summary: Statement of Deficiency - MHLCS Complaint

raw_content:
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

MHL011-371

A. BUILDING:

B. WING

STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE

GREEN LEVEL Il ASHEVILLE, NC 28806

(X2) MULTIPLE CONSTRUCTION

PRINTED: 12/13/2018
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
11/20/2018

(X4) ID
PREFIX
TAG

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

ID
PREFIX
TAG

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

(x5)
COMPLETE
DATE

V 000

Vv 112

INITIAL COMMENTS

Acomplaint survey was completed on November
20, 2018. The complaint was substantiated
(Intake #NC00144542). Deficiencies were cited.

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

27G .0205 (C-D)
Assessment/Treatment/Habilitation Plan

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

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

(d) The plan shall include:

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

(2) strategies;

(3) staff responsible;

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

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

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

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

STATE FORM

V 000

Vv 112

6899

LBXJ11

TITLE (X6) DATE

If continuation sheet 1 of 38

PRINTED: 12/13/2018
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
Cc
MHL011-371 B. WING ____ 11/20/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE

GREEN LEVEL Il ASHEVILLE, NC 28806

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

DEFICIENCY)
V 112| Continued From page 1 Vv 112

This Rule is not met as evidenced by:

Based on record review and interviews the facility
failed to develop and implement goals and
strategies to address the behaviors effecting 2 of
3 current clients (#1, #2) and 1 of 1 former
clients. The findings are:

Client #1:

Record review on 11/7/18 and 11/8/18 for Client
#1 revealed:

-Admitted on 8/16/18 with diagnoses of
Post-Traumatic Stress Disorder and Oppositional
Defiant Disorder.
-Transition/Discharge Summary dated 8/1/18
completed by a prior service provider indicated "
...Client had had a history of suicidal thoughts and
depression and anxiety. Mother reported that she
lies a lot, used marijuana, and was often truant
...Client does not seem to understand
consequences to her actions. Client would go
with her ex-boyfriend for days without letting me
know where she was ...Client had some success
retrieving credits during a summer school
program, yet has left several times without
permission and has frequently smoked marijuana
during lunch breaks. Client continues to leave
the home without permission and does not
comply with mothers expectations in the home
..client needs to address her depression and
anxiety which is also leading to increased
marijuana use ...Client is a rising senior...has had
significant truancy issues over the past year ..."
-Comprehensive Clinical Assessment Addendum
dated 8/3/18 indicated " ...Educational/Social
Issues: ...Client attended mini mester and
completed all her credits in one week, yet would
Division of Health Service Regulation

STATE FORM 6899 LBXJ11 If continuation sheet 2 of 38

PRINTED: 12/13/2018
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
Cc
MHL011-371 B. WING ____ 11/20/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE

GREEN LEVEL Il ASHEVILLE, NC 28806

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

DEFICIENCY)
V 112| Continued From page 2 Vv 112

be late or come back high after lunch. Client is
unable to maintain responsibility for any
significant amount of time ...Client has been
known to smoke marijuana daily, although she
reports reducing her daily intake to 1-3 joints a
day..."
-Intake Summary dated 9/13/18 indicated " ...
[Client #1] has been truant from school, home,
and work ...[Client #1] feels she is unable to
make good decisions about her whereabouts,
which poses ongoing risk of drug use, sexual
exploitation, and physical violence. Current
behaviors include: truancy, leaving home without
permission, drug use, lying, lack of medication
compliance, DJJ (Department of Juvenile Justice)
...She is reconnecting with negative people who
were in her life prior to her stay in a 3-day
assessment center program ...Reason for
Placement: ...Run Risk: Has run from home 4X
in the past year. These were planned runs. She
has been gone for 2-10 days ...she goes with her
boyfriend ...Substance Abuse: Marijuana,
alcohol, Xanax ..."

Review on 11/8/18 of the Treatment Plan dated
7/30/18 for Client #1 revealed:

-Goals included "(1) [Client #1] will demonstrate
an improvement in post-traumatic stress
symptoms as evidenced by: decreased
avoidance behaviors, decreased irritability,
elimination of angry outbursts, and expression of
wider range of emotions, and (2) [Client #1] will
demonstrate an improvement in symptoms of
oppositional-defiant/disruptive behavior
characteristics as evidenced by: Increased
impulse control, improved outward control of own
triggers, increased compliance with rules and
structure, increased honesty and increased ability
to accept responsibility for behavior."
-Strategies/Interventions for both goals were "To
Division of Health Service Regulation

STATE FORM 6899 LBXJ11 If continuation sheet 3 of 38

PRINTED: 12/13/2018

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL011-371 B. WING ____ 11/20/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE
GREEN LEVEL Ill
ASHEVILLE, NC 28806
(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

V 112| Continued From page 3 Vv 112

teach coping, pro-social, decision making,
problem solving and anger management skills.
To provide behavioral and crisis management
interventions. To monitor throughout sleeping
hours. To facilitate therapeutic leave. To
evaluate and monitor the efficacy and side effects
of medications as well as inform consumer and
guardian. One staff will provide transportation off
campus as safety allows".

-No goals to address the substance abuse.

-No strategies or interventions to address the
substance abuse, elopements, or behaviors and
non-compliance around therapeutic leave.

-It was unclear if supervision was provided during
after school activities by the facility, a therapist or
the guardian.

Review on 11/7/18 of incident reports for Client #1
from 10/1/18-11/7/18 revealed:

-On 10/2/18" ...Staff transitioned [Client #1] to
school at 3pm for an after school program. Staff
received a phone call around 8:45pm from [Client
#1's] mother, asked to speak to her. Staff
gathered from mom that [Client #1] told mom a
friend would drive her back to [facility] due to
mom being late. [Client #1] did not arrive back to
campus ...staff was filing a missing person's
report ...student did not return to campus ..."

-On 11/5/18 " ...Staff noticed the smell of
marijuana coming from the bathroom. Staff
checked the bathroom after [Client #1] had
finished using it. Staff found a small bag with
tobacco and marijuana and lighter. Staff checked
in with [Client #1] to tell her what was going to
happen but she was already under the influence
of the drug and would not focus on staff ..."

-On 11/6/18 at 8:00PM " ...[Client #1] told staff
that she was going to run but didn't want to run ...
[Client #1] told staff that she had marijuana on
her person and wanted to get rid of it so she
Division of Health Service Regulation

STATE FORM 6899 LBXJ11 If continuation sheet 4 of 38

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED
c
MHL011-371 B. WING 11/20/2018

NAME OF PROVIDER OR SUPPLIER

GREEN LEVEL Ill

(X1) PROVIDER/SUPPLIER/CLIA

STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE

ASHEVILLE, NC 28806

(X2) MULTIPLE CONSTRUCTION

PRINTED: 12/13/2018
FORM APPROVED

(X3) DATE SURVEY

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 112| Continued From page 4 Vv 112

would not get in any troub

le ...[Client #1] decided

to run with the marijuana on her person ...[Client
#1] returned later in the evening with the police

Review on 11/15/18 of dai
Client #1 revealed:

-On 8/28/18" ...[Client #1]
leave ...Staff were alerted
away during her therapeu
-On 9/4/18 " ...Staff noted
off-campus pass with her
Staff received a phone-ca

ly service notes for

was on therapeutic
that [Client #1] ran

ic leave ..."

[Client #1] went on her
mother at 3:20pm.

I from [Client #1]

stating that her mother wished her to come back
the following day ...Staff observed [Client #1] to
remain off campus on an unapproved pass ..."
-On 9/5/18 " ...[Client #1] stated she may not pass
drug test because she had used marijuana in
previous visit and may fail again. Staff asked
[Client #1] if she had used substance on pass
and [Client #1] did not answer ..."

-On 9/13/18" ...off campus ...[Client #1] did not
come back from pass last night (9/12/18)"

-On 9/14/18" ...Staff noted [Client #1] stating she
had a pass today ...upon returning to the cottage
and hearing her pass was not approved [Client

#1] entered a negative space ...[Client #1] left
with her without [facility] approval ..."

-On 9/15/18" ...off campus ..."

-On 9/16/18" ...returned to cottage at 7:50pm ..."
-On 9/20/18 " ...[Client #1] refused to return to
[facility] when staff went to pick her up. [Client

#1] remained AWOL ...Staff noticed [Client #1]
return to the cottage at 10:13pm ...[Client #1]
refused to take her drug test ...[Client #1] took her
drug test..."

-On 9/27/18" ...[Client #1] returned to cottage
with her mother around 2:30 ...Staff confronted
[Client #1] about leaving again with her mother for
an unwarranted pass. Staff directed [Client #1] to
Division of Health Service Regulation

STATE FORM

6899 LBXJ11 If continuation sheet 5 of 38

PRINTED: 12/13/2018
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
Cc
MHL011-371 B. WING ____ 11/20/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE

GREEN LEVEL Il ASHEVILLE, NC 28806

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

DEFICIENCY)
V 112| Continued From page 5 Vv 112

take a drug test since she ran away from school
and was suspended. Staff provided opportunity
for [Client #1] to stay with cottage instead of
leaving. Staff observed [Client #1] leave with her
mother ...[Client #1] returned to the cottage
around 8:30 ..."

-On 10/2/18 "(second shift note) ...Staff
transitioned [Client #1] to [local high school] to
pick up peers. Staff walked [Client #1] down to
an after school club she had approval for. Staff
noted [Client #1] was going to staff off campus
until 9pm. Staff noted [Client #1] did not return ...
(third shift note) ...[Client #1] remained AWOL for
the duration of this shift ..."

-On 10/23/18 " ...[Client #1] was in after school
activities for the majority of the shift. Staff noted
[Client #1] returning at 8:05pm ...Staff noted that
[Client #1] appeared to be under the influence of
a substance ..."
-On 11/1/18" ...Staff noted [Client #1] ran from
school and did not return to the cottage ..."

-On 11/2/18-11/4/18 " ...AWOL/runaway ..."

-On 11/5/18 " ...Staff observed that the bathroom
smelled of smoke, possibly marijuana, after
[Client #1] used it. Staff went into student
bathroom after [Client #1] had vacated and
discovered a lighter and a bag with something in
it. Staff contacted the PM (program manager) on
duty. Staff continually kept [Client #1] in eyesight
unless she was in the bathroom or sleeping ..."
-On 11/6/18" ...[Client #1] told staff that she was
had marijuana on her and that she wanted to get
rid of it so she didn't get in trouble. [Client #1]
told staff she was tempted to run so she could get
rid of the marijuana, but that she didn't want to
run and was feeling sad and frustrated. [Client
#1] ran and returned to the cottage later in the
evening ..."

Review on 11/9/18 of the Nursing Report from
Division of Health Service Regulation
STATE FORM 6899 LBXJ11 If continuation sheet 6 of 38

PRINTED: 12/13/2018
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
Cc
MHL011-371 B. WING ____ 11/20/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE

GREEN LEVEL Il ASHEVILLE, NC 28806

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

DEFICIENCY)
V 112| Continued From page 6 Vv 112

8/16/18-11/6/18 for Client #1 revealed:

-"8/16/18: [Client #1] was admitted to [facility]
today. She was not observed in the admissions
office due to running off campus upon arrival to
[facility] ... Mother and client report that she uses
marijuana, Xanax and alcohol frequently. [Client
#1] reports that she has used cocaine about 5
times total. [Client #1] reports having used
alcohol, Xanax and cannabis all last night ...rapid
UDS (urine drug screen) being positive for
Benzodiazapine and THC (marijuana) ..."
-"8/28/18: Patient was not on campus for medical
appointment" (Missed due to elopement while on
therapeutic leave).

-"8/29/18: ...Positive for THC ..."

-"9/5/18: Student arrives back to the cottage after
unexpected TL (therapeutic leave) last night
...She did not want to give her urine sample ..."
-"9/19/18: Student's Random Rapid UDS
continues to be the same as it was (+ for THC),
however, the green mark for temperature did not
register ..."

-"9/20/18: The student returned to Eliada
campus a little after 10 PM ... The student
seemed slightly out of it, seemed to be slightly
slurring her words and talking slowly. She also
seemed to struggling a little to keep her eyes
open. She did not smell of alcohol or smoke. |
attempted to have a conversation with the student
about where she had been, who she had been
with, what she had been doing, etc. but she would
barely engage. She told me that she had not
been with her mom the whole time, was with
friends, and was doing "stuff" ...At this point she
decided that she was not going to give urine for a
rapid UDS ..." (Note did not fully print but the
Nurse confirmed that UDS was collected and was
positive for THC and that urine seemed diluted).
-"9/27/18: Rapid UDS done on student. THC
positive ... Temperature gage did not change
Division of Health Service Regulation

STATE FORM 6899 LBXJ11 If continuation sheet 7 of 38

PRINTED: 12/13/2018
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
Cc
MHL011-371 B. WING ____ 11/20/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE

GREEN LEVEL Il ASHEVILLE, NC 28806

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

DEFICIENCY)
V 112| Continued From page 7 Vv 112

colors, although, urine did not look watered down.
Student reported getting suspended today d/t
(due to) drinking a small amount of a peers
alcoholic drink at school. Student did not appear
intoxicated ..."

-"10/1/18 Physically unable to take ...no cups
available"

-"10/3/18: Rapid UDS is positive for THC
(collected after student ran 10/2/18) ..."

-"10/4/18: ... THC was positive ..."

-"10/6/18: ...UDS is still showing positive result for
THC ..."
-"10/10/18: Student did not return to campus until
almost 2 am ...Student appeared to possibly be
under the influence of some type of substance.
Student denied use ...Rapid alcohol swab was
negative. Student reported no need to urinate,
herefore, rapid UDS was not completed ..."
-"10/16/18: ...UDS was completed ...positive for
-"10/20/18: Rapid UDS positive for THC ..."
-"10/23/18: [Client #1] was suppose to return to
campus at 8pm on 10/22 but instead didn't return
fo campus until 10/23 at 12:30am. She appeared
io be under the influence of THC and a rapid
UDS revealed positive result for THC ..."
-"10/24/18: On 10/19/18 student reported to the
RN (registered nurse) that she had been sexually
active and that she wanted to get on some sort of
BC (birth control) ..."

-"11/6/18: Urine drug screen positive for THC ..."

Review on 11/9/18 of the Therapy notes for Client
#1 from 8/17/18-10/26/18 revealed:

-On 8/29/18 the Individual Therapy note indicated
" ...Therapist engaged [Client #1] in conversation
io better understand why [Client #1] ran on a pass
... Therapist provided [Client #1] with
psychoeducation on what will be expected pf her
in future passes. Therapist began to process and
Division of Health Service Regulation

STATE FORM 6899 LBXJ11 If continuation sheet 8 of 38

PRINTED: 12/13/2018

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL011-371 B. WING ____ 11/20/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE
GREEN LEVEL Ill
ASHEVILLE, NC 28806
(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

V 112| Continued From page 8 Vv 112

develop skills to assist in not running away from
problems ..."

-On 9/6/18 the Individual Therapy note indicated "
... Therapist utilized motivational interviewing to
gage what stage of change [Client #1] was in for
her substance use and other behaviors.
Therapist provided [Client #1] with
psychoeducation based on those levels of
change ...[Client #1] showed responsibility in
recognize things she can do to reduce her
behaviors while at home ... Therapist will meet
with [Client #1] to discuss skills that she can
utilize at home ..."

-On 9/28/18 the Individual Therapy note indicated
" ..Therapist attempted to check in with [Client
#1] as [Client #1] has been on unapproved
passes or has been on the run on multiple
occasions when therapy was going to happen ..."
-On 10/25/18 the Individual Therapy note
indicated " ... Therapist continued to engage
[Client #1] in conversation about her motivation to
look into other things in her life that are impacting
her, including her behaviors in school and on
passes ...[Client #1] was smiling when the
conversation about her behavior about passes
and school was discussed and possible
consequences ..."

-Individual therapy sessions were conducted
additionally on 8/17/18, 8/21/18, 10/2/18,
10/10/18, 10/12/18, 10/17/18, 10/22/18, and
10/26/18. These sessions indicated
introductions, the use of Equine therapy, healthy
relationships, being healthy, and options to
destructive thinking, and issues going on in her
life but failed to address the continued substance
use while in level III treatment.

-No therapy documented between 9/6/18 and
9/28/18.

-No family therapy documented.

-No group therapy or individual therapy for
Division of Health Service Regulation

STATE FORM 6899 LBXJ11 If continuation sheet 9 of 38

PRINTED: 12/13/2018
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
Cc
MHL011-371 B. WING ____ 11/20/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE

GREEN LEVEL Il ASHEVILLE, NC 28806

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 112| Continued From page 9 Vv 112

substance abuse documented.

Review on 11/9/18 of the Multidisciplinary Staffing
documentation for Client #1 revealed:

-On 9/13/18" ...[Client #1] has expressed a
desire to begin family therapy as she recognizes
her issues and behaviors arise mainly at home ...
[Client #1] has utilized drugs on multiple
occasions while on pass with mother ...Family
therapy is scheduled to begin next week. [Client
#1] will also attend substance use group therapy
..." No recommendations documented.

-On 10/11/18 " ...she attends a court ordered
weekly group and frequently takes advantage of
this time to either leave her mother's supervision
or to convince her mother to return her late to
Eliada. She has shown an increase in behaviors
while at school (suspended for drinking alcohol
on school grounds or eloping from school
grounds) ...she continues to test positive for THC
and other drugs ...Focus of Treatment
Recommendations: Engagement in Eliada
expectations ..."

Review on 11/9/18 of the Child and Family Team
(CFT) Meeting Minutes for Client #1 revealed:
-CFT conducted on 9/13/18. Documentation
indicated a review of the Therapeutic
Leave/Visitation policy. No discussion of
non-compliance around therapeutic leave or
substance use. This documentation indicated
Family therapy to begin "next week". Parent,
School Representatives and Court Counselor
present.

-CFT conducted on 10/11/18. Documentation
indicated " ...Central issue ...[Client #1] is not
returning on time from family passes, not at the
van when staff goes to pick her up, and drug tests
are all positive for marijuana ... The supervisors
would like for her to be placed in day treatment.
Division of Health Service Regulation

STATE FORM 6899 LBXJ11 If continuation sheet 10 of 38

PRINTED: 12/13/2018
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
Cc
MHL011-371 B. WING ____ 11/20/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE

GREEN LEVEL Il ASHEVILLE, NC 28806

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

DEFICIENCY)
V 112| Continued From page 10 Vv 112

Day treatment was explained ..." Parent present
by phone.

No documentation available of any other
communication with the local high school or the
parent of Client #1.

Interview on 11/8/18 with Client #1 revealed:
-She had been at the facility for 3 months.

-She had been pulled out of school and was now
in the facility academy. She was not happy about
that because she wanted to graduate with her
senior class.

-She had urine drug screens done and they had
been positive. She indicated that staff talked to
her about the positive screens and that is why
she can't go on passes for a while.

-She met with her therapist once per week. She
had equine therapy on Fridays.

-She said recently staff smelled something in the
bathroom and the police came. She also stated
she ran away once and was gone a couple of
hours and came back on her own. When she got
back the police came.

Client #2:

Record review on 11/7/18 and 11/8/18 for Client
#2 revealed:

-Admitted on 8/13/18 with diagnoses of
Unspecified Depressive Disorder, Other Specified
Anxiety Disorder, Cannabis Use Disorder Severe,
Sedative, Hypnotic or Anxiolytic Use Disorder
Severe, Stimulant Use Disorder Severe and
Alcohol Use Disorder Moderate.

-Assessment dated 7/6/18 indicated "
...Presenting Problem ...history of ...substance
use, overdose, and relapses ...Adverse
Childhood Experiences: ...household substance
use ...DSS removed [Client #2] from home due to
Division of Health Service Regulation

STATE FORM 6899 LBXJ11 If continuation sheet 11 of 38

PRINTED: 12/13/2018
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
Cc
MHL011-371 B. WING ____ 11/20/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE

GREEN LEVEL Il ASHEVILLE, NC 28806

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

DEFICIENCY)
V 112| Continued From page 11 Vv 112

safety issues and family knowing about
substance use/not having safety plans in the
home around this ...Problems at School:

... Truancy due to substance use ...[Client #2] has
experimented with many drugs, and states many
times using drugs in combination with other drugs
or alcohol ...Any negative behaviors in [Client
#2's] history appears to be linked to Substance
Use ...If he is accepted to other Level 3
Residential programs it is important to evaluate
whether program will fit his needs regarding
Substance Use Treatment ...If it is not included in
the program, he can benefit from SAIOP
(Substance Abuse Intensive Outpatient Program)
in combination with Level 3 ...Experience
Blackouts and Overdoses ..."

-Assessment dated 7/6/18 indicated Substance
Use History as "Alcohol ...3 x week ...Marijuana
...multiple times per day ...Cocaine ...3-9 times in
his life ...Opiates ...Oxy (OxyContin) and Percocet
up to 1 x per week ...Prescription pills ...end of
2017 around 4-5 x week ...Hallucinogens

.. increased to daily in early 2018. LSD once
every 2 months ..."

Review on 11/8/18 of the Treatment Plan dated
8/1/18 (with updates on 9/17/18, 10/1/18 and
10/15/18) for Client #2 revealed:

-Goals included " ...[Client #2] will demonstrate an
improvement in symptoms Cannabis Use
Disorder as evidenced by increased honesty
about Cannabis use, elimination of Cannabis use,
and decrease involvement with substance using
friends ...[Client #2] will demonstrate an
improvement in symptoms of Sedative, Hypnotic
or Anxiolytic Use Disorder as evidenced by
increased honesty about Sedative use, and
elimination of sedative use ...[Client #2] will
demonstrate an improvement in symptoms of
Stimulant Use Disorder as evidenced by

Division of Health Service Regulation

STATE FORM 6899 LBXJ11 If continuation sheet 12 of 38

PRINTED: 12/13/2018
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
Cc
MHL011-371 B. WING ____ 11/20/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE

GREEN LEVEL Il ASHEVILLE, NC 28806

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

DEFICIENCY)
V 112| Continued From page 12 Vv 112

increased honesty about Stimulant Use and
elimination of Stimulant use...[Client #2] will
demonstrate an improvement in symptoms of
Alcohol Use Disorder as evidenced by increased
honesty about Alcohol Use and elimination of
Alcohol use ..."

-Strategies/Interventions for all goals were "To
teach coping, pro-social, decision making,
problem solving and anger management skills.
To provide behavioral and crisis management
interventions. To monitor throughout sleeping
hours. To facilitate therapeutic leave. One staff
will provide transportation off campus as safety
allows ...Medication Management: To evaluate
and monitor the efficacy and side effects of
medications as well as inform consumer and
guardian ..."

-Treatment plan failed to specify specific
interventions used to address the substance use,
elopements or school truancy.

Review on 11/7/18 of incident reports for Client #2
rom 10/1/18-11/7/18 revealed:

-On 11/6/18 at 5:00PM " ...Staff noticed the smell
of marijuana coming from the restroom. Staff
went in the restroom after [Client #2] was done
and did not find anything. [Client #2] told staff
hat he had smoked and that he had more
marijuana on his person ...[Client #2] told staff
hat he acquired the marijuana from a peer in the
cottage ..."

-On 11/13/18 " ...[Client #2] came out of his room
io use the restroom. [Client #2] went back to his
room after 2 minutes ...Staff did a scheduled 5
min check on [Client #2]. Staff noted [Client #2]
had left his room through his bedroom window
...Staff went outside to check if they could see
[Client #2] ...11/14/18-[Client #2] returned to the
cottage on his own around 3:45pm, coming to the
cottage door trying to get in ...[Client #2] told staff
Division of Health Service Regulation

STATE FORM 6899 LBXJ11 If continuation sheet 13 of 38

PRINTED: 12/13/2018

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL011-371 B. WING ____ 11/20/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE
GREEN LEVEL Ill
ASHEVILLE, NC 28806
(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

V 112| Continued From page 13 Vv 112

he slept in an abandoned mansion and was
having a great day ..."

Review on 11/19/18 of daily service notes for
Client #2 revealed:

-Service note for second shift on 9/24/18 not
documented.

-Third shift service note for 9/24/18 indicated
"Staff observed [Client #2] to be off campus when
3rd shift stepped on the floor. Staff observed
[Client #2] arrive back to the cottage by [local law
enforcement] and staff around 10:37 pm
...provided nursing his urine sample ...Staff
observed [Client #2's] demeanor to be out of the
ordinary and suspected he had used some kind
of substance while away from campus ...Staff
observed [Client #2] talk with staff about where
he had run to [local grocery store] and taken an
over the counter drug as to which he referred to
as triple c's. Staff listened as [Client #2] told staff
the "he felt great and that he was so f***ed up"
and then laughed about it ...observing [Client #2]
as he out of nowhere vomited into the sink ...
continuing to vomit ...Staff called nursing ...he
then told staff he had taken 39 of them ...[Client
#2] spoke up saying oh well if you overdose you
overdose it happens shouldn't take so many |
guess and laughed about it ..."

-On 10/22/18 " ...Staff went to [local high school]
to pick up [Client #2] from police custody ...Staff
checked in with [Client #2] about what
substances he took and the quantity of these
substances ...[Client #2] was in an intoxicated
state when staff picked him up from school ...
[Client #2] told staff he had drunk alcohol and
how much he drank ...staff came to take him to
the hospital ..."

-On 11/3/18 " ...Staff redirected [Client #2] when
he became hyper focused on not being able to go
Division of Health Service Regulation

STATE FORM 6899 LBXJ11 If continuation sheet 14 of 38

PRINTED: 12/13/2018
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
Cc
MHL011-371 B. WING ____ 11/20/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE

GREEN LEVEL Il ASHEVILLE, NC 28806

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 112| Continued From page 14 Vv 112

off campus due to the level 3 vehicles being
occupied ...Staff redirected [Client #2] when he
threatened to leave campus if he did not get to go
off campus ...Staff disengaged from [Client #2]
when he repeatedly made suicidal ideations
about dying from an overdose. Staff checked in
with [Client #2] about going off campus and
provided him with expectations ...staff observed
[Client #2] walk away without staff permission ...
[Client #2] continued to walk off campus ...Staff
redirected [Client #2] when he tried to go to [local
pharmacy] and stated he was going to steal an
energy drink or go to [local grocery store] to steal
coffee ...staff provided increased checks on
[Client #2] upon returning to the cottage ..."

Review on 11/9/18 of the Nursing Report from
8/15/18-11/4/18 for Client #2 revealed:

-"9/5/18: Rapid UDS appears to be negative,
however the line double line for THC is faint on
the bottom (possibly inconclusive) ..."

-UDS testing on 9/10/18, 9/19/18, and 9/23/18
were negative for illicit substances.

-"9/24/18: [Client #2] was brought back to
campus at 11pm by Cottage supervisor after
running off campus at around 5pm. [Client #2]
appeared to be under the influence when he
reentered the cottage. Nursing performed a rapid
UDS sample but was not a valid sample. Nursing
performed a saliva alcohol swap that showed a
very faint line showing a possible indication of
alcohol consumption ...nursing was called due to
him throwing up and admitting to consuming a
large amount of the substance, triple c. He
stated he consumed 39 of these pills
..fecommendation was made to take him to be
evaluated at the emergency department."

-Urine drug screens were documented as
administered on 9/29/18, 10/5/18 and 10/11/18
but no results were documented by the nurses.
Division of Health Service Regulation

STATE FORM 6899 LBXJ11 If continuation sheet 15 of 38

PRINTED: 12/13/2018
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
Cc
MHL011-371 B. WING ____ 11/20/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE

GREEN LEVEL Il ASHEVILLE, NC 28806

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 112| Continued From page 15 Vv 112

-"10/17/18 negative for all substances."
-"10/22/18: Student was brought home from
school today after skipping and reportedly going
0 [local grocery store] and buying ETOH
(alcohol) (400z he says) and drinking it all. He
did appear intoxicated. He get up to go to the
bathroom and after walking through the door of
he bathroom fell on the floor. Upon checking on
him, he immediately go up and reported that he
got dizzy and fell. He did not having observable
injuries from the fall. He took a while in the
bathroom but did bring a Rapid UDS specimen to
his RN (registered nurse). The temperature
gage did not read accurately (by turning green).
Therefore, was inconclusive. His ETOH swab
was negative for ETOH=or greater than 0.02%
ETOH. [Therapist], [Residential Services
Director] and this RN felt it was in his best interest
io go to the ED (emergency department) for
safety purposes and to determine if he was on
any other illicit drugs ..."

-"10/23/18: [Client #2] returned from the
Emergency department ...diagnosed him with
acute alcohol intoxication and no further
recommendations. His blood work revealed that
his blood alcohol level was 0.059 ..."

-Aurine drug screen was documented as
administered on 10/29/18 but indicated "cup left
in cottage. Student aware". Aresult was not
documented.

Review on 11/15/18 of the hospital records for
Client #2 revealed:

-Emergency room report dated 9/25/18 ...Chief
Complaint: Substance Misuse/Intoxication
...Diagnosis: Acetaminophen overdose,
Intentional drug overdose ...Pt (patient) did not
attempt suicide and this was an attempt to get
high. Pt denies SI (suicidal ideation) ..."
-Emergency room report dated 10/22/18
Division of Health Service Regulation

STATE FORM 6899 LBXJ11 If continuation sheet 16 of 38

PRINTED: 12/13/2018

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL011-371 B. WING ____ 11/20/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE
GREEN LEVEL Ill
ASHEVILLE, NC 28806
(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

V 112| Continued From page 16 Vv 112

...Diagnosis: Acute alcohol intoxication ..."

Review on 11/9/18 of the Therapy notes for Client
#2 from 8/15/18-11/5/18 revealed:

-Individual therapy session on 9/28/18 indicated "
... Therapist engaged [Client #2] in conversation to
best understand how he bounced back from his
incident Monday night (overdose) ... Therapist
assessed [Client #2's] level of motivation to move
forward and utilize skills he is working on such as
asking for help and utilizing his coping skills ..."
-Individual therapy session on 10/22/18 indicated
" ..Therapist engaged [Client #2] in conversation
eventhough he was intoxicated from alcohol.
Therapist assessed [Client #2's] level of
judgement and understanding of potential
consequences ...[Client #2] discussed making a
poor decision ...expressed regret for his
behaviors and understood potential
consequences ..."

-Additional individual therapy sessions were
conducted on 8/15/18, 8/21/18, 8/29/18, 9/4/18,
9/15/18, 9/18/18, 9/20/18, 10/3/18, 10/9/18,
10/15/18, 10/18/18, 10/24/18, 10/29/18, and
11/5/18.

-These therapy sessions addressed use of
coping skills when wanting to engage in risky
behavior, how to ask for help, effective
communication, how to express emotions,
smoking cigarettes on campus, how to address
anger, behavior control and the implementation of
Equine Therapy. These sessions did not indicate
that substance use was addressed as part of his
treatment.

-Two family therapy sessions documented on
9/24/18 and 10/1/18.

-No group therapy for substance abuse
documented.

Review on 11/9/18 of the Multidisciplinary Staffing

Division of Health Service Regulation
STATE FORM 6899 LBXJ11 If continuation sheet 17 of 38

PRINTED: 12/13/2018
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
Cc
MHL011-371 B. WING ____ 11/20/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE

GREEN LEVEL Il ASHEVILLE, NC 28806

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

DEFICIENCY)
V 112| Continued From page 17 Vv 112

documentation for Client #2 revealed:

-On 9/13/18" ...[Client #2's] UDS have been
negative.**Important to note that his drugs of
choice historically have been over the counter
and will not show up on a drug screen ...[Client
#2] has shown resistance to the level Ill program
...He has attempted to have conversations with
his peers about how to fool a drug test and which
substances they could use that would leave their
system quickly ...He attends public school at
[local high school] and so far there have been no
reported issues. [Client #2] informed staff that if
they do a weekly random drug test, it just means
that the next day the students are clear to use
substances until the next week ...[Client #2] will
begin engaging in a substance use group next
week ..."
-On 10/11/18 " ...[Client #2] has continued to
show symptoms of substance use ...Academic
Update: ...no disciplinary actions to report ..."

Review on 11/9/18 of the Child and Family Team
(CFT) Meeting Minutes for Client #2 revealed:
-CFT conducted on 9/17/18. This documentation
indicated " ...[Client #2] begins substance use
group therapy this week ..."

-CFT conducted on 10/1/18. This documentation
indicated " ...emergency CFT was called by
[Client #2's] team due to his behavior a week
prior in which he ran away from the cottage and
overdosed ..." Absences were indicated in
several school classes and the report indicated "
...Clinician will follow up for absence dates
...Clinician will begin anger management therapy

-CFT conducted on 10/15/18. This
documentation indicated " ...[Client #2] actively
engages in substance use group therapy once
every other week currently ...Clinician discussed
the possibilities if a pattern of marijuana use
Division of Health Service Regulation

STATE FORM 6899 LBXJ11 If continuation sheet 18 of 38

PRINTED: 12/13/2018
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
Cc
MHL011-371 B. WING ____ 11/20/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE

GREEN LEVEL Il ASHEVILLE, NC 28806

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 112| Continued From page 18 Vv 112

continues, which could include day leaving public
school and going to day treatment. Clinician
discussed substance use treatment not being one
the table for marijuana. Clinician further
discussed is use is a problem, a higher level of
care is possible ...Educational/Vocational:

... There are a couple unexplained absences and
tardies ..."

-No school representatives participated in any of
the CFT meetings.

Interview attempted on 11/8/18 but Client #2
refused.

There was no policy for Urine Drug Screening
available for review.

Interview on 11/9/18 with the Lead Registered
Nurse (RN) revealed:

-All students that attended public school were
tested weekly for drugs through a urine drug
screen.

-Students also had a urine drug screen
conducted following any visit off campus.
-Nurses conducted the urine drug screening.
-Client #1 consistently tested positive for
marijuana.

-On 10/1/18 Client #1 did not receive a UDS
because the facility had run out of cups. She
indicated that the testing cups were either on
back order or were not delivered timely by the
pharmacy.

-When Client #2 had an oral alcohol swab
completed on 10/22/18, the alcohol did not
register on their swab. She indicated that they
had not used swabs a lot and that they needed
more sensitive swabs for alcohol testing.

-She stated that when the temperature gage did
not register green something was either wrong
with the temperature gage or the urine had been
Division of Health Service Regulation

STATE FORM 6899 LBXJ11 If continuation sheet 19 of 38

PRINTED: 12/13/2018
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
Cc
MHL011-371 B. WING ____ 11/20/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE

GREEN LEVEL Il ASHEVILLE, NC 28806

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 112| Continued From page 19 Vv 112
diluted.

-She indicated that on the dates Client #2 had no
result documented for his UDS either the test
occurred and it was not charted or the test
actually did not occur. Her assumption was that
Client #2 did not have the test.

Interview on 11/8/18 with Residential Counselor
#1 revealed:

-He worked second shift.

-On 11/5/18 Client #1 was picked up from school
by the Therapist and Cottage Supervisor. Both
the Therapist and Supervisor suspected that
Client #1 had drugs on her person but that
information was not communicated to him. He
indicated that he "had no idea what was going on"
and he "was not in the loop". He indicated that he
would have kept a closer eye on Client #1. Client
#1 asked to take a shower and the staff smelled
marijuana while she was in the shower. After she
was finished with her shower the bathroom was
searched and staff found a bag that contained a
ighter and a "blunt". They notified the Cottage
Supervisor and the local police department.

-He stated that Client #1 was observed to have
red eyes, decreased focus, decreased
communication and she appeared to "space out".
He indicated that he had seen her "high" before.
-He stated that they determined that Client #1 had
offered the drugs to Client #3 but they were able
io locate the drugs before Client #3 had used any.
-On 11/6/18 Client #2 wanted to take a shower
after school which he indicated was unusual.
Staff again smelled marijuana in the bathroom
and searched the bathroom but found nothing.

He stated that Client #2 also appeared impaired.
Client #2 admitted to smoking marijuana in the
bathroom and informed staff that he had hidden
he marijuana in his crotch. He stated that they
attempted multiple times to get Client #2 to turn
Division of Health Service Regulation

STATE FORM 6899 LBXJ11 If continuation sheet 20 of 38

PRINTED: 12/13/2018
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
Cc
MHL011-371 B. WING ____ 11/20/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE

GREEN LEVEL Il ASHEVILLE, NC 28806

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 112| Continued From page 20 Vv 112

over the marijuana.

-Additionally, on 11/6/18, Client #1 said she had
marijuana but refused to give it to staff after
multiple attempts to convince her to do so.
Shortly thereafter, Client #1 eloped and later
returned to the facility impaired. Local law
enforcement had been contacted when Client #1
ran out of sight and were in the facility when
Client #1 returned. A body search was conducted
on Client #1 by law enforcement. Urine drug
screens were conducted for Client #1 and Client
#2 and both tested positive for marijuana.

-He indicated a team meeting was conducted on
11/7/18 to discuss steps to take with Client #1
and Client #2.

-Every time a client returned from being off
campus searches were conducted.

-The searches involved emptying out pockets,
shaking out clothing, underwear bands and bra
bands. Shoes were also removed and checked.

Interviews on 11/7/18, 11/13/18 and 11/15/18 with
Residential Counselor #2 revealed:

-He was a Night Residential Counselor.

-He stated that the current census was "the worst
group right now for sneaking things in".

-Client #1 had run 6 or 7 times. He stated she
would leave school with "her boyfriend" and return
to the cottage "high" at 1:00AM. He stated she
"was high" every time she returned to the cottage
and tested positive for marijuana consistently.
Furthermore, he stated she was off campus every
week and was supposed to be with her mom but
“they knew that wasn't happening". Client #1 was
going on passes but some days would not return
to the cottage.

-The incidents on 11/5/18 and 11/6/18 was the
first time that drugs were coming into the cottage.
-Every time Client #1 returned to the cottage on
his shift he observed her to be lethargic, have
Division of Health Service Regulation

STATE FORM 6899 LBXJ11 If continuation sheet 21 of 38

PRINTED: 12/13/2018
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
Cc
MHL011-371 B. WING ____ 11/20/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE

GREEN LEVEL Il ASHEVILLE, NC 28806

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 112| Continued From page 21 Vv 112

slow reactions, and her eyes were glazed over.
-He indicated that her behavior "has been allowed
to continue" and she was "continued to let go on
pass".

-The incident on 11/6/18 for Client #2 was not the
first time he was involved in drug use. He stated
that Client #2 had eloped on a prior date and
used drugs and also eloped from school on one
occasion got drunk.

-Most recently, Client #2, who wore an ankle
bracelet, cut it off his ankle and eloped again
from his bedroom window in the cottage. Client
#2 was gone overnight and returned to campus
the following day. Client #2 reported that he had
stayed in an abandoned building overnight.
Probation officers came on site upon Client #2's
return and escorted him to the local jail.

Interview on 11/7/18 with Residential Counselor
#3 revealed:

-She worked second shift.

-On “at least" 2 occasions when she went to pick
up Client #1 from school she was not there. She
indicated that she went to the office and her
name was called over the loud speaker. The
attendance record was checked and Client #1
had "skipped class". She immediately called the
Cottage Supervisor and Therapist. She stated
that "sometimes" a missing persons report was
completed.

-"She (Client #1) usually shows up." She
indicated that sometimes Client #1 showed up to
the facility later the same night. Client #1 was
returned to campus by someone who was not her
parent. She stated that one time Client #1 was
spotted at a gas station.

-She indicated that every time Client #1 returned
to the cottage she was "on drugs".

-She stated that there had been threats to pull
Client #1 out of public school which finally
Division of Health Service Regulation

STATE FORM 6899 LBXJ11 If continuation sheet 22 of 38

PRINTED: 12/13/2018
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
Cc
MHL011-371 B. WING ____ 11/20/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE

GREEN LEVEL Il ASHEVILLE, NC 28806

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 112| Continued From page 22 Vv 112

occurred on 11/5/18. She indicated that the
therapeutic leave overnight visits stopped "2
weeks ago".

Interview on 11/7/18 with Residential Counselor
#4 revealed:

-Whenever clients returned to the cottage after
school or therapeutic leave a search was
conducted.

-The process involved use of a wand on the
client, search of any bags, emptying pockets,
shaking out of clothing and rim of socks, and
shoe removal.

-Documentation of the search was included in
their service notes.

-They did not pat down the clients. He indicated
that if they observed "a bulge" they would ask the
client to show them.

-He had interaction with Client #1 after the
incident on 11/6/18. Client #1 asked to check in
with him. She informed him that she wanted to
run and admitted that she had marijuana on her
person. He stated he talked to her for an hour
and tried to convince her to turn over the drugs
and the potential outcomes of what could happen.
He indicated that after a while he returned back
into the cottage (they had been on the front
porch) but still maintained eyesight through the
open door. She then eloped, he followed and
eventually lost eyesight of her at which time he
contacted the authorities.

Interviews on 11/8/18 and 11/19/18 with the
Cottage Supervisor revealed:

-Client #1 typically eloped from school or while on
pass.
-Most recently on 11/1/18 she gave the School
Resource Officer a fake name of someone that
was to pick her up from school. She was picked
up from school by someone no one knew but they
Division of Health Service Regulation

STATE FORM 6899 LBXJ11 If continuation sheet 23 of 38

PRINTED: 12/13/2018
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
Cc
MHL011-371 B. WING ____ 11/20/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE

GREEN LEVEL Il ASHEVILLE, NC 28806

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 112| Continued From page 23 Vv 112

suspected the person was a former boyfriend.
She was gone until she returned to school on
Monday 11/5/18. She was returned to campus
and admitted into their day treatment program.
On that date she was removed from the local
high school.

-There were times that staff would pick up from
school and she was gone.

-She indicated that the teachers at the local high
school did not take attendance. She never
received a call that Client #1 or Client #2 were not
in class.

-At the first Child and Family Team meeting
transportation to and from the therapy group
(Love Notes, therapy group about relationships
that had been court ordered) and after school
activities had been arranged with Client #1's
mother. On 10/2/18 Client #1's mother indicated
she had a problem with her vehicle but did not
communicate with the facility.

-When on therapeutic leave with her mother
sometimes she would return and sometimes not.
-Therapeutic leave passes stopped in
mid-October.

Interviews on 11/8/18 and 11/20/18 with the
Therapist for Client #1 and Client #2 revealed:
-She was an LCAS-A (Licensed Clinical Addiction
Specialist) and LCSW (Licensed Clinical Social
Worker).

-She conducted 1 hour therapy per week with
each client.

-She conducted 2 hours of family per month and

1 Child and Family Team meeting per month.
-She had not added any goals to Client #2's
treatment plan to address elopements.

-She had not included any goals or strategies to
address substance abuse for Client #1 because
Client #1 had not been diagnosed with a
substance abuse disorder. She felt that the goals
Division of Health Service Regulation

STATE FORM 6899 LBXJ11 If continuation sheet 24 of 38

PRINTED: 12/13/2018

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL011-371 B. WING ____ 11/20/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE
GREEN LEVEL Ill
ASHEVILLE, NC 28806
(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

V 112| Continued From page 24 Vv 112

in her plan would be applicable to that issue.
-Client #1 would elope primarily while on
therapeutic leave. When with her mother Client
#1 would end up with friends and indicated that
her mother did not know how to handle the issue.
-Client #1 was on the run at times when her
therapy was scheduled so there were weeks
when she may not have had a session.
-Therapeutic leave was ended for Client #1
around approximately 10/25/18.

-She stated that the facility was not informed
when the clients were not in class. She indicated
that just recently they began to call the school
and verify if their clients were in class.

-There had been instances when Client #1 would
refuse to get in the van when staff picked up after
school. Client #1 would go back into school and
then they were unable to locate her and would file
a missing persons report.

-Client #1 was removed from the school and
admitted to their day treatment program on
11/5/18.
-Client #1 had not passed one urine drug screen.
-There had been "many conversations" with
Client #1 about removing her from public school if
the running and drug use continued.

-She indicated that she "had talked to mom a lot
about what was going on during passes".

-She stated that ideally she talked to guardians
once per week but that varied based on the
needs of the student.

-She stated that she had one family therapy
session that had been scheduled for Client #1
and Client #1's mother did not show up. She
attempted to reschedule but they were unable to
work out a time.

-She had conducted 3 or 4 group therapy
sessions for substance abuse but had been told
not to document those sessions because there
“was no code". She stated it was frustrating to try
Division of Health Service Regulation

STATE FORM 6899 LBXJ11 If continuation sheet 25 of 38

PRINTED: 12/13/2018
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
Cc
MHL011-371 B. WING ____ 11/20/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE

GREEN LEVEL Il ASHEVILLE, NC 28806

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

DEFICIENCY)
V 112| Continued From page 25 Vv 112

and arrange group sessions because Client #1
would be missing. She also indicated it "became
a staffing issue".

-The topics she covered in the group sessions for
substance abuse were "recovery mindset,
characteristics of a substance abuse disorder and
relationships".

-Client #2 had been removed from the local public
high school following his last elopement (on
11/9/18).

-She was unaware of the attendance problems
for Client #2 at the local public high school. She
stated that she found out on his last day that his
grades and attendance had declined significantly.
She indicated that she had called the school daily
for the last two weeks and was told he was in
class. She stated that when she requested his
attendance record his attendance was
inconsistent with what she had been told.
-Her primary avenue for communication with the
school was the CFT (Child and Family Team)
meetings.

Interview on 11/9/18 with the Clinical Director
revealed:
-Individual therapy was conducted weekly and
should address both mental health issues as well
as substance abuse issues.
-Family therapy was conducted twice monthly.
-The Group therapy was currently being "beefed
up". The Therapist had started to conduct some
groups but had stopped. The Licensee had just
received a new model curriculum to use for group
therapy but the Therapist would need to be
trained for proper implementation.

-Client #1 did not have a substance abuse
diagnosis and therefore no goals or strategies
had been included in her treatment plan. She
stated that goals for the PCP's were based on
each diagnoses that were indicated.

Division of Health Service Regulation

STATE FORM 6899 LBXJ11 If continuation sheet 26 of 38

PRINTED: 12/13/2018

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL011-371 B. WING ____ 11/20/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE
GREEN LEVEL Ill
ASHEVILLE, NC 28806
(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

V 112| Continued From page 26 Vv 112

-Diagnostic changes would have been addressed
in the multi-disciplinary team meetings and then
he treatment plan would be updated. This
should have occurred for Client #1 due to her
level of substance abuse but it did not.

-The Licensee was currently in the process of
changing the entire person centered plan process
io ensure interventions were more individualized.
-The interventions in the treatment plans for
Client #1 and Client #2 were not specific to
substance abuse.

nterviews on 11/15/18 and 11/16/18 with the local
high school Resource Officer revealed:
-He was working on 11/1/18 when Client #1
eloped from school. She jumped into the car of a
tiend (non-student) and left school. He had
contact with Eliada on this date and they asked
him to file a missing persons report. Client #1
returned to school a few days later.
-He stated that Client #2 "would run off just about
daily from school". He further indicated that
Client #2 was caught intoxicated at school and
was "busted smoking in the woods". He said that
Client #2 would leave school and go to the local
grocery store and obtain alcohol.

-His contact with Eliada was only when the
problem became a law enforcement issue. He
had no conversations with Eliada about the
behaviors of Client #1 or Client #2.

Attempts were made on 11/15/18, 11/16/18 and
twice on 11/19/18 to contact the School Social
Worker. All attempts were unsuccessful.

Interview on 11/20/18 with the Residential
Services Director revealed:

-Family therapy was to occur at a minimum of
twice monthly. It was designed around the needs
of the child and family and what worked best for
Division of Health Service Regulation

STATE FORM 6899 LBXJ11 If continuation sheet 27 of 38

PRINTED: 12/13/2018

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHLO011-374 B. WING 11/20/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE
GREEN LEVEL Ill
ASHEVILLE, NC 28806
(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 112| Continued From page 27 Vv 112
the family.

-Client #1's mother did not speak English and all
communication went through an interpreter. Staff
would report issues to the interpreter who then
would communicate with the mother. Her mother
did not always participate in meetings.

-He was not aware of how much family therapy
was accomplished with Client #1 and her mother.
-He indicated that they struggled with how to
engage Client #1's mother and work with Juvenile
Justice who wanted Client #1 to remain in public
school. He stated that in meetings they had tried
to get through to Client #1 but it finally got to the
point that she wasn't safe and the decision was
made to pull her out of public high school.

-He was not sure if the Group therapy for
Substance Abuse ever got off the ground. There
was no model for substance abuse therapy that
had been utilized.

-There was no policy in place for the urine drug
screening. Staff were not clear on the
procedures for urine drug screening. He did not
know how the procedures used by the nursing
staff had been established.

-"We have work to do on urine drug screening.”
-Treatment plans should address the substance
abuse issues.

-There had been ongoing problems working with
the local high school and communication with the
Guidance Counselor had been problematic.

This deficiency is cross referenced into 10A

NCAC 27G .1701 Scope (293) for a Type A1 rule
violation and must be corrected within 23 days.

V 293} 27G .1701 Residential Tx. Child/Adol - Scope V 293

10A NCAC 27G .1701 SCOPE
(a) Aresidential treatment staff secure facility for

Division of Health Service Regulation
STATE FORM 6899 LBXJ11 If continuation sheet 28 of 38

PRINTED: 12/13/2018
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
Cc
MHL011-371 B. WING ____ 11/20/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE

GREEN LEVEL Il ASHEVILLE, NC 28806

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

DEFICIENCY)
V 293] Continued From page 28 V 293

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

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

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

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

(2) treatment in a staff secure setting.
(e) Services shall be designed to:

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

(2) minimize the occurrence of behaviors
related to functional deficits;

(3) ensure safety and deescalate out of

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

(f) The residential treatment staff secure facility
shall coordinate with other individuals and

Division of Health Service Regulation
STATE FORM 6899 LBXJ11 If continuation sheet 29 of 38

PRINTED: 12/13/2018

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL011-371 B. WING ____ 11/20/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE
GREEN LEVEL Ill
ASHEVILLE, NC 28806
(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

V 293] Continued From page 29 V 293

agencies within the child or adolescent's system
of care.

This Rule is not met as evidenced by:

Based on record review and interview the facility
failed to design services that would minimize the
occurrence of behaviors, ensure safety and
deescalate out of control behaviors and failed to
coordinate with other individuals and agencies
within the child's system of care affecting 2 of 3
current clients (#1, #2) and 1 of 1 former clients.
The findings are:

Cross Reference: 10A NCAC 27G .0205
Assessment and Treatment/Habilitation or
Service Plan (V112) Based on record review and
interviews the facility failed to develop and
implement goals and strategies to address the
behaviors effecting 2 of 3 current clients (#1, #2)
and 1 of 1 former clients.

Review on 11/9/18 and 11/20/18 of the Plan of
Protection signed and dated by the Director of
Performance/Quality Improvement on 11/9/18
and 11/20/18 revealed:

What will you immediately do to correct the above
rule violations in order to protect clients from
further risk?

"-A full cottage safety sweep and room search will
be completed on Saturday afternoon after 2pm.
Students will be notified immediately prior to the
Division of Health Service Regulation

STATE FORM 6899 LBXJ11 If continuation sheet 30 of 38

PRINTED: 12/13/2018

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL011-371 B. WING ____ 11/20/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE
GREEN LEVEL Ill
ASHEVILLE, NC 28806
(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

V 293] Continued From page 30 V 293

search and will be present. The search will be
facilitated by Eliada's Crisis Manager with the
full-time Green Residential Counselors on shift.
The students will be supported during this
process by Eliada's Clinical Director. This will
ensure the environment is free from substances
and any other prohibited items that might
jeopardize the safety of the students.
-Room checks will be increased to every 5
minutes when students are in their respective
bedrooms. This will be conducted during both
waking and sleeping hours for all students. The
room checks will be documented and maintained
in the cottage safety binder and reviewed by the
Cottage Supervisor daily.
-The students in Green Cottage will have no
off-campus activities until further notice.

-The staff in Green Cottage will maintain
structured activity blocks daily to keep the
students engaged as a group. This will be clearly
documented in the progress notes for each
student on each shift.

-Green Residential Counselors will facilitate one
psycho-educational group with the students daily,
beginning on Saturday, 11/10/18. Staff have
been provided with manualized group therapy
workbooks and will address topics related to
self-esteem, positive decision-making, managing
emotions, resisting peer influences and recovery
principles. The daily group topic and therapeutic
activities will be detailed in each students
progress note.

-One student, who has not engaged in substance
use nor secretive behaviors will maintain a
therapeutic leave visit this weekend, in support
and preparation for the upcoming discharge and
transition to the family home.

-Eliada's Residential Director and Green's Clinical
Supervisor (both of whom have clinical expertise
in substance abuse treatment will provide a
Division of Health Service Regulation

STATE FORM 6899 LBXJ11 If continuation sheet 31 of 38

PRINTED: 12/13/2018
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
Cc
MHL011-371 B. WING ____ 11/20/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE

GREEN LEVEL Il ASHEVILLE, NC 28806

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 293] Continued From page 31 V 293

required training for ALL Eliada Level III
Residential Treatment Staff on Wednesday,
November 14 from 9am-11am. This training will
address Adolescent Substance Use, Prevention
and Intervention Strategies.

-The Clinical Supervisor will follow up with the
identified students and their affiliated Child and
Family Team to update diagnosis and PCPs
(person centered plans) to reflect the need for
interventions and treatment related to substance
use by Thursday, 11/15/18.

-Alternate school arrangements have been
secured for the two students with recent
significant drug use. Education will be provided
on Eliada's campus and will eliminate the
opportunity for the either to secure substances.
A meeting with local high school personnel was
conducted with Eliada staff on 11/9/18 to finalize
these arrangements for the second student.
-**All (4) students in Green Cottage will be
reviewed through the process of a Clinical Case
Review, to be completed by Wednesday,
11/28/19. Eliada has revised the Clinical Case
Review process and documentation, which now
has an embedded Individual Crisis Management
Plan/Strategies for the Comprehensive Crisis
Plan. This plan includes student-specific details
for:

i. Pre-Crisis: What is the student's baseline?
What does it look like when the student is doing
well?

ii. Triggering: (events and early signs that
student is not doing well)

iii. Prevention and Early Intervention Strategies:
(Engagement and calming strategies: what works
well, doesn't work well)

iv. Escalation and Outburst: (strategies for crisis
response and stabilization)

v. Recovery: (specific needs or supports after
crisis)"

Division of Health Service Regulation

STATE FORM 6899 LBXJ11 If continuation sheet 32 of 38

PRINTED: 12/13/2018

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL011-371 B. WING ____ 11/20/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE
GREEN LEVEL Ill
ASHEVILLE, NC 28806
(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

V 293] Continued From page 32 V 293

Describe your plans to make sure the above
happens:

"-The cottage search and environmental safety
sweep will be monitored by the Crisis Manager.
The search will be documented as an incident
report and will have the accompany search and
seizure documentation. The guardians will be
notified of this event and any findings.

-The Supervisor on site will review the Room
Check logs on Sunday evening for Saturday and
Sunday. The Cottage Supervisor will review the
Room Check Logs daily beginning on Monday,
11/12/18, to ensure that increased room checks
are completed and documented. The Residential
Director will be notified of any deficiencies or
student non-compliance.

-The Supervisor on Site will review all shift notes
for the students in Green Cottage on Sunday
evening for 11/10/18-11/11/18. The Residential
Administrative Assistant will review all shift notes
for the students in Green Cottage daily beginning
on Monday, 11/12/18, to ensure structured block
activities have been facilitated and documented,
as well as the daily psycho-educational groups.
-A PQI (Performance Quality Improvement) team
representative will attend the required training on
Wednesday, 11/14/18, with the Level III
Residential Treatment staff to assess for content
and delivery. The PQI Director will also identify
and assign additional trainings related to
Substance Use and Intervention in RELIAS (an
online training portal) for Level Ill Residential
Treatment Staff to complete within the next 30
days.
-Eliada's Medical Director and Clinical Director
will review the PCP revision with updated
diagnostic information, goals and intervention
strategies by 11/15/18.

-**The Residential Director will participate in the
Division of Health Service Regulation

STATE FORM 6899 LBXJ11 If continuation sheet 33 of 38

PRINTED: 12/13/2018

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL011-371 B. WING ____ 11/20/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE
GREEN LEVEL Ill
ASHEVILLE, NC 28806
(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

V 293] Continued From page 33 V 293

Green/L3 Clinical Case Review meeting to
confirm development of the individualized crisis
plans and strategies for service delivery on
11/28/18. The Clinical Supervisor for Green
Cottage will lead the development of the
intervention strategies and provide coaching for
staff related to implementation."

Client #1 and Client #2 both had histories of
extensive substance use, truancy and
elopements. The facility failed to have a system
in place to meet the complex treatment needs
and manage the behaviors of both clients.
Random urine drug screening was conducted
weekly for both clients, however, there was no
urine drug testing policy in place. Staff were
unclear about testing procedures and were not
consistent in the implementation of that process.
Testing supplies were inadequate at times which
resulted in inconclusive results. Client #1 and
Client #2 on occasion left school premises and
there was no system of communication with the
local high school that ensured school attendance
and their safety. Group therapy for substance
abuse was indicated as a needed component in
the treatment for both clients but was never fully
implemented. Communication with the guardian
of Client #1 was problematic and family therapy
sessions did not occur. The chronic elopement
behaviors that usually occurred when Client #1
was on therapeutic leave went unaddressed for 2
months. Neither treatment plan for Client #1 nor
Client #2 indicated strategies to address these
behaviors nor did the therapy sessions
consistently indicate that these treatment needs
were addressed. As a result, Client #1 was out of
the facility on unapproved leave eight times for
periods of time ranging from 1 to 4 days. She
tested positive for marijuana following every
extended period of absence. Since admission
Division of Health Service Regulation

STATE FORM 6899 LBXJ11 If continuation sheet 34 of 38

PRINTED: 12/13/2018
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
Cc
MHL011-371 B. WING ____ 11/20/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE

GREEN LEVEL Il ASHEVILLE, NC 28806

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

DEFICIENCY)
V 293] Continued From page 34 V 293

Client #1 tested positive for marijuana a total of
11 times. Client #2 experienced two hospital
emergency room admissions due to overdose
and alcohol intoxication both of which occurred
following an elopement from school. Most
recently, drugs were brought into the facility by
Client #1 after a 4 day elopement. Client #1 kept
the drugs on her person knowing that the facility
could not conduct a body search. Both Client #1
and Client #2 proceeded to smoke marijuana
inside the cottage. These systemic failures to
provide services to meet the specific needs of
these clients constitute a Type A1 rule violation
for serious neglect and must be corrected within
23 days. An administrative penalty of $1000.00 is
imposed. If the violation if not corrected within 23
days, an additional administrative penalty of
$500.00 per day will be imposed for each day the
facility is out of compliance beyond the 23rd day.

V 503} 27D .0103 Client Rights - Search And Seizure V 503
Policy

10A NCAC 27D .0103 SEARCH AND
SEIZURE POLICY

(a) Each client shall be free from unwarranted
invasion of privacy.

(b) The governing body shall develop and
implement policy that specifies the conditions
under which searches of the client or his living
area may occur, and if permitted, the procedures
for seizure of the client's belongings, or property
in the possession of the client.

(c) Every search or seizure shall be documented.
Documentation shall include:

(1) scope of search;

(2) reason for search;

(3) procedures followed in the search;
(4) a description of any property seized;

Division of Health Service Regulation
STATE FORM 6899 LBXJ11 If continuation sheet 35 of 38

PRINTED: 12/13/2018
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
Cc
MHL011-371 B. WING ____ 11/20/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE

GREEN LEVEL Il ASHEVILLE, NC 28806

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

DEFICIENCY)
V 503 | Continued From page 35 V 503
and
(5) an account of the disposition of seized
property.

This Rule is not met as evidenced by:

Based on record review and interviews the facility
failed to document scope of search, reason for
search, procedures followed in the search, a
description of any property seized, and an
account of the disposition of seized property for
every search or seizure affecting 2 of 3 audited
clients (#1, #2). The findings are:

Record review on 11/7/18 and 11/8/18 for Client
#1 revealed:

-Admitted on 8/16/18 with diagnoses of
Post-Traumatic Stress Disorder and Oppositional
Defiant Disorder.

Record review on 11/7/18 and 11/8/18 for Client
#2 revealed:

-Admitted on 8/13/18 with diagnoses of
Unspecified Depressive Disorder, Other Specified
Anxiety Disorder, Cannabis Use Disorder Severe,
Sedative, Hypnotic or Anxiolytic Use Disorder
Severe, Stimulant Use Disorder Severe and
Alcohol Use Disorder Moderate.

Review on 11/9/18 of the Search and Seizure
policy revealed:

-" ...when there is reasonable cause to suspect
that a client has contraband on their person or
within the program, staff/foster parent will conduct
a search of the client and/or premises
...Staff/foster parents may search a client and
their possessions when they are returning to the
program from an off-campus visit or after
receiving visitors when it is reasonable to believe
the client may have items in their possession that
Division of Health Service Regulation

STATE FORM 6899 LBXJ11 If continuation sheet 36 of 38

PRINTED: 12/13/2018
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
Cc
MHL011-371 B. WING ____ 11/20/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE

GREEN LEVEL Il ASHEVILLE, NC 28806

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

DEFICIENCY)
V 503 | Continued From page 36 V 503

are dangerous, illegal ...all searches will be
documented and maintained on file ..."

Review on 11/9/18 of the "Security Scan
Procedure" revealed:

-" ...students will engage in a security scan upon
arrival to campus. This scan will be completed
every time a student enter an Eliada treatment
acility after spending time in the community
...students will be directed to remove outerwear,
urn out pockets, take off/shake out shoes, turn
out waist band, pull up pant legs ...Eliada staff will
pass the wand across their arms and down their
lorso and legs ...students will be prompted to
open backpacks and other bags to make the
contents visible ..."

Review on 11/9/18 of a sample of daily service
notes for Client #1 and Client #2 revealed:

-On 10/1/18" ...Staff led bag and body checks on
[Client #1] ..."

-On 10/1/18" ...Staff led bag and body searches
on [Client #2]. Staff confiscated a cell phone ..."
-On 10/2/18" ...Staff led bag and body searches
...[Client #2] complied with bag and body checks

-On 10/3/18 " ...Staff performed a bag and body
search before allowing [Client #1] to enter the
cottage ..."

-On 10/3/18" ...Staff returned to [cottage] with
[Client #2]. Staff led bag and body searches.
Staff noticed an empty pack of cigarettes ..."

-On 10/5/18 " ...Staff transported [Client #1] back
to campus where staff performed a bag and body
search before allowing her to enter the cottage ..."
-Documentation did not include scope of search,
reason for search, procedure followed in search,
description of property seized or disposition of
seized property.

Division of Health Service Regulation
STATE FORM 6899 LBXJ11 If continuation sheet 37 of 38

PRINTED: 12/13/2018

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHLO011-374 B. WING 11/20/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE

GREEN LEVEL Il ASHEVILLE, NC 28806

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 503 | Continued From page 37 V 503
Interview on 11/8/18 with Residential Counselor
#1 revealed:
-Clients were searched every time they had been
off campus.

-Clients were required to empty pockets and
shake out underwear/bra/clothing and remove
shoes.

Interview on 11/7/18 with Residential Counselor
#4 revealed:
-When clients returned to the cottage from school
or from therapeutic leave a search and scan was
completed. Staff used a wand over their body
and searched any bags. Clients were required to
empty pockets, shake out baggy clothing, turn
down the rim of their socks and take off shoes.
This was documented in their service note.

Interview on 11/9/18 with the Residential Services
Director revealed:

-Scans were conducted on clients after returning
to campus from school or if they had been in the
community.

-These "scans" were not documented as search
and seizure.

Division of Health Service Regulation
STATE FORM 6899 LBXJ11 If continuation sheet 38 of 38

document_type: Statement of Deficiency