| Review on 5/7/24 and 5/8/24 of the facility's fire
| and disaster drill log revealed:

-No documentation of fire drills on first shift for
third quarter 2023 (July-September).

-No documentation of fire drills on first shift for |
fourth quarter 2023 (October-December). - |
-No documentation of fire drills on first shift for |
first quarter 2024 (January-March).
-No documentation the clients were present for |
disaster drills on first shift for third and fourth |
quarter 2023 (July-December). |

Interview on 5/9/24 with the Residential
Supervisor revealed:

-Staff determined when fire drills were completed.
| -Was responsible to make sure drills were

| completed.

Interview on 5/13/24 with the Residential Director
revealed:

-"| make sure they (fire drills) are done." |
-"Documenting that it (disaster drills) is happening
on campus but not necessarily in the cottage." |

Interview on 5/13/24 with the Chief Compliance
Officer revealed:

-Was the respensibility of the Residential Director
to make sure drills were completed correctly.
-The Quality Assurance Manager would check the
fire and disaster drill logs.

Interview on 5/13/24 with the Quality Assurance
Manager revealed:

-Disaster drills were completed even if no clients
were present in the facility. |
-Would alternate who was responsible for |
completing the fire drills. |

Division of Health Service Regulation
STATE FORM ase SPU611 If continuation sheet 2 of 2