summary: Statement of Deficiency - MHLCS Annual

raw_content:
Division of Health Service Regulation

A MOTHER'S LOVE

PRINTED: 08/01/2019
FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
MHL001-259 B. WING 07/18/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1227 WESTMORLAND DRIVE
BURLINGTON, NC 27215

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

ID
PREFIX
TAG

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

(x5)
COMPLETE
DATE

V 000} INITIAL COMMENTS

An annual survey was completed on 7/18/19.
Deficiencies were cited.

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

V 107| 27G .0202 (A-E) Personnel Requirements

10A NCAC 27G .0202 PERSONNEL
REQUIREMENTS

(a) All facilities shall have a written job
description for the director and each staff position
which:

(1) specifies the minimum level of education,
competency, work experience and other
qualifications for the position;

(2) specifies the duties and responsibilities of
the position;

(3) is signed by the staff member and the
supervisor; and

(4) is retained in the staff member's file.

(b) All facilities shall ensure that the director,
each staff member or any other person who
provides care or services to clients on behalf of
the facility:

(1) is at least 18 years of age;

(2) is able to read, write, understand and
follow directions;

(3) meets the minimum level of education,
competency, work experience, skills and other
qualifications for the position; and

(4) has no substantiated findings of abuse or
neglect listed on the North Carolina Health Care
Personnel Registry.

(c) All facilities or services shall require that all
applicants for employment disclose any criminal
conviction. The impact of this information on a
decision regarding employment shall be based
Division of Health Service Regulation

V 000

Vv 107

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

STATE FORM

6899

TITLE

(X6) DATE

GVM411 If continuation sheet 1 of 19

PRINTED: 08/01/2019

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
MHL001-259 B. WING 07/18/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1227 WESTMORLAND DRIVE
A MOTHER'S LOVE
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 107 | Continued From page 1 Vv 107

upon the offense in relationship to the job for
which the applicant is applying.

(d) Staff of a facility or a service shall be
currently licensed, registered or certified in
accordance with applicable state laws for the
services provided.

(e) Afile shall be maintained for each individual
employed indicating the training, experience and
other qualifications for the position, including
verification of licensure, registration or
certification.

This Rule is not met as evidenced by:

Based on record reviews, observation and
interviews, the facility management failed to
maintain a file for 1 of 3 (#1) audited staff. The
findings are:

Observation on 7/18/19 at approximately 5:00 PM
of staff working in the facility revealed:

- One staff (Staff #1) person engaged in assisting
a client in preparing dinner for residents in the
facility.

During interview on 7/18/19, Staff #1 reported:

- She began working in the facility on 6/10/19 as a
paraprofessional.

- She works both 2nd and 3rd shift and on an
as-needed basis.

During interview on 7/18/19, the Licensee
confirmed:

Division of Health Service Regulation

STATE FORM 6899 GVM411 If continuation sheet 2 of 19

PRINTED: 08/01/2019
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:
MHL001-259 B. WING _____ 07/18/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1227 WESTMORLAND DRIVE

A MOTHER'S LOVE 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 107} Continued From page 2 Vv 107

- Staff #1 began working in the facility in the past
month. She has known Staff #1 who has worked
for the Licensee on an as-needed basis in her
other facility for several years.

- She did not have a file for Staff #1 with a written
job description, documentation of the training,
experience, other requirements and qualifications
for the position.

V 108] 27G .0202 (F-I) Personnel Requirements V 108

10A NCAC 27G .0202 PERSONNEL
REQUIREMENTS

(f) Continuing education shall be documented.
(g) Employee training programs shall be
provided and, at a minimum, shall consist of the
following:

(1) general organizational orientation;

(2) training on client rights and confidentiality as
delineated in 10A NCAC 27C, 27D, 27E, 27F and
10A NCAC 26B;

(3) training to meet the mh/dd/sa needs of the
client as specified in the treatment/habilitation
plan; and

(4) training in infectious diseases and
bloodborne pathogens.

(h) Except as permitted under 10a NCAC 27G
.5602(b) of this Subchapter, at least one staff
member shall be available in the facility at all
times when a client is present. That staff
member shall be trained in basic first aid
including seizure management, currently trained
to provide cardiopulmonary resuscitation and
trained in the Heimlich maneuver or other first aid
techniques such as those provided by Red Cross,
the American Heart Association or their
equivalence for relieving airway obstruction.

(i) The governing body shall develop and
implement policies and procedures for identifying,

Division of Health Service Regulation
STATE FORM 6899 GVM411 If continuation sheet 3 of 19

PRINTED: 08/01/2019

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
MHL001-259 B. WING ____ 07/18/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1227 WESTMORLAND DRIVE

A MOTHER'S LOVE 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 108} Continued From page 3 V 108

reporting, investigating and controlling infectious
and communicable diseases of personnel and
clients.

This Rule is not met as evidenced by:
Based on record reviews, observation and
interviews, the facility management failed to
assure 1 of 3 (#1) audited staff was currently
trained in basic first and cardiopulmonary
resuscitation (CPR.) The findings are:

Observation on 7/18/19 at approximately 5:00 PM
of staff working in the facility revealed:

- One staff (Staff #1) person engaged in assisting
a client in preparing dinner for residents in the
facility.

During interview on 7/18/19, Staff #1 reported:

- She began working in the facility on 6/10/19 as a
paraprofessional.

- She may work on 2nd or 3rd shift and is the only
staff in the facility when she is working.

During interview on 7/18/19, the Licensee
confirmed:

- Staff #1 began working in the facility in the past
month.

- There was no documentation Staff #1 was
currently trained to provide CPR and trained in
the Heimlich maneuver or other first aid
techniques such as those provided by Red Cross,
the American Heart Association or their
equivalence for relieving airway obstruction.

- Staff #1 may work alone in the facility when she
is working.

Division of Health Service Regulation
STATE FORM 6899 GVM411 If continuation sheet 4 of 19

PRINTED: 08/01/2019
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:
MHL001-259 B. WING _____ 07/18/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1227 WESTMORLAND DRIVE

A MOTHER'S LOVE 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 131} Continued From page 4 Vv 131

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

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

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

This Rule is not met as evidenced by:

Based on record reviews, observation and
interviews, the facility management failed to a
HCPR check was completed prior to hire for 1 of
3 (#1) audited staff. The findings are:

Observation on 7/18/19 at approximately 5:00 PM
of staff working in the facility revealed:

- One staff (Staff #1) person engaged in assisting
a client in preparing dinner for residents in the
facility.

During interview on 7/18/19, Staff #1 reported:

- She began working in the facility on 6/10/19 as a
paraprofessional.

- She may work on 2nd or 3rd shift and is the only
staff in the facility when she is working.

During interview on 7/18/19, the Licensee
confirmed:

- Staff #1 began working in the facility in the past
month.

Division of Health Service Regulation
STATE FORM 6899 GVM411 If continuation sheet 5 of 19

PRINTED: 08/01/2019
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:
MHL001-259 B. WING _____ 07/18/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1227 WESTMORLAND DRIVE

A MOTHER'S LOVE 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 131] Continued From page 5 Vv 131

- There was no documentation a HCPR check
was completed prior to hire for Staff #1.

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

G.S. §122C-80 CRIMINAL HISTORY RECORD
CHECK REQUIRED FOR CERTAIN
APPLICANTS FOR EMPLOYMENT.

(a) Definition. - As used in this section, the term
"provider" applies to an area authority/county
program and any provider of mental health,
developmental disability, and substance abuse
services that is licensable under Article 2 of this
Chapter.
(b) Requirement. - An offer of employment by a
provider licensed under this Chapter to an
applicant to fill a position that does not require the
applicant to have an occupational license is
conditioned on consent to a State and national
criminal history record check of the applicant. If
the applicant has been a resident of this State for
less than five years, then the offer of employment
is conditioned on consent to a State and national
criminal history record check of the applicant. The
national criminal history record check shall
include a check of the applicant's fingerprints. If
the applicant has been a resident of this State for
five years or more, then the offer is conditioned
on consent to a State criminal history record
check of the applicant. A provider shall not
employ an applicant who refuses to consent to a
criminal history record check required by this
section. Except as otherwise provided in this
subsection, within five business days of making
the conditional offer of employment, a provider
shall submit a request to the Department of
Justice under G.S. 114-19.10 to conduct a
criminal history record check required by this
section or shall submit a request to a private

Division of Health Service Regulation
STATE FORM 6899 GVM411 If continuation sheet 6 of 19

PRINTED: 08/01/2019
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:
MHL001-259 B. WING _____ 07/18/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1227 WESTMORLAND DRIVE

A MOTHER'S LOVE 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 133} Continued From page 6 V 133

entity to conduct a State criminal history record
check required by this section. Notwithstanding
G.S. 114-19.10, the Department of Justice shall
return the results of national criminal history
record checks for employment positions not
covered by Public Law 105-277 to the
Department of Health and Human Services,
Criminal Records Check Unit. Within five
business days of receipt of the national criminal
history of the person, the Department of Health
and Human Services, Criminal Records Check
Unit, shall notify the provider as to whether the
information received may affect the employability
of the applicant. In no case shall the results of the
national criminal history record check be shared
with the provider. Providers shall make available
upon request verification that a criminal history
check has been completed on any staff covered
by this section. A county that has adopted an
appropriate local ordinance and has access to
the Division of Criminal Information data bank
may conduct on behalf of a provider a State
criminal history record check required by this
section without the provider having to submit a
request to the Department of Justice. In such a
case, the county shall commence with the State
criminal history record check required by this
section within five business days of the
conditional offer of employment by the provider.
All criminal history information received by the
provider is confidential and may not be disclosed,
except to the applicant as provided in subsection
(c) of this section. For purposes of this
subsection, the term "private entity" means a
business regularly engaged in conducting
criminal history record checks utilizing public
records obtained from a State agency.

(c) Action. - If an applicant's criminal history
record check reveals one or more convictions of

Division of Health Service Regulation
STATE FORM 6899 GVM411 If continuation sheet 7 of 19

PRINTED: 08/01/2019
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:
MHL001-259 B. WING _____ 07/18/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1227 WESTMORLAND DRIVE

A MOTHER'S LOVE 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 133} Continued From page 7 V 133

a relevant offense, the provider shall consider all
of the following factors in determining whether to
hire the applicant:

(1) The level and seriousness of the crime.

(2) The date of the crime.

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

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

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

(6) The prison, jail, probation, parole,
rehabilitation, and employment records of the
person since the date the crime was committed.
(7) The subsequent commission by the person of
a relevant offense.

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

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

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

(e) Relevant Offense. - As used in this section,

Division of Health Service Regulation
STATE FORM 6899 GVM411 If continuation sheet 8 of 19

PRINTED: 08/01/2019
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:
MHL001-259 B. WING _____ 07/18/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1227 WESTMORLAND DRIVE

A MOTHER'S LOVE 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 133} Continued From page 8 V 133

“relevant offense" means a county, state, or
federal criminal history of conviction or pending
indictment of a crime, whether a misdemeanor or
felony, that bears upon an individual's fitness to
have responsibility for the safety and well-being of
persons needing mental health, developmental
disabilities, or substance abuse services. These
crimes include the criminal offenses set forth in
any of the following Articles of Chapter 14 of the
General Statutes: Article 5, Counterfeiting and
Issuing Monetary Substitutes; Article 5A,
Endangering Executive and Legislative Officers;
Article 6, Homicide; Article 7A, Rape and Other
Sex Offenses; Article 8, Assaults; Article 10,
Kidnapping and Abduction; Article 13, Malicious
njury or Damage by Use of Explosive or
ncendiary Device or Material; Article 14, Burglary
and Other Housebreakings; Article 15, Arson and
Other Burnings; Article 16, Larceny; Article 17,
Robbery; Article 18, Embezzlement; Article 19,
False Pretenses and Cheats; Article 19A,
Obtaining Property or Services by False or
Fraudulent Use of Credit Device or Other Means;
Article 19B, Financial Transaction Card Crime
Act; Article 20, Frauds; Article 21, Forgery; Article
26, Offenses Against Public Morality and
Decency; Article 26A, Adult Establishments;
Article 27, Prostitution; Article 28, Perjury; Article
29, Bribery; Article 31, Misconduct in Public
Office; Article 35, Offenses Against the Public
Peace; Article 36A, Riots and Civil Disorders;
Article 39, Protection of Minors; Article 40,
Protection of the Family; Article 59, Public
ntoxication; and Article 60, Computer-Related
Crime. These crimes also include possession or
sale of drugs in violation of the North Carolina
Controlled Substances Act, Article 5 of Chapter
90 of the General Statutes, and alcohol-related
offenses such as sale to underage persons in

Division of Health Service Regulation
STATE FORM 6899 GVM411 If continuation sheet 9 of 19

PRINTED: 08/01/2019
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:
MHL001-259 B. WING _____ 07/18/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1227 WESTMORLAND DRIVE

A MOTHER'S LOVE 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 133] Continued From page 9 V 133

violation of G.S. 18B-302 or driving while
impaired in violation of G.S. 20-138.1 through
G.S. 20-138.5.

(f) Penalty for Furnishing False Information. - Any
applicant for employment who willfully furnishes,
supplies, or otherwise gives false information on
an employment application that is the basis for a
criminal history record check under this section
shall be guilty of a Class A1 misdemeanor.

(g) Conditional Employment. - A provider may
employ an applicant conditionally prior to
obtaining the results of a criminal history record
check regarding the applicant if both of the
following requirements are met:

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

This Rule is not met as evidenced by:

Based on record reviews, observation and
interviews, the facility management failed to
assure a state and national criminal record check
was completed within five days of the offer of
employment for 1 of 3 (#1) audited staff. The
findings are:

Observation on 7/18/19 at approximately 5:00 PM
Division of Health Service Regulation
STATE FORM 6899 GVM411 If continuation sheet 10 of 19

PRINTED: 08/01/2019
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:
MHL001-259 B. WING _____ 07/18/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1227 WESTMORLAND DRIVE

A MOTHER'S LOVE 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 133] Continued From page 10 V 133

of staff working in the facility revealed:

- One staff (Staff #1) person engaged in assisting
a client in preparing dinner for residents in the
facility.

During interview on 7/18/19, Staff #1 reported:

- She began working in the facility on 6/10/19 as a
paraprofessional.

- She may work on 2nd or 3rd shift and is the only
staff in the facility when she is working.

During interview on 7/18/19, the Licensee
confirmed:

- Staff #1 began working in the facility in the past
month.

- There was no documentation a state and
national criminal record check as completed for
Staff #1 in the time frame required by rule.

V 366} 27G .0603 Incident Response Requirments V 366

10A NCAC 27G .0603 INCIDENT
RESPONSE REQUIREMENTS FOR
CATEGORY AAND B PROVIDERS
(a) Category A and B providers shall develop and
implement written policies governing their
response to level I, II or Ill incidents. The policies
shall require the provider to respond by:

(1) attending to the health and safety needs
of individuals involved in the incident;

(2) determining the cause of the incident;
(3) developing and implementing corrective

measures according to provider specified
timeframes not to exceed 45 days;
(4) developing and implementing measures
to prevent similar incidents according to provider
specified timeframes not to exceed 45 days;

(5) assigning person(s) to be responsible
for implementation of the corrections and

Division of Health Service Regulation
STATE FORM 6899 GVM411 If continuation sheet 11 of 19

PRINTED: 08/01/2019
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:
MHL001-259 B. WING _____ 07/18/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1227 WESTMORLAND DRIVE

A MOTHER'S LOVE
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 366 | Continued From page 11 V 366

preventive measures;

(6) adhering to confidentiality requirements
set forth in G.S. 75, Article 2A, 10A NCAC 26B,
42 CFR Parts 2 and 3 and 45 CFR Parts 160 and
164; and

(7) maintaining documentation regarding
Subparagraphs (a)(1) through (a)(6) of this Rule.
(b) In addition to the requirements set forth in
Paragraph (a) of this Rule, ICF/MR providers
shall address incidents as required by the federal
regulations in 42 CFR Part 483 Subpart |.

(c) In addition to the requirements set forth in
Paragraph (a) of this Rule, Category A and B
providers, excluding ICF/MR providers, shall
develop and implement written policies governing
their response to a level III incident that occurs
while the provider is delivering a billable service
or while the client is on the provider's premises.
The policies shall require the provider to respond

by:

(1) immediately securing the client record
by:

(A) obtaining the client record;

(B) making a photocopy;

(C) certifying the copy's completeness; and
(D) transferring the copy to an internal
review team;

(2) convening a meeting of an internal

review team within 24 hours of the incident. The
internal review team shall consist of individuals
who were not involved in the incident and who
were not responsible for the client's direct care or
with direct professional oversight of the client's
services at the time of the incident. The internal
review team shall complete all of the activities as
follows:

(A) review the copy of the client record to
determine the facts and causes of the incident
and make recommendations for minimizing the

Division of Health Service Regulation
STATE FORM 6899 GVM411 If continuation sheet 12 of 19

PRINTED: 08/01/2019
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:
MHL001-259 B. WING _____ 07/18/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1227 WESTMORLAND DRIVE

A MOTHER'S LOVE 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 366 | Continued From page 12 V 366
occurrence of future incidents;
(B) gather other information needed;
(C) issue written preliminary findings of fact

within five working days of the incident. The
preliminary findings of fact shall be sent to the
LME in whose catchment area the provider is
located and to the LME where the client resides,
if different; and

(D) issue a final written report signed by the
owner within three months of the incident. The
final report shall be sent to the LME in whose
catchment area the provider is located and to the
LME where the client resides, if different. The
final written report shall address the issues
identified by the internal review team, shall
include all public documents pertinent to the
incident, and shall make recommendations for
minimizing the occurrence of future incidents. If
all documents needed for the report are not
available within three months of the incident, the
LME may give the provider an extension of up to
three months to submit the final report; and

(3) immediately notifying the following:

(A) the LME responsible for the catchment
area where the services are provided pursuant to
Rule .0604;

(B) the LME where the client resides, if
different;

(C) the provider agency with responsibility

for maintaining and updating the client's
treatment plan, if different from the reporting
provider;

(D) the Department;

(E) the client's legal guardian, as
applicable; and

(F) any other authorities required by law.

Division of Health Service Regulation
STATE FORM 6899 GVM411 If continuation sheet 13 of 19

PRINTED: 08/01/2019

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
MHL001-259 B. WING 07/18/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1227 WESTMORLAND DRIVE
A MOTHER'S LOVE
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 366 | Continued From page 13 V 366

This Rule is not met as evidenced by:

Based on record reviews, observation and
interviews, the facility failed to implement written
policies governing their response to incidents.
The findings are:

Review on 7/18/19 of Client #1's record revealed:
- Admission date of 6/12/19

- Age 12

- Diagnoses of Other Specified Disruptive
Impulsive Control and Conduct Disorder;
Unspecified Trauma and Stress-Related
Disorder; Attention Deficit Hyperactivity
Disorder,by History.

- Assessment documenting the following:

1. Has made "passive" suicidal statements - last
on 4/9/19 resulting in engagement with Mobile
Crisis Unit.

2. Exhibits "clinically significant" symptoms of
depression.

3. Received a charged for "misdemeanor larceny"
and is under juvenile supervision/monitoring for
stealing "items" from snack box at school.

Observation on 7/18/19 of Client #1's bedroom
revealed:

- Window was easily opened by pushing bottom
window up leaving an opening of approximately
24 to 30 inches.

- Bedroom window ledge was a drop-down of
approximately 5 to 6 feet from the ground.

- Window did not have a window screen or an
alarm to alert it had been opened.

During interview on 7/18/19, the Licensee
confirmed:

Division of Health Service Regulation

STATE FORM 6899 GVM411 If continuation sheet 14 of 19

PRINTED: 08/01/2019

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
MHL001-259 B. WING 07/18/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1227 WESTMORLAND DRIVE
A MOTHER'S LOVE
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 366 | Continued From page 14 V 366

- Client #1 has attempted to elope from the facility
by jumping out of her bedroom window on at least
two occasions since her admission to the facility.
- The facility's incident response policy requires
the facility to:

a. develop and implement measures to prevent
similar incidents and

b. maintain documentation regarding the incident
(incident report)

- The incidents and measures to prevent Client
#1 from repeatedly engaging in elopement
attempts had not been documented.

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

Division of Health Service Regulation
STATE FORM 6899 GVM411 If continuation sheet 15 of 19

PRINTED: 08/01/2019

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
MHL001-259 B. WING 07/18/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1227 WESTMORLAND DRIVE
A MOTHER'S LOVE
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 15 V 536

methods to determine passing or failing the
course.

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

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

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

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

(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:

Division of Health Service Regulation
STATE FORM 6899 GVM411 If continuation sheet 16 of 19

PRINTED: 08/01/2019
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:
MHL001-259 B. WING _____ 07/18/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1227 WESTMORLAND DRIVE

A MOTHER'S LOVE 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
(A) who participated in the training and the
outcomes (pass/fail);
(B) when and where they attended; and
(C) instructor's name;
(2) The Division of MH/DD/SAS may

review/request this documentation at any time.

(i) Instructor Qualifications and Training
Requirements:

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

(2) Trainers shall demonstrate competence
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

Division of Health Service Regulation
STATE FORM 6899 GVM411 If continuation sheet 17 of 19

PRINTED: 08/01/2019
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:
MHL001-259 B. WING _____ 07/18/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1227 WESTMORLAND DRIVE

A MOTHER'S LOVE 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

aimed at preventing, reducing and eliminating the
need for restrictive interventions at least once
annually.

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

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

(1) Documentation shall include:

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

(B) when and where attended; and

(C) instructor's name.

(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 reviews, observation and
interviews, the facility management failed to
assure 1 of 3 (#1) audited staff was trained in
alternatives to restrictive intervention prior to
providing services to clients in the facility. The
findings are:

Division of Health Service Regulation
STATE FORM 6899 GVM411 If continuation sheet 18 of 19

PRINTED: 08/01/2019

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
MHL001-259 B. WING ____ 07/18/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1227 WESTMORLAND DRIVE

A MOTHER'S LOVE 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

Observation on 7/18/19 at approximately 5:00 PM
of staff working in the facility revealed:

- One staff (Staff #1) person engaged in assisting
a client in preparing dinner for residents in the
facility.

During interview on 7/18/19, Staff #1 reported:

- She began working in the facility on 6/10/19 as a
paraprofessional.

- She may work on 2nd or 3rd shift and is the only
staff in the facility when she is working.

During interview on 7/18/19, the Licensee
confirmed:

- Staff #1 began working in the facility in the past
month.

- There was no documentation Staff #1 was
trained in alternatives to restrictive intervention.

- Staff #1 may work alone in the facility when she
is working.

Division of Health Service Regulation
STATE FORM 6899 GVM411 If continuation sheet 19 of 19

inspection_type: MHLCS Annual


state: NC

facility_name: Luca's Hope III

summary: Statement of Deficiency - MHLCS Follow-up

raw_content:
Division of Health Service Regulation

PRINTED: 02/26/2026

FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
R
MHL002-028 02/10/2026
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
\ 243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(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

A follow up survey was attempted on February
10, 2026. According to the Chief Executive
Officer/Director/Licensee (CEO/D/L) there are no
clients being served at the facility. The last time
clients were served at the facility was 10/25/25.

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

Review on 2/10/26 of Former Client (FC) #1's
record revealed:

-Date of Admission: 10/28/24.

-Diagnoses: Unspecified Trauma and Stressor
Related Disorder; Oppositiional Defiant Disorder;
Attention Defict Hyperactivity Disorder.

-Date of Discharge: 10/25/25.

Interview on 2/10/26 with the CEO/D/L revealed:
-FC #1 was discharged from the facility on
10/25/25 and transferred to a Sister Facility.
-"We haven't been getting funded and we don't
currently have any clients" at Luca's Hope Ill.

-"| have started interviewing...Hopefully we will
have clients there (at Luca's Hope III) in March
(2026)."

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

STATE FORM

6899

TITLE

(X6) DATE

If continuation sheet 1 of 1

inspection_type: MHLCS Follow-up

document_type: Statement of Deficiency