state: NC

facility_name: Adrienne's House

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

raw_content:
PRINTED: 11/13/2024
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:
R
MHL013-212 B. WING _____ 10/23/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

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

DEFICIENCY)
V 000} INITIAL COMMENTS V 000

An annual, complaint and follow up survey was
completed on 10/23/24. The complaint was
substantiated (intake #NC00222477).
Deficiencies were cited.

This 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 4 and currently has a
census of 4. The survey sample consisted of
audits of 3 current clients.

V 132) G.S. 131E-256(G) HCPR-Notification, V 132
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 OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

STATE FORM 6899 YUBE11 If continuation sheet 1 of 23

PRINTED: 11/13/2024
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:
R
MHL013-212 B. WING _____ 10/23/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

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

DEFICIENCY)
V 132] Continued From page 1 V 132

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
(0 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
acility failed to report all allegations of abuse to
he Health Care Personnel Registry (HCPR)
affecting 1 of 3 staff and failed to protect 1 of 4
clients during an investigation . The findings are:

Review on 10/4/24 of Staff #1's record revealed:
-Hire date of 6/24/24.
-Job tile is Direct Care Staff.

Review on 10/3/24 of Client #1's record revealed:
-Admission date of 3/6/24.

-Diagnoses of Intermittent Explosive Disorder,
Generalized Anxiety Disorder, Other Depressive
Disorder and Post Traumatic Stress Disorder.

Review on 10/1/24 of the facility's internal incident
reports from September 1, 2024 to September
30, 2024 revealed:

-On 9/22/24 Client #1 tried to elope and was

laken to the hospital for evaluation.

-Client #1 reported to hospital staff that Staff #1,
“put their hands on her."

-Client #1 told hospital staff that Staff #1 pushed
her and denied her water.

Review on 10/9/24 of video footage with audio
dated 9/22/24 of the facility revealed:

Division of Health Service Regulation

STATE FORM 6899 YUBE11 If continuation sheet 2 of 23

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES

(X1) PROVIDER/SUPPLIER/CLIA

(X2) MULTIPLE CONSTRUCTION

PRINTED: 11/13/2024
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL013-212 B. WING 10/23/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
120 TODD DRIVE NW
ADRIENNE'S HOUSE
CONCORD, NC 28025
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 132] Continued From page 2 V 132

-Client #1 was standing in the doorway to her
bedroom yelling at Staff #1 because Staff #1 was
talking to her about being on "restriction" and
could not leave her bedroom.

-Client #1 walked out of her bedroom and sat on
he couch in the living room, and Staff #1 tried to
redirect her by asking her to go back to her
bedroom.

-Staff #1 stepped outside on the front porch of the
acility with a phone to her ear.

-Client #1 came out the door behind Staff #1 and
was trying to leave the facility.

-Staff #1 grabbed Client #1's right arm near the
elbow and pulled on her shirt to stop her from
leaving.

-Staff #4 came outside and told Staff #1 to "just
let her go."

nterview on 10/17/24 with Client #1 revealed:
-On 9/22/24 she was on restriction for cursing
and could not leave her bedroom.
-She stood at the doorway to her bedroom to talk
'o other clients.
-Staff #1 came and pushed her back into her
bedroom.
-She tried to come out for water and Staff #1 said
"no."

Interview on 10/17/24 with Client #2 revealed:

-On 9/22/24, "They (Staff #1 and Client #1) were
arguing but | did not see [Staff #1] put her hands
on [Client #1]."]

Interview on 10/17/24 with Client #3 revealed:
-She did not witness Staff #1 push or hit Client #1
on 9/22/24.

Interview on 10/18/24 with Staff #4 revealed:
-Client #1 was upset because she had been
placed on restriction for 9/22/24 and could not

Division of Health Service Regulation
STATE FORM 6899

YUBE11

If continuation sheet 3 of 23

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-212 B. WING

NAME OF PROVIDER OR SUPPLIER
120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 11/13/2024
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
10/23/2024

leave her bedroom.

-Client #1 began to argue with Staff #1 and
threatened to leave the facility.

-Staff #1 went on the front porch to call the
Executive Director (ED)/ Qualified Professional
(QP).

-"| heard [Staff #1] saying, "come back", so | went
outside to see what was going on."

-"[Staff #1] was holding [Client #1's] arm trying to
keep her from leaving. | told her [Staff #1] to just
let her go."

-Did not witness Staff #1 push or hit Client #1.

Interview on 10/18/24 with Staff #1 revealed:
-On 9/22/24 Client #1 was on restriction for her
behavior.

-Client #1 was standing at her bedroom door
talking to other clients and she (Staff #1) asked
her to go back into her bedroom.

-"She (Client #1) got upset and start yelling, and
threatening to leave."

-"| stepped outside (of the facility) to call the
[ED/QP] and she (Client #1) came out the door
behind me trying to leave."

-She "grabbed" Client #1's shirt to keep her from
leaving.

-Denied pushing Client #1.

Interview on 10/17/24 with the Executive Director/
QP revealed:

-Was not aware Client #1 accused Staff #1 of
pushing her.

-She reviewed video footage and did not see Staff
#1 push Client #1.

-Would had suspended Staff #1 if she had known
about the allegation.

-Client #1 continued to work after she learned of
the allegation.

-"There was no need for an investigation, | had
watched the video footage. | knew it was not
Division of Health Service Regulation

STATE FORM

6899 YUBE11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 132] Continued From page 3 V 132

If continuation sheet 4 of 23

PRINTED: 11/13/2024

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL013-212 B. WING 10/23/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
120 TODD DRIVE NW
ADRIENNE'S HOUSE
CONCORD, NC 28025
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 132] Continued From page 4 V 132
true."
V 364] G.S. 122C- 62 Additional Rights in 24 Hour V 364
Facilities

§ 122C-62. Additional Rights in 24-Hour
Facilities.

(a) In addition to the rights enumerated in G.S.
122C-51 through G.S. 122C-61, each adult client
who is receiving treatment or habilitation in a
24-hour facility keeps the right to:

(1) Send and receive sealed mail and have
access to writing material, postage, and staff
assistance when necessary;

(2) Contact and consult with, at his own expense
and at no cost to the facility, legal counsel, private
physicians, and private mental health,
developmental disabilities, or substance abuse
professionals of his choice; and

(3) Contact and consult with a client advocate if
there is a client advocate.

The rights specified in this subsection may not be
restricted by the facility and each adult client may
exercise these rights at all reasonable times.

(b) Except as provided in subsections (e) and (h)
of this section, each adult client who is receiving
treatment or habilitation in a 24-hour facility at all
times keeps the right to:

(1) Make and receive confidential telephone
calls. All long distance calls shall be paid for by
the client at the time of making the call or made
collect to the receiving party;

(2) Receive visitors between the hours of 8:00
a.m. and 9:00 p.m. for a period of at least six
hours daily, two hours of which shall be after 6:00
p.m.; however visiting shall not take precedence
over therapies;

(3) Communicate and meet under appropriate
supervision with individuals of his own choice

Division of Health Service Regulation
STATE FORM 6899 YUBE11 If continuation sheet 5 of 23

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-212 B. WING

NAME OF PROVIDER OR SUPPLIER
120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 11/13/2024
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
10/23/2024

upon the consent of the individuals;

(4) Make visits outside the custody of the facility
unless:

a. Commitment proceedings were initiated as
the result of the client's being charged with a
violent crime, including a crime involving an
assault with a deadly weapon, and the
respondent was found not guilty by reason of
insanity or incapable of proceeding;

b. The client was voluntarily admitted or
committed to the facility while under order of
commitment to a correctional facility of the
Division of Adult Correction of the Department of
Public Safety; or

c. The client is being held to determine capacity
to proceed pursuant to G.S. 15A-1002;

A court order may expressly authorize visits
otherwise prohibited by the existence of the
conditions prescribed by this subdivision;

(5) Be out of doors daily and have access to
facilities and equipment for physical exercise
several times a week;

(6) Except as prohibited by law, keep and use
personal clothing and possessions, unless the
client is being held to determine capacity to
proceed pursuant to G.S. 15A-1002;

(7) Participate in religious worship;

(8) Keep and spend a reasonable sum of his
own money;

(9) Retain a driver's license, unless otherwise
prohibited by Chapter 20 of the General Statutes;
and

(10)Have access to individual storage space for
his private use.

(c) In addition to the rights enumerated in G.S.
122C-51 through G.S. 122C-57 and G.S.
122C-59 through G.S. 122C-61, each minor client
who is receiving treatment or habilitation in a
24-hour facility has the right to have access to

Division of Health Service Regulation

STATE FORM 6899

YUBE11

(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 364] Continued From page 5 V 364

If continuation sheet 6 of 23

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

MHL013-212

(X2) MULTIPLE CONSTRUCTION

A. BUILDING:

B. WING

120 TODD DRIVE NW
CONCORD, NC 28025

ADRIENNE'S HOUSE

PRINTED: 11/13/2024
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
10/23/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

proper adult supervision and guidance. In
recognition of the minor's status as a developing
individual, the minor shall be provided
opportunities to enable him to mature physically,
emotionally, intellectually, socially, and
vocationally. In view of the physical, emotional,
and intellectual immaturity of the minor, the
24-hour facility shall provide appropriate
structure, supervision and control consistent with
the rights given to the minor pursuant to this Part.
The facility shall also, where practical, make
reasonable efforts to ensure that each minor
client receives treatment apart and separate from
adult clients unless the treatment needs of the
minor client dictate otherwise.

Each minor client who is receiving treatment or
habilitation from a 24-hour facility has the right to:
(1) Communicate and consult with his parents or
guardian or the agency or individual having legal
custody of him;

(2) Contact and consult with, at his own expense
or that of his legally responsible person and at no
cost to the facility, legal counsel, private
physicians, private mental health, developmental
disabilities, or substance abuse professionals, of
his or his legally responsible person's choice; and
(3) Contact and consult with a client advocate, if
there is a client advocate.

The rights specified in this subsection may not be
restricted by the facility and each minor client
may exercise these rights at all reasonable times.
(d) Except as provided in subsections (e) and (h)
of this section, each minor client who is receiving
treatment or habilitation in a 24-hour facility has
the right to:

(1) Make and receive telephone calls. All long
distance calls shall be paid for by the client at the
time of making the call or made collect to the
receiving party;

Division of Health Service Regulation
STATE FORM

6899 YUBE11

(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 364] Continued From page 6 V 364

If continuation sheet 7 of 23

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-212 B. WING

NAME OF PROVIDER OR SUPPLIER
120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 11/13/2024
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
10/23/2024

(2) Send and receive mail and have access to
writing materials, postage, and staff assistance
when necessary;

(3) Under appropriate supervision, receive
visitors between the hours of 8:00 a.m. and 9:00
p.m. for a period of at least six hours daily, two
hours of which shall be after 6:00 p.m.; however
visiting shall not take precedence over school or
therapies;

(4) Receive special education and vocational
training in accordance with federal and State law;
(5) Be out of doors daily and participate in play,
recreation, and physical exercise on a regular
basis in accordance with his needs;

(6) Except as prohibited by law, keep and use
personal clothing and possessions under
appropriate supervision, unless the client is being
held to determine capacity to proceed pursuant to
G.S. 15A-1002;

(7) Participate in religious worship;

(8) Have access to individual storage space for
the safekeeping of personal belongings;

(9) Have access to and spend a reasonable sum
of his own money; and

(10)Retain a driver's license, unless otherwise
prohibited by Chapter 20 of the General Statutes.
(e) No right enumerated in subsections (b) or (d)
of this section may be limited or restricted except
by the qualified professional responsible for the
formulation of the client's treatment or habilitation
plan. A written statement shall be placed in the
client's record that indicates the detailed reason
for the restriction. The restriction shall be
reasonable and related to the client's treatment or
habilitation needs. A restriction is effective for a
period not to exceed 30 days. An evaluation of
each restriction shall be conducted by the
qualified professional at least every seven days,
at which time the restriction may be removed.

Division of Health Service Regulation

STATE FORM 6899

YUBE11

(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 364] Continued From page 7 V 364

If continuation sheet 8 of 23

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-212 B. WING

NAME OF PROVIDER OR SUPPLIER

120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 11/13/2024
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
10/23/2024

Each evaluation of a restriction shall be
documented in the client's record. Restrictions on
rights may be renewed only by a written
statement entered by the qualified professional in
the client's record that states the reason for the
renewal of the restriction. In the case of an adult
client who has not been adjudicated incompetent,
in each instance of an initial restriction or renewal
of a restriction of rights, an individual designated
by the client shall, upon the consent of the client,
be notified of the restriction and of the reason for
it. In the case of a minor client or an incompetent
adult client, the legally responsible person shall
be notified of each instance of an initial restriction
or renewal of a restriction of rights and of the
reason for it. Notification of the designated
individual or legally responsible person shall be
documented in writing in the client's record.

This Rule is not met as evidenced by:

Based on record review and interview, clients did
not have the opportunity to make telephone calls
at all reasonable times affecting 4 of 4 clients.
The findings are:

Review on 10/8/24 of the facility's client rules
revealed:

-Clients could "only make calls on their assigned
days and times."

-Clients were "assigned two alternating days a
week to make calls."

Interview on 10/17/24 with Client #1 revealed:
-"They (staff) don't let us use the phone."

-"They (staff) only let us use the phone but once a
Division of Health Service Regulation

STATE FORM

6899 YUBE11

(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 364] Continued From page 8 V 364

If continuation sheet 9 of 23

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-212 B. WING

NAME OF PROVIDER OR SUPPLIER

120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 11/13/2024
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
10/23/2024

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 364] Continued From page 9 V 364

week."

-"If we (clients) miss our phone time we have to
wait until our next assigned day to use the
phone."

Interview on 10/17/23 with Client #2 revealed:
get to use the phone.”

don't have anyone to call."

lerview on 10/17/24 with Client #3 revealed:
was having a bad day and wanted to call my
social worker and they (staff) said no."

-She is not allowed to use the phone unless it is
her assigned day.

Interview on 10/18/24 with Staff #1 revealed:
-"The rule is that clients cannot use the phone
unless it is their assigned day."

-"They (clients) have to wait until it is their day
unless it is an emergency."

nterview on 10/18/24 with Staff #4 revealed:
-Clients get to use the phone "two days a week."
"If they (clients) want to use it (phone) and it's not
heir day, we tell them to wait until it's their day."
-"It has to be a real emergency for them (clients)
io use it on days when it's not their turn."

nterview on 10/17/24 with the Executive
Director/Qualified Professional revealed:

-Was not aware clients had the right to call their
guardian when they want to.

-"| did not know it's restricting their rights to limit
heir phone use."

-Would let clients use the telephone daily during
designated times.

V 367| 27G .0604 Incident Reporting Requirements V 367

Division of Health Service Regulation

STATE FORM 6899

YUBE11

If continuation sheet 10 of 23

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-212 B. WING

NAME OF PROVIDER OR SUPPLIER
120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 11/13/2024
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
10/23/2024

10A NCAC 27G .0604 INCIDENT
REPORTING REQUIREMENTS FOR
CATEGORY AAND B PROVIDERS

(a) Category A and B providers shall report all
level Il incidents, except deaths, that occur during
the provision of billable services or while the
consumer is on the providers premises or level III
incidents and level II deaths involving the clients
to whom the provider rendered any service within
90 days prior to the incident to the LME
responsible for the catchment area where
services are provided within 72 hours of
becoming aware of the incident. The report shall
be submitted on a form provided by the
Secretary. The report may be submitted via mail,
in person, facsimile or encrypted electronic
means. The report shall include the following
information:

(1) reporting provider contact and
identification information;

(2) client identification information;

(3) type of incident;

(4) description of incident;

(5) status of the effort to determine the

cause of the incident; and

(6) other individuals or authorities notified
or responding.

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

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

(c) Category A and B providers shall submit,

Division of Health Service Regulation

STATE FORM 6899

YUBE11

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

DEFICIENCY)
V 367 | Continued From page 10 V 367

If continuation sheet 11 of 23

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-212 B. WING

NAME OF PROVIDER OR SUPPLIER
120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 11/13/2024
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
10/23/2024

upon request by the LME, other information
obtained regarding the incident, including:

(1) hospital records including confidential
information;

(2) reports by other authorities; and

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

(e) Category A and B providers shall send a
report quarterly to the LME responsible for the
catchment area where services are provided.
The report shall be submitted on a form provided
by the Secretary via electronic means and shall
include summary information as follows:

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

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

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

(5) the total number of level II and level III
incidents that occurred; and

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

Division of Health Service Regulation

STATE FORM 6899

YUBE11

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

DEFICIENCY)
V 367 | Continued From page 11 V 367

If continuation sheet 12 of 23

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-212 B. WING

NAME OF PROVIDER OR SUPPLIER

120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 11/13/2024
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
10/23/2024

through (4) of this Paragraph.

This Rule is not met as evidenced by:

Based on record review and interviews, the
facility failed to report Il incidents to the Local
Management Entity/Managed Care Organization
(LME/MCO) responsible for the catchment area
where services were provided within 72 hours of
becoming aware of the incident. The findings are:

Review on 8/21/24 of the facility's internal incident
reports revealed:

-On 9/22/24 Client #1 tried to elope and was
taken to the hospital for evaluation.

-Client #1 reported to hospital staff that Staff #1,
“put their hands on her."

-Client #1 told hospital staff that Staff #1 pushed
her and denied her water.

Review on 10/21/24 of the North Carolina
Incident Response Improvement System (IRIS)
from 9/1/24- 10/21/24 revealed:

-No incident reports submitted by the facility.

Interview on 10/17/24 with Client #1 revealed:
-On 9/22/24 she was on restriction for cursing
and could not leave her bedroom.

-She stood at the door to her bedroom to talk to
other clients.

- Staff #1 came and pushed her back into her
bedroom.

-She tried to come out for water and Staff #1 said
"no."

Division of Health Service Regulation

STATE FORM

6899 YUBE11

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

DEFICIENCY)
V 367 | Continued From page 12 V 367

If continuation sheet 13 of 23

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-212 B. WING

NAME OF PROVIDER OR SUPPLIER
120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 11/13/2024
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
10/23/2024

-Reported allegation to hospital staff.

nterview on 10/18/24 with Staff #1 revealed:

-On 9/22/24 Client #1 was on restriction for her
behavior.

-Client #1 was standing at her bedroom door
alking to other clients and she (Staff #1) asked
her to go back into her bedroom.

-"She (Client #1) got upset and start yelling, and
hreatening to leave."

-"| stepped outside (of the facility) to call the
(Executive) Director (Qualified Professional (QP))
and she (Client #1) came out the door behind me
rying to leave."

-She grabbed Client #1's shirt in an attempted to
keep her from leaving.

-Reported the incident to the ED/QP.

"She (ED/QP) does all of the incident reporting."

Interview on 10/18/24 with Staff #4 revealed:
-Client #1 was upset because she had been
placed on restriction and could not leave her
bedroom.
-Client #1 began to argue with Staff #1 and
threatened to leave the facility.

-Staff #1 went on the front porch to call the
Executive Director (ED)/ Qualified Professional
(QP).
-"| heard [Staff #1] saying, "come back", so | went
outside to see what was going on."

-"[Staff #1] was holding [Client #1's] (right) arm
trying to keep her from leaving. | told her [Staff

#1] to just let her go."

-Did not witness Staff #1 push or hit Client #1.
-The incident was reported to the ED/QP.

Interview on 10/17/24 with the ED/QP revealed:
-Was not aware Client #1 accused Staff #1 of
pushing her and denying her water.

-She reviewed video footage and did not see Staff
Division of Health Service Regulation

STATE FORM

6899 YUBE11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 367 | Continued From page 13 V 367

If continuation sheet 14 of 23

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

MHL013-212

NAME OF PROVIDER OR SUPPLIER

ADRIENNE'S HOUSE

STREET ADDRESS, CITY, STATE, ZIP CODE

120 TODD DRIVE NW
CONCORD, NC 28025

PRINTED: 11/13/2024

FORM APPROVED
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
A. BUILDING: COMPLETED
R
B.WING 10/23/2024

Alternative

10A NCAC 27E .0101
ALTERNATIVE

(a) Each facility shall provide services/supports
that promote a safe and respectful environment.
These include:

(1) using the least restrictive and most
appropriate settings and methods;

(2) promoting coping and engagement
skills that are alternatives to injurious behavior to
self or others;

(3) providing choices of activities
meaningful to the clients served/supported; and
(4) sharing of control over decisions with
the client/legally responsible person and staff.
(b) The use of a restrictive intervention
procedure designed to reduce a behavior shall
always be accompanied by actions designed to
insure dignity and respect during and after the
intervention. These include:

(1) using the intervention as a last resort;
and

(2) employing the intervention by people
trained in its use.

LEAST RESTRICTIVE

This Rule is not met as evidenced by:

Division of Health Service Regulation
STATE FORM

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 367 | Continued From page 14 V 367
#1 push Client.
-Did not know an IRIS report should've been
submitted.
This deficiency constitutes a re-cited deficiency
and must be corrected within 30 days.
V 513) 27E .0101 Client Rights - Least Restrictive V 513

6899

YUBE11 If continuation sheet 15 of 23

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-212 B. WING

NAME OF PROVIDER OR SUPPLIER

120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 11/13/2024
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
10/23/2024

Based on record review, and interviews, the
facility failed to provide services using the least
restrictive and most appropriate methods. The
findings are:

Review on 10/8/24 of the facility's client rules
revealed:

-Clients "cannot have water to drink after 8pm of
weekdays and 10pm on the weekends."

Interview on 10/17/24 with Client #1 revealed:
-"They (staff) don't let us have water after a
certain time."

-"| asked for a bottle of water and [Staff #1] said
no."

-"They restrict how much we eat and drink."
-"They (staff) gives us our meds (medication)
around 7pm and then they cut off water."

interview on 10/17/24 with Client #2 revealed:
-"We (clients) can't have water after 8pm."

Interview on 10/17/24 with Client #3 revealed:
"We (clients) aren't allowed to have anything to
drink after 8pm or 10pm."

Interview on 10/18/24 with Staff #1 revealed:
-"They (Clients) cannot have any water after 8pm
on the weekdays and 10pm on the weekends."
-"Water is cut off at a certain time to prevent bed
wetting."

-"It has to be an emergency to get water after
10pm."

Interview on 10/18/24 with Staff #4 revealed:

-"| usually stop giving them (clients) water at
10pm."

-"If it is an emergency I'll give them a little bit
(water)."

-Did not know why that was a rule at the facility.
Division of Health Service Regulation

STATE FORM

6899 YUBE11

(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 513] Continued From page 15 V 513

If continuation sheet 16 of 23

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

MHL013-212

ADRIENNE'S HOUSE

STREET ADDRESS, CITY, STATE, ZIP CODE
120 TODD DRIVE NW
CONCORD, NC 28025

PRINTED: 11/13/2024

FORM APPROVED
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
A. BUILDING: COMPLETED
R
B.WING 10/23/2024

(X4) ID
PREFIX
TAG

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

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

ID
PREFIX
TAG

(x5)
COMPLETE
DATE

V 513

V 537

Continued From page 16

Interview on 10/17/24 with the Executive
Director/Qualified Professional revealed:

-"We (staff) came up with a rule to limit water
intake due to bed wetting in the past."

-"The rule is no water after 8pm on the weekdays
and 10pm on the weekends."
-She did not know she was violating the clients’
rights.

-Would end the water restrictions.

27E .0108 Client Rights - Training in Sec Rest &
ITO

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

(a) Seclusion, physical restraint and isolation
time-out may be employed only by staff who have
been trained and have demonstrated
competence in the proper use of and alternatives
to these procedures. Facilities shall ensure that
staff authorized to employ and terminate these
procedures are retrained and have demonstrated
competence at least annually.

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

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

(d) The training shall be competency-based,

Division of Health Service Regulation
STATE FORM

V 513

V 537

6899 YUBE11 If continuation sheet 17 of 23

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-212 B. WING

NAME OF PROVIDER OR SUPPLIER
120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 11/13/2024
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
10/23/2024

include measurable learning objectives,
measurable testing (written and by observation of
behavior) on those objectives and measurable
methods to determine passing or failing the
course.

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

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

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

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

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

(3) emphasis on safety and respect for the

rights and dignity of all persons involved (using
concepts of least restrictive interventions and
incremental steps in an intervention);

(4) strategies for the safe implementation
of restrictive interventions;

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

(6) prohibited procedures;

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

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

(1) Documentation shall include:

Division of Health Service Regulation

STATE FORM 6899

YUBE11

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

DEFICIENCY)
V 537 | Continued From page 17 V 537

If continuation sheet 18 of 23

PRINTED: 11/13/2024

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL013-212 B. WING 10/23/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

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

DEFICIENCY)
V 537 | Continued From page 18 V 537
(A) who participated in the training and the
outcomes (pass/fail);
(B) when and where they attended; and
(C) instructor's name.
(2) The Division of MH/DD/SAS may

review/request this documentation at any time.

(i) Instructor Qualification and Training
Requirements:

(1) Trainers shall demonstrate competence
by scoring 100% on testing in a training program
aimed at preventing, reducing and eliminating the
need for restrictive interventions.
(2) Trainers shall demonstrate competence
by scoring 100% on testing in a training program
teaching the use of seclusion, physical restraint
and isolation time-out.
(3) Trainers shall demonstrate competence
by scoring a passing grade on testing in an
instructor training program.
(4) The training shall be
competency-based, include measurable learning
objectives, measurable testing (written and by
observation of behavior) on those objectives and
measurable methods to determine passing or
failing the course.

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

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

(A) understanding the adult learner;

(B) methods for teaching content of the
course;

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

(7) Trainers shall be retrained at least

annually and demonstrate competence in the use

Division of Health Service Regulation
STATE FORM 6899 YUBE11 If continuation sheet 19 of 23

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-212 B. WING

NAME OF PROVIDER OR SUPPLIER
120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 11/13/2024
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
10/23/2024

of seclusion, physical restraint and isolation
time-out, as specified in Paragraph (a) of this

Rule.

(8) Trainers shall be currently trained in
CPR.

(9) Trainers shall have coached experience

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

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

(1) Documentation shall include:

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

(B) when and where they attended; and
(C) instructor's name.
(2) The Division of MH/DD/SAS may

review/request this documentation at any time.
(1) Qualifications of Coaches:

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

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

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

Division of Health Service Regulation

STATE FORM 6899

YUBE11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 537 | Continued From page 19 V 537

If continuation sheet 20 of 23

PRINTED: 11/13/2024

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL013-212 B. WING 10/23/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

120 TODD DRIVE NW
CONCORD, NC 28025

ADRIENNE'S HOUSE

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

DEFICIENCY)
V 537 | Continued From page 20 V 537

This Rule is not met as evidenced by:

Based on observation, record review and
interview, the facility failed to ensure 1 of 3
audited staff (#1) demonstrated competency in
the proper use of restrictive interventions. The
findings are:

Review on 10/4/24 of Staff #1's employee record
revealed:

-Hire date of 6/24/24.

-Nonviolent Crisis Intervention (NCI) training
completed on 6/24/24.

Review on 10/9/24 of video footage and audio of
he facility dated 9/22/24 revealed:

-Client #1 was yelling at Staff #1 because she
placed on "restriction" and could not leave her
bedroom.

-Client #1 walked out of her bedroom and Staff #1
ried to redirect her by asking her to go back to
her bedroom.

-Staff #1 stepped outside on the front porch of the
acility with a phone to her ear.

-Client #1 came out the door behind Staff #1 and
was trying to leave the facility.

-Staff #1 grabbed Client #1's right arm at the
elbow, and pulled on her shirt to stop her from
leaving (facility).

-Staff #4 came outside and told Staff #1 to "just
let her go."

nterview on 10/17/24 with Client #1 revealed:

-On 9/22/24 she was placed on restriction and

could not leave her bedroom.

-She stood at her bedroom door and talked with

other clients.

-Staff #1 approached her and pushed her back

into her bedroom.

-She got upset and tried to leave the facility, Staff

Division of Health Service Regulation

STATE FORM 6809 YUBE11

If continuation sheet 21 of 23

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL013-212 B. WING

NAME OF PROVIDER OR SUPPLIER
120 TODD DRIVE NW

ADRIENNE'S HOUSE CONCORD, NC 28025

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 11/13/2024
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
10/23/2024

#1 tried to push her back into the house.
-"She (Staff #1) grabbed me and pulled on my
shirt but | pushed her off me."

-She requested to go to the hospital "to calm
down" and Staff #4 took her to the hospital.
-She was not injured.

Interview on 10/18/24 with Staff #1 revealed:

-On 9/22/24 Client #1 became upset because she
was put on restriction and could not leave her
bedroom.
-"She (Client #1) started cursing, packing her
things and threatening to leave (facility)."

-"| stepped outside of the facility to call the
Director (Executive Director/Qualified
Professional) to let her know what was going on,
and that's when [Client #1] tried to walk pass me
to leave (facility)."

-"| tried to stop her (Client #1). | grabbed her arm
but she pulled away from me."

-Client #1 was taken to the hospital for a mental
health evaluation.

-Client #1 was not injured.

-"| didn't think about restraining her (Client #1), |
was just trying to stop her."

-"Grabbing arms and pulling on clothes is not
taught in NCI training."

Interview on 10/18/24 with Staff #4 revealed:
-On 9/22/24 Client #1 was upset because she
had been placed on restriction and could not
leave her bedroom.

-Client #1 began to argue with Staff #1 and
threatened to leave the facility.

-Staff #1 went on the front porch to call the
Executive Director (ED)/ Qualified Professional
(QP).

-"| heard [Staff #1] saying, "come back", so | went
outside to see what was going on."

-"[Staff #1] was holding [Client #1's] arm trying to
Division of Health Service Regulation

STATE FORM

6899 YUBE11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 537 | Continued From page 21 V 537

If continuation sheet 22 of 23

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

MHL013-212

(X2) MULTIPLE CONSTRUCTION

A.

B.

BUILDING:

WING

STREET ADDRESS, CITY, STATE, ZIP CODE

120 TODD DRIVE NW
CONCORD, NC 28025

ADRIENNE'S HOUSE

PRINTED: 11/13/2024
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
10/23/2024

keep her from leaving. | told her (Staff #1) to just
let her (Client #1) go."

-"| was able to talk her (Client #1) into coming
back (to the facility), but she asked to go to the
hospital."

-Took Client #1 to the hospital because she
requested to go.

-"Pulling and grabbing is not taught in NCI
training."

Interview on 10/17/24 with the Executive
Director/Qualified Professional revealed:

-Was not aware Staff #1 grabbed Client #1's arm
and pulled on her shirt to prevent her from
leaving.

-Would retrain Staff #1 in NCI.

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

Division of Health Service Regulation
STATE FORM

6899

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 537 | Continued From page 22 V 537

YUBE11

If continuation sheet 23 of 23

inspection_type: MHLCS Annual, Complaint, and Follow-up

document_type: Statement of Deficiency


summary: Statement of Deficiency - MHLCS Annual and Complaint

raw_content:
Division of Health Service Regulation

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

MHLO013-212

NAME OF PROVIDER OR SUPPLIER

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 08/01/2022

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

07/27/2022

120 TODD DRIVE NW
ADRIENNE'S HOUSE
CONCORD, NC 28025
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000} INITIAL COMMENTS V 000
An annual and complaint survey was completed
on 7-27-22. The complaint was unsubstantiated
(#NC00189598). Deficiencies were cited.
This 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 four and currently has
a census of three. The survey sample consisted
of three current clients.
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 review and interview the facility
failed to ensure that the HPCR (Health Care
Personnel Registry) was accessed before hire,
effecting two of two staff (Staff #1 and Staff #2).
The findings are:

Review on 7-26-22 of Staff #1's personnel record
revealed:

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

STATE FORM

6899

NCHK11

TITLE

(X6) DATE

If continuation sheet 1 of 19

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHLO013-212

A. BUILDING:

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/01/2022
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

07/27/2022

STREET ADDRESS, CITY, STATE, ZIP CODE

PREFIX
TAG

(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

PREFIX
TAG

120 TODD DRIVE NW
ADRIENNE'S HOUSE
CONCORD, NC 28025
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)

(EACH CORRECTIVE ACTION SHOULD BE.
CROSS-REFERENCED TO THE APPROPRIATE,
DEFICIENCY)

COMPLETE
DATE

Vv 131

V 295]

Continued From page 1

-Hire date 7-1-22.
-HPCR accessed 7-25-22.

Review on 7-26-22 of Staff #2's personnel record
revealed:

-Hire date of 9-14-21.

-HPCR accessed on 9-15-21.

Interview on 7-27-22 with the Qualified
Professional/Co-Owner revealed:
-She would sometimes forget to print out the
information when she did her HPCR checks.
-Going forward she would ensure that all
information was printed and in all of the personnel
records.

27G .1703 Residential Tx. Child/Adol - Req. for A
Pp

10A NCAC 27G .1703 REQUIREMENTS FOR
ASSOCIATE PROFESSIONALS.

(a) In addition to the qualified professional
specified in Rule .1702 of this Section, each
facility shall have at least one full-time direct care
staff who meets or exceeds the requirements of
an associate professional as set forth in 10A
NCAC 27G .0104(1).

(b) The governing body responsible for each
facility shall develop and implement written
policies that specify the responsibilities of its
associate professional(s). At a minimum these
policies shall address the following:

(1) management of the day to day
day-to-day operations of the facility;

(2) supervision of paraprofessionals
regarding responsibilities related to the
implementation of each child or adolescent's
treatment plan; and

(3) participation in service planning

Division of Health Service Regulation
STATE FORM

Vv 131

V 295

6809

NCHK11

If continuation sheet 2 of 19

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/01/2022
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED
MHL013-212 07/27/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
120 TODD DRIVE NW
ADRIENNE'S HOUSE
CONCORD, NC 28025
(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 295] Continued From page 2 V 295
meetings.
This Rule is not met as evidenced by:
Based on record review and interview the facility
failed to maintain one full time employee that met
the requirements for an Associate Professional.
The findings are:
Review on 7-14-22 of staffing list revealed:
-No employee identified as being the
Associate Professional.
Interview on 7-21-22 with the Qualified
Professional/Co-Owner revealed:
-They do not have an Associate Professional
at this time.
-All of the people that had applied wanted
more money than they could afford.
-They would continue to search for an
Associate Professional.
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 |, Il 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

Division of Health Service Regulation
STATE FORM

6809

NCHK11

If continuation sheet 3 of 19

PRINTED: 08/01/2022

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
MHL013-212 07/27/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
\ 120 TODD DRIVE NW
ADRIENNE'S HOUSE
CONCORD, NC 28025
(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 3 V 366

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
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 I.

(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 Ill 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

Division of Health Service Regulation
STATE FORM

6809

NCHK11

If continuation sheet 4 of 19

PRINTED: 08/01/2022

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
MHL013-212 07/27/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
\ 120 TODD DRIVE NW
ADRIENNE'S HOUSE
CONCORD, NC 28025
(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 4

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
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;

V 366

Division of Health Service Regulation
STATE FORM

6809

NCHK11

If continuation sheet 5 of 19

Division of Health Service Regulation

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

MHLO013-212

NAME OF PROVIDER OR SUPPLIER

A. BUILDING:

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/01/2022

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

07/27/2022

120 TODD DRIVE NW
ADRIENNE'S HOUSE
CONCORD, NC 28025
(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 5 V 366
(E) the client's legal guardian, as
applicable; and
(F) any other authorities required by law.

This Rule is not met as evidenced by:

Based on record review and interviews the facility
failed to implement corrective actions for
incidents. The findings are:

Review on 7-26-22 of Discharge Planning notice
revealed:

-Client was upset, destroyed blinds in her
room and cut her left forearm. She then went
AWOL (absent without leave), and staff followed
and deescalated. Client returned home and
proceeded to choke and gag herself. Emergency
Medical Squad was called and took her to the
hospital.

Interview on 7-14-22 with Client #1 revealed:

-She had gone to the hospital twice for self
harming. One was for 3 days and one was for two
weeks.

Interview on 7-21-22 and 7-27-22 with the
Executive Director revealed:

-Client #1 will self harm and choke and gag
herself.

-She had been to the hospital several times.

-She doesn't know why the 5-17-22 hospital
visit was not documented as an incident report.

-Going forward they would ensure that all
incidents were documented and reviewed for
corrective actions.

Division of Health Service Regulation
STATE FORM

6809

NCHK11

If continuation sheet 6 of 19

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHLO013-212

A. BUILDING:

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/01/2022
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

07/27/2022

STREET ADDRESS, CITY, STATE, ZIP CODE

120 TODD DRIVE NW
ADRIENNE'S HOUSE
CONCORD, NC 28025
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)

10A NCAC 27G .0604 INCIDENT
REPORTING REQUIREMENTS FOR
CATEGORY AAND B PROVIDERS

(a) Category A and B providers shall report all
level Il incidents, except deaths, that occur during
the provision of billable services or while the
consumer is on the providers premises or level III
incidents and level II deaths involving the clients
to whom the provider rendered any service within
90 days prior to the incident to the LME
responsible for the catchment area where
services are provided within 72 hours of
becoming aware of the incident. The report shall
be submitted on a form provided by the
Secretary. The report may be submitted via mail,
in person, facsimile or encrypted electronic
means. The report shall include the following
information:

(1) reporting provider contact and
identification information;

(2) client identification information;

(3) type of incident;

(4) description of incident;

(5) status of the effort to determine the

cause of the incident; and

(6) other individuals or authorities notified
or responding.

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

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

Division of Health Service Regulation
STATE FORM

6809

NCHK11

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 367] 27G .0604 Incident Reporting Requirements V 367

If continuation sheet 7 of 19

PRINTED: 08/01/2022

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
MHL013-212 07/27/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
\ 120 TODD DRIVE NW
ADRIENNE'S HOUSE
CONCORD, NC 28025
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

V 367] Continued From page 7

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

(1) hospital records including confidential
information;

(2) reports by other authorities; and

(3) the provider's response to the incident.

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

(e) Category A and B providers shall send a
report quarterly to the LME responsible for the
catchment area where services are provided.

The report shall be submitted on a form provided
by the Secretary via electronic means and shall
include summary information as follows:

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

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

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

(5) the total number of level II and level III
incidents that occurred; and

(6) a statement indicating that there have

been no reportable incidents whenever no
incidents have occurred during the quarter that
meet any of the criteria as set forth in Paragraphs

Division of Health Service Regulation
STATE FORM

V 367

6809

NCHK11

If continuation sheet 8 of 19

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHLO013-212

A. BUILDING:

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/01/2022
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

07/27/2022

STREET ADDRESS, CITY, STATE, ZIP CODE

(a) and (d) of this Rule and Subparagraphs (1)
through (4) of this Paragraph.

This Rule is not met as evidenced by:

Based on record review and interviews the facility
failed to report all level II incidents to the
managing entity within 72 hours. The findings are:

Review on 7-21-22 of Client #1's discharge plan
revealed:

-"Client upset with peer and that all in-person
visits were cancelled due to COVID outbreak.
Client destroyed room, used the blinds she tore
down from the windows to cut left forearm and
soon after client went AWOL (absent without
leave) and staff ran after client and were a few
blocks up from the group home QP (Qualified
Professional) deescalated client via staff phone
and when returned client proceeded to choke and
gag self in her room. EMS (Emergency Medical
Services) called and client transported to hospital
for safety and discharged 5-18-22."

Review on 7-21-22 of IRIS (Incident Response
Improvement System) revealed:

-No incident report submitted for 5-17-22
incident.

Interview on 7-27-22 with the Executive Director
revealed:

-She did not know why there had been no
level Il incident report submitted to IRIS.
-She had thought the QP/Co-Owner had

Division of Health Service Regulation

STATE FORM

6809

NCHK11

\ 120 TODD DRIVE NW
ADRIENNE'S HOUSE
CONCORD, NC 28025

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

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

DEFICIENCY)
V 367 | Continued From page 8 V 367

If continuation sheet 9 of 19

PRINTED: 08/01/2022

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
MHL013-212 07/27/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
\ 120 TODD DRIVE NW
ADRIENNE'S HOUSE
CONCORD, NC 28025
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

V 367] Continued From page 9

submitted it.

-Going forward they would make sure that all
level Il incidents were submitted in a timely
manner.

V 536] 27E .0107 Client Rights - Training on Alt to Rest.
Int.

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

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

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

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

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

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

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

Division of Health Service Regulation
STATE FORM

V 367

V 536

6809

NCHK11

If continuation sheet 10 of 19

PRINTED: 08/01/2022

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
MHL013-212 07/27/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
\ 120 TODD DRIVE NW
ADRIENNE'S HOUSE
CONCORD, NC 28025
(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 10

Paragraph (g) of this Rule.

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

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

(2) recognizing and interpreting human
behavior;

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

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

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

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

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

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

(9) positive behavioral supports (providing

means for people with disabilities to choose
activities which directly oppose or replace
behaviors which are unsafe).

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

(1) Documentation shall include:

(A) who participated in the training and the
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:

Division of Health Service Regulation
STATE FORM

V 536

6809

NCHK11

If continuation sheet 11 of 19

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHLO013-212

A. BUILDING:

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/01/2022
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

07/27/2022

STREET ADDRESS, CITY, STATE, ZIP CODE

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

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

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

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

(5) Acceptable instructor training programs
shall include but are not limited to presentation of:

(A) understanding the adult learner;

(B) methods for teaching content of the
course;

(C) methods for evaluating trainee

performance; and

(D) documentation procedures.

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

(7) Trainers shall teach a training program
aimed at preventing, reducing and eliminating the
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.

Division of Health Service Regulation
STATE FORM

6809

NCHK11

\ 120 TODD DRIVE NW
ADRIENNE'S HOUSE
CONCORD, NC 28025

(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 11 V 536

If continuation sheet 12 of 19

PRINTED: 08/01/2022

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
MHL013-212 07/27/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
\ 120 TODD DRIVE NW
ADRIENNE'S HOUSE
CONCORD, NC 28025
(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 12

(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.

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

This Rule is not met as evidenced by:

Based on record reviews and interviews the
facility failed to ensure that one of two audited
staff (Staff #1) received initial training to
alternatives to restrictive interventions before
providing services. The findings are:

Review on 7-26-22 of Staff #1's personnel record
revealed:

-Hire date of 7-1-22.

-No training in alternatives to restrictive
interventions documented.

Interview on 7-21-22 with Staff #1 revealed:
-She had been working at the facility since
Division of Health Service Regulation

STATE FORM

V 536

6809

NCHK11

If continuation sheet 13 of 19

PRINTED: 08/01/2022

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
MHL013-212 07/27/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
\ 120 TODD DRIVE NW
ADRIENNE'S HOUSE
CONCORD, NC 28025
(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 13

the beginning of July.

-She had not had any training in alternatives
to restrictive interventions yet, but knew she
would be getting it.

Interview on 27-22 with the Qualified
Professional/Co-Owner revealed:

-Their policy book said that employees had
90 days to complete training.

-It was harder to get people trained since
classes have been cut back.

-She would be getting Staff #1 trained as
soon as possible.

V 537] 27E .0108 Client Rights - Training in Sec Rest &
ITO

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

(a) Seclusion, physical restraint and isolation
time-out may be employed only by staff who have
been trained and have demonstrated
competence in the proper use of and alternatives
to these procedures. Facilities shall ensure that
staff authorized to employ and terminate these
procedures are retrained and have demonstrated
competence at least annually.

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

(c) Apre-requisite for taking this training is
demonstrating competence by completion of

Division of Health Service Regulation
STATE FORM

V 536

V 537

6809

NCHK11

If continuation sheet 14 of 19

PRINTED: 08/01/2022

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
MHL013-212 07/27/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
\ 120 TODD DRIVE NW
ADRIENNE'S HOUSE
CONCORD, NC 28025
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

V 537 Continued From page 14

training in preventing, reducing and eliminating
the need for restrictive interventions.

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

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

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

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

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

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

(3) emphasis on safety and respect for the
rights and dignity of all persons involved (using
concepts of least restrictive interventions and
incremental steps in an intervention);

(4) strategies for the safe implementation
of restrictive interventions;
(5) the use of emergency safety

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

(6) prohibited procedures;

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

(8) documentation methods/procedures.

(h) Service providers shall maintain

Division of Health Service Regulation
STATE FORM

V 537

6809

NCHK11

If continuation sheet 15 of 19

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHLO013-212

A. BUILDING:

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/01/2022
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

07/27/2022

STREET ADDRESS, CITY, STATE, ZIP CODE

documentation of initial and refresher training for
at least three years.

(1) Documentation shall include:

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

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

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

(i) Instructor Qualification and Training
Requirements:

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

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

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

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

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

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

(A) understanding the adult learner;

(B) methods for teaching content of the
course;

(C) evaluation of trainee performance; and

Division of Health Service Regulation
STATE FORM

6809

NCHK11

\ 120 TODD DRIVE NW
ADRIENNE'S HOUSE
CONCORD, NC 28025

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

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

DEFICIENCY)
V 537] Continued From page 15 V 537

If continuation sheet 16 of 19

Division of Health Service Regulation

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

MHLO013-212

NAME OF PROVIDER OR SUPPLIER

A. BUILDING:

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/01/2022

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

07/27/2022

\ 120 TODD DRIVE NW
ADRIENNE'S HOUSE
CONCORD, NC 28025

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

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

DEFICIENCY)
V 537] Continued From page 16 V 537

(D) documentation procedures.

(7) Trainers shall be retrained at least
annually and demonstrate competence in the use
of seclusion, physical restraint and isolation
time-out, as specified in Paragraph (a) of this

Rule.

(8) Trainers shall be currently trained in
CPR.

(9) Trainers shall have coached experience

in teaching the use of restrictive interventions at
least two times with a positive review by the
coach.

(10) Trainers shall teach a program on the
use of restrictive interventions at least once
annually.

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

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

(1) Documentation shall include:

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

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

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

review/request this documentation at any time.
(!) Qualifications of Coaches:

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

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

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

Division of Health Service Regulation
STATE FORM

6809

NCHK11

If continuation sheet 17 of 19

PRINTED: 08/01/2022

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
MHL013-212 07/27/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
\ 120 TODD DRIVE NW
ADRIENNE'S HOUSE
CONCORD, NC 28025
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

V 537] Continued From page 17

This Rule is not met as evidenced by:

Based on record reviews and interviews the
facility failed to ensure that one of two audited
staff (Staff #1) received initial training in training
in seclusion, physical restraint and isolation
time-out before providing services. The findings
are:

Review on 7-26-22 of Staff #1's personnel record
revealed:

-Hire date of 7-1-22.

-No training in restrictive interventions was
documented.

Interview on 7-21-22 with Staff #1 revealed:

-She had been working at the facility since
the beginning of July.

-She had never done a restraint.

-She had not had any training in restrictive
interventions yet, but knew she would be getting
it.

Interview on 27-22 with the Qualified
Professional/Co-Owner revealed:

-Their policy book said that employees had
90 days to complete training.

-It was harder to get people trained since
classes have been cut back.

-She would be getting Staff #1 trained in
physical restraints as soon as possible.

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

10A NCAC 27G .0304 FACILITY DESIGN AND
EQUIPMENT
(b) Safety: Each facility shall be designed,

Division of Health Service Regulation
STATE FORM

V 537

V 752

6809

NCHK11

If continuation sheet 18 of 19

Division of Health Service Regulation

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

NAME OF PROVIDER OR SUPPLIER

MHLO013-212

A. BUILDING:

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/01/2022

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

07/27/2022

constructed and equipped in a manner that
ensures the physical safety of clients, staff and
visitors.

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

This Rule is not met as evidenced by:

Based on interviews and observation the facility
failed to ensure hot water was between 100 and
116 degrees in areas where clients had access to
hot water. The findings are:

Observation on 7-21-22 at approximately 5:00
revealed:

-The hot water in the client's bathrooms and
the kitchen were all 80 degrees.

Interview on 7-21-22 with Client #2 revealed:
-The hot water was "warmish."
-It had only been that way a short while and
was usually hot.

Interview on 7-21-22 with the Executive Director
revealed:

-The hot water had just stopped working the
day before.

-They had called a maintenance man to get it
fixed.

Division of Health Service Regulation
STATE FORM

6809

NCHK11

\ 120 TODD DRIVE NW
ADRIENNE'S HOUSE
CONCORD, NC 28025

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

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

DEFICIENCY)
V 752] Continued From page 18 V 752

If continuation sheet 19 of 19

inspection_type: MHLCS Annual and Complaint