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Division of Health Service Regulation

STATEMENT OF DEFICIENCIES

(X1) PROVIDER/SUPPLIER/CLIA

(X2) MULTIPLE CONSTRUCTION

PRINTED: 11/13/2020
FORM APPROVED

(X3) DATE SURVEY

10A NCAC 27G .0201 GOVERNING BODY
POLICIES

(a) The governing body responsible for each
facility or service shall develop and implement
written policies for the following:

(1) delegation of management authority for the
operation of the facility and services;

(2) criteria for admission;

(3) criteria for discharge;

(4) admission assessments, including:

(A) who will perform the assessment; and

(B) time frames for completing assessment.

(5) client record management, including:

(A) persons authorized to document;

(B) transporting records;

(C) safeguard of records against loss, tampering,
defacement or use by unauthorized persons;
(D) assurance of record accessibility to
authorized users at all times; and

(E) assurance of confidentiality of records.

(6) screenings, which shall include:

(A) an assessment of the individual's presenting
problem or need;

(B) an assessment of whether or not the facility
can provide services to address the individual's
needs; and

(C) the disposition, including referrals and

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

STATE FORM

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL004-016 B. WING 11/10/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY WADESBORO, NC 28170
(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000) INITIAL COMMENTS V 000
Acomplaint and follow up survey was completed
on November 10, 2020. The complaint was
substantiated (intake #NC00170720).
Deficiencies were cited.
This facility is licensed for the following service
category: 10A NCAC 27G. 1900 Psychiatric
Residential Treatment Facility for Children and
Adolescents
V 105} 27G .0201 (A) (1-7) Governing Body Policies V 105

6899 $7C011

TITLE (X6) DATE

If continuation sheet 1 of 9

PRINTED: 11/13/2020

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
MHL004-016 B. WING 11/10/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY
WADESBORO, NC 28170
(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 105] Continued From page 1 V 105
recommendations;

(7) quality assurance and quality improvement
activities, including:

(A) composition and activities of a quality
assurance and quality improvement committee;
(B) written quality assurance and quality
improvement plan;

(C) methods for monitoring and evaluating the
quality and appropriateness of client care,
including delineation of client outcomes and
utilization of services;

(D) professional or clinical supervision, including
a requirement that staff who are not qualified
professionals and provide direct client services
shall be supervised by a qualified professional in
that area of service;

(E) strategies for improving client care;

(F) review of staff qualifications and a
determination made to grant
treatment/habilitation privileges:

(G) review of all fatalities of active clients who
were being served in area-operated or contracted
residential programs at the time of death;

(H) adoption of standards that assure operational
and programmatic performance meeting
applicable standards of practice. For this
purpose, "applicable standards of practice"
means a level of competence established with
reference to the prevailing and accepted
methods, and the degree of knowledge, skill and
care exercised by other practitioners in the field;

Division of Health Service Regulation
STATE FORM 6899 $7C011 If continuation sheet 2 of 9

PRINTED: 11/13/2020
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
c
MHL004-016 B. WING _____ 11/10/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

129 WALLCE ROAD

CORNERSTONE TREATMENT FACILITY WADESBORO, NC 28170

(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 105} Continued From page 2 V 105

This Rule is not met as evidenced by:
Based on record review and interviews, the
acility failed to follow the written policy for
discharge. The findings are:

Review on 11/9/20 of the facility's policies
revealed:
-The policy for Discharge/Transfer from a
Residential Facility had the following:
"Cornerstone Treatment Facility shall not
discharge or transfer any resident from a facility
except in case of emergency, without the
advance written notification of the treatment
feam, including the legally responsible
person... The [Qualified Professional and Clinical
Director] will, in consultation with [Executive
Director], develop a plan for discharging the
client. Every effort will be made to maintain the
client for a sufficient period of time to allow the
legally responsible person to obtain alternative
resources."

Review on 11/9/20 of former client (FC #12)
record revealed:

- Admission date of 11/19/19

- Diagnoses of Disruptive Mood Dysregulation
Disorder, Conduct Disorder, Child Sexual Abuse,
Cannabis Use Disorder and Attention Deficit
Hyperactivity Disorder.

- Age 16

-Discharge date 9/21/20

-Discharge Report dated and signed 9/22/20 by
he Executive Director had the following. FC #12
was being discharged due to maximum benefit
termination. "[FC #12] continues to face
challenges with compliance and anger
management at this time. [FC #12] remains
physically and verbally aggressive with staff and
peers. She has become a complete disruption to
Division of Health Service Regulation

STATE FORM 6899 $7C011 If continuation sheet 3 of 9

PRINTED: 11/13/2020

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
MHL004-016 B. WING 11/10/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY
WADESBORO, NC 28170
(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 105} Continued From page 3 V 105

her and peer's overall treatment, safety and
overall healthy emotional wellbeing. She is not
interested in getting better at this time and
refuses to actively work on her treatment or the
betterment of her overall mental health...Current
recommendation is lateral Psychiatric Residential
Treatment Facility (PRTF) transition. Department
of Social Services/Managed Care Organization
(DSS/MCO) was made aware on 8/25/20 that
lateral Psychiatric Residential Treatment Facility
(PRTF) will begin to be sought. Psychiatric
Residential Treatment Facility (PRTF) continued
to seek lateral Psychiatric Residential Treatment
Facility (PRTF) placement however client was
involuntarily committed (IVC'd) on 9/19/20 and no
provider has been identified. [FC #12] was
discharged on 9/21/20 due to: Encouraging other
peers to fight; peers report feeling unsafe with
her; excessive fighting staff and peers, continued
io be very disruptive and aggressive within out
herapeutic milieu. She posed a threat to majority
of our clients and even staff. Lack of compliance
with rules, bullying peers. It continues to be
recommended that client be in Psychiatric
Residential Treatment Facility (PRTF) placement.
[FC #12] was seen by psychiatrist at [Name of
local hospital] under involuntarily committed (IVC)
and deemed inappropriate for ongoing
hospitalization. Department of Social Services
discharged [FC #15] from hospital on 9/21/20."

nterview with the Assistant Clinical Director on
11/10/20 revealed:

-FC #12 reason for discharge was that she had
met maximum benefit.

-They had pretty much exhausted all of the ways
to ensure FC #12 got services needed to address
her aggression.

-FC #12's guardian was made aware of the
issues and that FC #12 would be discharged at
Division of Health Service Regulation

STATE FORM 6899 $7C011 If continuation sheet 4 of 9

PRINTED: 11/13/2020

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
MHL004-016 B. WING 11/10/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY
WADESBORO, NC 28170
(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 105} Continued From page 4 V 105

the end of September 2020.

-She thought she emailed FC #12's Guardian to
inform her about the discharge.

-FC #12's guardian was told, FC #12 would be
discharged on 9/30/20.

-During the treatment team meetings on
September 3 and 17, it was reiterated that FC
#12 was being discharged at the end of
September 2020.

-She thought FC #12's guardian was on the call
on September 17th, but she was not sure about
September 3rd.

-They had been looking for placement for FC
#12, but were unsuccessful.

-FC #12 was going to be discharged at end of
month whether they found placement or not.
-There were several emails and conversations via
telephone about the discharge and places for FC
#12 to be transferred.

-She could not find placement within that
timeframe.

-There were several barriers she faced trying to
find placement.

-When FC #12 went to the hospital on 9/21/20
due to her behaviors, they decided to discharge
her before the discharge date of 9/30/20.

-They did not do a written discharge notice for FC
#12 prior to the discharge on 9/21/20.

-The guardian was not given a discharge notice in
writing for FC #12 prior to the discharge.

-They normally would do a notice of discharge
letter for the parent or guardian.

-In this case they emailed and called the
treatment team for FC #12 about her discharge.
-She confirmed the facility failed to follow the
written policy for discharge.

Interviews with the Executive Director on 11/9/20
and 11/10/20 revealed:

-She thought FC #12 left the facility in September
Division of Health Service Regulation

STATE FORM 6899 $7C011 If continuation sheet 5 of 9

PRINTED: 11/13/2020

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
MHL004-016 B. WING 11/10/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY WADESBORO, NC 28170
(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 105} Continued From page 5 V 105
2020.
-She was discharged due to fighting staff and
clients.
-FC #12 made threats to kill all the clients in their
sleep.

-She was bullying most of the clients.

-Her behaviors were too aggressive and out of
control.

-The police were called because FC #12 tried to
hit another client with a chair.

-One of the former clients tried to jump in, the
other clients were upset and afraid.

-FC #12 was trying to fight staff and peers.

-Once the police arrived, FC #12 was still out of
control.

-FC #12 she was fighting two other clients.

-FC #12 was handcuffed by the police and they
recommended she be involuntarily committed.
-FC #12 was admitted to a local hospital.

-They had already planned to be discharge FC
#12 from the facility.

-They decided to discharge her once she went to
the hospital.

-The Clinical Team here decided to discharge her
earlier than expected.

-She was originally supposed to be discharged on
Sept 29, 2020.

-Once FC #12 left the hospital her guardian
picked her up.

-She was not sure what happened from their
because the guardian was looking for placement.
-FC #12 was supposed to be a lateral move from
this Psychiatric Residential Treatment Facility
(PRTF) to another PRTF.

-She really was not the person responsible for
doing the discharge notice prior to a client being
discharged.

-The Assistant Clinical Director or Clinical Director
would normally be responsible for that process.
-They would be responsible for sending the
Division of Health Service Regulation

STATE FORM 6899 $7C011 If continuation sheet 6 of 9

PRINTED: 11/13/2020

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
MHL004-016 B. WING 11/10/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

129 WALLCE ROAD

CORNERSTONE TREATMENT FACILITY WADESBORO, NC 28170

(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 105} Continued From page 6 V 105

written discharge notice to the clients parent or
guardian.

-She was not sure if the Assistant Clinical Director
or Clinical Director sent a written notice of
discharge to FC #12's guardian.

-She confirmed the facility failed to follow the
written policy for discharge.

V 736| 27G .0303(c) Facility and Grounds Maintenance | V 736

10A NCAC 27G .0303 LOCATION AND
EXTERIOR REQUIREMENTS

(c) Each facility and its grounds shall be
maintained in a safe, clean, attractive and orderly
manner and shall be kept free from offensive
odor.

This Rule is not met as evidenced by:

Based on observation and interview, the facility
failed to ensure facility grounds were maintained
in a safe, clean, attractive and orderly manner.
The findings are:

Observation on 11/10/20 at approximately 8:40
AM of the facility revealed the following issues:
-Hallway/Common Area-There was tape on the
floor, there were approximately 15 strips.
-Clients #7 and #5 bedroom-There was sticker
residue on the plexiglass window. There was a
set of broken blinds. There were playing cards,
papers, notebooks, stuffed animals and clothes
on the floor.

-Client #10's bedroom-The paint was peeling off
the wall.

-Bathroom A-The paint was peeling from wall in

Division of Health Service Regulation
STATE FORM 6899 $7C011 If continuation sheet 7 of 9

PRINTED: 11/13/2020

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
MHL004-016 B. WING 11/10/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY
WADESBORO, NC 28170
(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 736 | Continued From page 7 V 736

two areas. The paint was two different colors on
wall. There was a missing tile on floor.

-Client #8's bedroom-There was sticker residue
on the plexiglass window. There were shoes,
papers, books, notebooks, playing cards and
puzzles on the floor. There was paint peeling near
the bedroom door.

-Client #1's bedroom-There was a broken set of
blinds. There was a white and two brownish spots
on wall. There were pictures, paper, books, and
pencils on the floor.

-Bathroom B-There was peeling paint underneath
the light switch. There were particles of dirt and
dust on the floor behind the toilet area.

-Client #11's bedroom-There were playing cards,
shoes, papers and books on the floor.

-Client #9's bedroom-There were puzzle pieces,
paper, trash and clothes on the floor.

-Bathroom C-There was writing on the door. The
paint was peeling on the walls.

-Client #2's bedroom-There was a broken set of
blinds. The ceiling vent had a portion of the metal
missing. There was sticker debris on the
plexiglass window. The bedroom door had sticker
debris on it.

-Client #6's bedroom- The inside of closet wall
had peeling paint. There was sticker debris on the
plexiglass window.

-The back door to the facility would not close all
the way. The opening was approximately three
inches wide.

Interview with the Executive Director on 11/10/20
revealed:

-She knew the back door to the the facility would
not close all the way.

-Two former clients were responsible for the back
door being that way, they kept kicking it.

-A maintenance person came out and said the
door needed to be replaced.

Division of Health Service Regulation

STATE FORM 6899 $7C011 If continuation sheet 8 of 9

PRINTED: 11/13/2020

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
MHL004-016 B. WING 11/10/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

129 WALLCE ROAD

CORNERSTONE TREATMENT FACILITY WADESBORO, NC 28170

(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 736 | Continued From page 8 V 736
-The maintenance person could not fix the back
door.
-She thought the door has been broken for about
a month.
-She was aware of most of the issues with the
facility.

-She has put in some work orders for the issues
with the facility.

-Some of the issues were addressed, but others
were not.

-She confirmed the facility failed to ensure facility
grounds were maintained in a safe, clean,
attractive and orderly manner.

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

Division of Health Service Regulation
STATE FORM 6899 $7C011 If continuation sheet 9 of 9


state: NC

facility_name: Cornerstone Treatment Facility

summary: Statement of Deficiency - MHLCS Complaint

raw_content:
Division of Health Service Regulation

PRINTED: 09/11/2020
FORM APPROVED

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

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

(1) reporting provider contact and
identification information;

(2) client identification information;

(3) type of incident;

(4) description of incident;

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

(6) other individuals or authorities notified

or responding.
(b) Category A and B providers shall explain any

Division of Health Service Regulation

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

STATE FORM

6899

G4HJ11

TITLE

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL004-016 09/08/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY
WADESBORO, NC 28170
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000} INITIAL COMMENTS V 000
Acomplaint survey was completed on September
8, 2020. The complaint (intake #NC00167664)
was substantiated. Deficiencies cited.
This facility is licensed for the following service
category: 10A NCAC 27G. 1900
Psychiatric Residential Treatment Facility for
Children and Adolescents
V 367] 27G .0604 Incident Reporting Requirements V 367

(X6) DATE

If continuation sheet 1 of 20

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/11/2020
FORM APPROVED

(X3) DATE SURVEY

missing or incomplete information. The provider
shall submit an updated report to all required
report recipients by the end of the next business
day whenever:

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

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

(1) hospital records including confidential
information;

(2) reports by other authorities; and

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

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

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

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

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

Division of Health Service Regulation
STATE FORM

6809

G4HJ11

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL004-016 09/08/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY
WADESBORO, NC 28170
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 367 | Continued From page 1 V 367

If continuation sheet 2 of 20

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/11/2020
FORM APPROVED

(X3) DATE SURVEY

the definition of a level II or level III incident;

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

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

(6) a statement indicating that there have

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

This Rule is not met as evidenced by:

Based on record review and interview the facility
failed to ensure a Level II incident report was
completed and submitted to the Local Managed
Entity/Managed Care Organization (LME/MCO)
within 72 hours. The findings are:

Review on 9/1/20 of the Facility's Level | Incident
report dated 6/19/20 at 2:30 p.m. revealed:

- "[Client #2] was in the self-reflection processing
with [Executive Director] about the incident that
happened earlier and stated [Client #2] don't want
to be here. [Client #2] begin to yell, scream, and
punch the wall. [Client #2] walked out of the
self-reflection from and made a left and walked
out [Client #2's] assigned area going to the front
lobby and a 733 was called. [Executive Director]
and [Staff #8] in behind [Client #2] and escorted
[Client #2] back to [Client #2's] room. First
Responder [Staff #3] on the scene witched out

Division of Health Service Regulation

STATE FORM

6809

G4HJ11

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL004-016 09/08/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY
WADESBORO, NC 28170
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 367 | Continued From page 2 V 367

If continuation sheet 3 of 20

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/11/2020
FORM APPROVED

(X3) DATE SURVEY

with [Executive Director] to escort [Client #2] to
her room. [Client #2] in [Client #2's] room
continue to yell and scream stating [Client #2]
want her family. Staff monitoring [Client #2] and
[Client #2] grab a piece of clothing and
headphones and attempt to put it around [Client
#2's] neck. First Responder [Staff #3] and Senior
First Responder [Staff #14] intervene to secure
the scene. [Clinical Director] notified all clients
items removed to due to safety issues. Staff
continued monitoring throughout the shift.
Guardian was notified."

Review on 9/1/20 of the Facility's Level II Incident
report dated 6/19/20 at 5:00 p.m. revealed:

- "[Client #2] became angry, loud and cursing at
peers. [Client #2] was upset because she could
not get her DVD player due to safety issues.
[Client #2] was told to go to [Client #2's] room.
[Client #2] kicked wall and door. [Client #2]
closed bedroom door on staff. [Client #2] was
kicking and hitting staff. Supported staff was
called and a 2-man therapeutic hold was
administered for 15 minutes. [Client #2] was able
to calm down reach tension reduction. Staff
processed with [client #2] in [Client #2's] room."

Review on 9/1/20 of the Facility's Level II Incident
report dated 7/11/20 at 8:40 p.m. revealed:

- "While inside the conference room, [Client #2]
informed staff that [Client #2] wanted to go inside
the closet and retrieve the bingo game. Staff
informed [Client #2] that it is the responsibility of
staff and they would get it for [client #2]. [Client
#2] became upset and left the conference area
and went into [Client #2's] room. While preparing
consumers to go to the recreation area to enjoy
outdoor activities, staff walked to [Client #2's]
room and opened the door in order to maintain a
direct line of site. [Client #2] jumped and

Division of Health Service Regulation

STATE FORM

6809

G4HJ11

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL004-016 09/08/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY
WADESBORO, NC 28170
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 367 | Continued From page 3 V 367

If continuation sheet 4 of 20

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/11/2020
FORM APPROVED

(X3) DATE SURVEY

attempted to place an unknown object inside of
[Client #2's] clothing. Staff inform supported staff
of the [Client #2's] actions. Staff went to process
with [Client #2]. [Client #2] became verbally
aggressive shouting at staff to leave [Client #2]
alone and get out of [Client #2's] room while
clutching [Client #2's] hand. Staff searched
[Client #2] personal affects. While staff was
searching, [Client #2] became increasingly
verbally aggressive toward staff. [Client #2] got
up and attempted to grab clothes from staff.
While searching [Client #2's] personal items staff
removed broken headphone with exposed wire,
brown color pencil and one marker. Staff
attempted to search a package of hair that was
on the [Client #2's] bed for contraband. When
staff picked up the hair, [Client #2] pushed and
kicked staff attempting to take the hair. [Client
#2] was placed in a two-man therapeutic hold
lasting two minutes until tension reduction was
met."

Interview on 9/3/20 with Representative from
State Agency revealed:

-She did not receive the 2:30 p.m. Level II
incident report dated 6/19/20.

-She received the 5:00 p.m. Level II incident
report dated 6/19/20 on 6/23/20.

-She received the 7/11/20 Level II incident report
on 7/15/20.

-She reported the incident reports should be
submitted within 24 hours or if on a Friday the
next working day.

Interview on 9/8/20 with the Executive Director
revealed:

-Level | reports were submitted to the
Administrative Assistant to complete Level II
reports.

-Administrative Assistant was responsible for

Division of Health Service Regulation

STATE FORM

6809

G4HJ11

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL004-016 09/08/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY
WADESBORO, NC 28170
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 367 | Continued From page 4 V 367

If continuation sheet 5 of 20

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/11/2020
FORM APPROVED

(X3) DATE SURVEY

10A NCAC 27E .0104 SECLUSION,
PHYSICAL RESTRAINT AND ISOLATION
TIME-OUT AND PROTECTIVE DEVICES USED
FOR BEHAVIORAL CONTROL

(c) Restrictive interventions shall not be
employed as a means of coercion, punishment or
retaliation by staff or for the convenience of staff
or due to inadequacy of staffing. Restrictive
interventions shall not be used in a manner that
causes harm or abuse.

(d) In accordance with Rule .0101 of Subchapter
27D, the governing body shall have policy that
delineates the permissible use of restrictive
interventions within a facility.

This Rule is not met as evidenced by:

Based on record review and interviews the
facility failed to (1)notify others when restrictive
intervention was utilized; (2)assure authorization
for intervention made by a phyisician; (3)conduct
review/report of restrict intervention; (4)
implement policies/procedures by submitting
reports to agencies after restrictive intervention
for one of three auditied clients (#2). The findings
are:

Review on 9/1/20 of the Facility's Level | Incident
report dated 6/19/20 at 2:30 p.m. revealed:

- "[Client #2] was in the self-reflection processing
with [Executive Director] about the incident that
happened earlier and stated [Client #2] don't want
to be here. [Client #2] begin to yell, scream, and

Division of Health Service Regulation
STATE FORM

6809

G4HJ11

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL004-016 09/08/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY
WADESBORO, NC 28170
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 367 | Continued From page 5 V 367
completing Level Il reports and sending to
appropriate agencies within 72 hours.
V 517] 27E .0104(c-d) Client Rights - Sec. Rest. & ITO V 517

If continuation sheet 6 of 20

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/11/2020
FORM APPROVED

(X3) DATE SURVEY

punch the wall. [Client #2] walked out of the
self-reflection from and made a left and walked
out [Client #2's] assigned area going to the front
lobby and a 733 was called. [Executive Director]
and [Staff #8] in behind [Client #2] and escorted
[Client #2] back to [Client #2's] room. First
Responder [Staff #3] on the scene witched out
with [Executive Director] to escort [Client #2] to
her room. [Client #2] in [Client #2's] room
continue to yell and scream stating [Client #2]
want her family. Staff monitoring [Client #2] and
[Client #2] grab a piece of clothing and
headphones and attempt to put it around [Client
#2's] neck. First Responder [Staff #3] and Senior
First Responder [Staff #14] intervene to secure
the scene. [Clinical Director] notified all clients
items removed to due to safety issues. Staff
continued monitoring throughout the shift.
Guardian was notified."

-There was no level Il report completed.

-There was no level Il report submitted or
received by the appropriate agencies.

-There was no documentation client #2's
guardian was contacted, time and discussion.
-There was no documentation of follow-up care
with the therapist.

-There was no residential staff shift notes to
monitor client #2 throughout the shift and day.
-Level | report documented by Registered Nurse
#2 indicated follow-up time was 1 hour.

-There were no nurse notes after the restraint.
-There was no evidence of debriefing with client
#2 and staff.

Review on 9/1/20 of the Facility's Level II Incident
report dated 6/19/20 at 5:00 p.m. revealed:

- "[Client #2] became angry, loud and cursing at
peers. [Client #2] was upset because she could
not get her DVD player due to safety issues.
[Client #2] was told to go to [Client #2's] room.

Division of Health Service Regulation

STATE FORM

6809

G4HJ11

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL004-016 09/08/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY
WADESBORO, NC 28170
(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 517] Continued From page 6 V 517

If continuation sheet 7 of 20

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/11/2020
FORM APPROVED

(X3) DATE SURVEY

[Client #2] kicked wall and door. [Client #2]
closed bedroom door on staff. [Client #2] was
kicking and hitting staff. Supported staff was
called and a 2-man therapeutic hold was
administered for 15 minutes. [Client #2] was able
to calm down reach tension reduction. Staff
processed with [client #2] in [Client #2's] room."
-Level | incident report did not indicate reason for
the restraint.

-Level Il incident was not submitted and received
appropriate agencies until 6/23/20.

-There was no documentation client #2's
guardian was contacted, time and discussion.
-There was no documentation of follow-up care
with the therapist.

-There was no residential staff shift notes to
monitor client #2 throughout the shift and day.

- Level | or Level II did not identify staff involved in
restraining client #2.

Review on 9/1/20 of the Facility's Level II Incident
report dated 7/11/20 at 8:40 p.m. revealed:

- "While inside the conference room, [Client #2]
informed staff that [Client #2] wanted to go inside
the closet and retrieve the bingo game. Staff
informed [Client #2] that it is the responsibility of
staff and they would get it for [client #2]. [Client
#2] became upset and left the conference area
and went into [Client #2's] room. While preparing
consumers to go to the recreation area to enjoy
outdoor activities, staff walked to [Client #2's]
room and opened the door in order to maintain a
direct line of site. [Client #2] jumped and
attempted to place an unknown object inside of
[Client #2's] clothing. Staff inform supported staff
of the [Client #2's] actions. Staff went to process
with [Client #2]. [Client #2] became verbally
aggressive shouting at staff to leave [Client #2]
alone and get out of [Client #2's] room while
clutching [Client #2's] hand. Staff searched

Division of Health Service Regulation

STATE FORM

6809

G4HJ11

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL004-016 09/08/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY
WADESBORO, NC 28170
(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 517] Continued From page 7 V 517

If continuation sheet 8 of 20

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/11/2020
FORM APPROVED

(X3) DATE SURVEY

[Client #2] personal affects. While staff was
searching, [Client #2] became increasingly
verbally aggressive toward staff. [Client #2] got
up and attempted to grab clothes from staff.
While searching [Client #2's] personal items staff
removed broken headphone with exposed wire,
brown color pencil and one marker. Staff
attempted to search a package of hair that was
on the [Client #2's] bed for contraband. When
staff picked up the hair, [Client #2] pushed and
kicked staff attempting to take the hair. [Client
#2] was placed in a two-man therapeutic hold
lasting two minutes until tension reduction was
met."

-Level Il incident was not submitted and received
by appropriate agencies until 7/15/20.

-There was no documentation client #2's
guardian was contacted, time and discussion.
-There was no documentation of follow-up care
with the therapist.

-There was no residential staff shift notes to
monitor client #2 throughout the shift and day.
-Level | or Level II did not identify staff involved in
restraining client #2.

-Level | indicated telephone order for restraint on
7/11/20 by the medical doctor.

-There was no evidence the doctor signed the
telephone verbal order within 24 hours.

Review on 9/1/20 of the Facility's Level II Incident
report dated 7/13/20 at 9:08 p.m. revealed:

- "[Client #2] was in nursing station speaking to
the Clinical Director about prior altercation.

[Client #2] walked to [Client #2's] room and began
to beat on the wall in an aggressive manner.

Staff approached [Client #2] room and asked who
was beating on the wall the peer stated the [Client
#2] did. [Client #2] ran pass staff and hit peer in
the face. Staff intervened and the [Client #2] tried
to approach peer again. When separated [Client

Division of Health Service Regulation

STATE FORM

6809

G4HJ11

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL004-016 09/08/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY
WADESBORO, NC 28170
(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 517] Continued From page 8 V 517

If continuation sheet 9 of 20

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/11/2020
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL004-016 09/08/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY
WADESBORO, NC 28170
(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 517] Continued From page 9 V 517

#2] kicked leg and hit staff in the face and ran
down the hall to the community area. Staff was
notified by the Clinical Director to call the police.
The police arrived and processed with [Client #2].
[Client #2] had no regard, remorse or respect for
the officers. Staff continued to process with
[Client #2] approximately one hour. [Client #2]
stated [Client #2] was going to throw water at
staff. Staff tried to redirect [Client #2's] actions.
[Client #2] picked up the cup of water and
attempted to throw it at staff. Staff was able to
grab the cup preventing the water from splashing
on staff. [Client #2] became physically
aggressive kicking and biting staff. [Client #2]
was put in a 2-man therapeutic hold for 5 minutes
until tension reduction had been reached. [Client
#2] became verbally aggressive toward staff.
[Client #2] walked over to staff attempting to hit
staff. Staff prevented consumer from hitting staff.
[Client #2] became upset and grabbed staff's eye
glasses off the table and broke them. [Client #2]
attempted to assault staff again by walking up to
them. As [Client #2] was approaching staff,
[Client #2] slipped on the water that [Client #2]
threw at staff, hitting [Client #2's] head on the
floor. [Client #2] held [Client #2's] head and
began to cry. Staff continued to process with
[Client #2] as [Nurse #2] performed a physical
assessment."

-There was no documentation client #2's
guardian was contacted, time and discussion.
-There was no documentation of follow-up care
with the therapist.

-There was no residential staff shift notes to
monitor client #2 throughout the shift and day.
-Level | indicated telephone order for restraint on
7/13/20 by the medical doctor.

-There was no evidence the doctor signed the
telephone verbal order within 24 hours.

Division of Health Service Regulation
STATE FORM

6809

G4HJ11

If continuation sheet 10 of 20

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/11/2020
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL004-016 09/08/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY
WADESBORO, NC 28170
(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 517] Continued From page 10 V 517

Interview on 9/3/20 with Representative from
State Agency revealed:

-She did not receive the 2:30 p.m. Level II
incident report dated 6/19/20.

-She received the 5:00 p.m. Level II incident
report dated 6/19/20 on 6/23/20.

-She received the 7/11/20 Level II incident report
on 7/15/20.

-She reported the incident reports should be
submitted within 24 hours or if on a Friday the
next working day.

Interview on 9/8/20 with the Executive Director
revealed:

-Level | reports were submitted to the
Administrative Assistant to complete Level II
reports.

-Administrative Assistant was responsible for
completing Level Il reports and sending to
appropriate agencies within 72 hours.

-She contacted the clinical director to submit
therapy notes regarding restraints and follow-up
care with client #2.

-The doctor had 24 hours to sign telephone
verbal restraint orders.

-There were no residential shift notes provided
upon exit.

-There were no clinical notes from the clinical
director provided upon exit.

-She confirmed requesting clinical notes from the
clinical director.

-The clinical director split time with the company's
other facility and was not always at the facility.
-She would be the person to contact the
guardians often less than 1 hour of the restraint
or between 1-2 hours.

-Confirmed she did not have documentation to
support the contact with client #2's guardian.
-She would address all identified issues and
concerns with direct care and professional staff.

Division of Health Service Regulation
STATE FORM

6809

G4HJ11

If continuation sheet 11 of 20

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/11/2020
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL004-016 09/08/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY
WADESBORO, NC 28170
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 536] 27E .0107 Client Rights - Training on Alt to Rest. V 536

Int.

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

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

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

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

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

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

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

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

(1) knowledge and understanding of the
people being served;
(2) recognizing and interpreting human

Division of Health Service Regulation
STATE FORM

6809

G4HJ11

If continuation sheet 12 of 20

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/11/2020
FORM APPROVED

(X3) DATE SURVEY

behavior;

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

(4) strategies for building positive
relationships with persons with disabilities;
(5) recognizing cultural, environmental and

organizational factors that may affect people with
disabilities;

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

(7) skills in assessing individual risk for
escalating behavior;
(8) communication strategies for defusing

and de-escalating potentially dangerous behavior;
and

(9) positive behavioral supports (providing
means for people with disabilities to choose
activities which directly oppose or replace
behaviors which are unsafe).

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

(1) Documentation shall include:

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

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

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

(i) Instructor Qualifications and Training
Requirements:

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

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

Division of Health Service Regulation
STATE FORM

6809

G4HJ11

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL004-016 09/08/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY
WADESBORO, NC 28170
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 536 | Continued From page 12 V 536

If continuation sheet 13 of 20

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/11/2020
FORM APPROVED

(X3) DATE SURVEY

instructor training program.

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

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

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

(A) understanding the adult learner;

(B) methods for teaching content of the
course;

(C) methods for evaluating trainee

performance; and

(D) documentation procedures.

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

(7) Trainers shall teach a training program
aimed at preventing, reducing and eliminating the
need for restrictive interventions at least once
annually.

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

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

(1) Documentation shall include:

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

(B) when and where attended; and

(C) instructor's name.

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

Division of Health Service Regulation
STATE FORM

6809

G4HJ11

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL004-016 09/08/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY
WADESBORO, NC 28170
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 536 | Continued From page 13 V 536

If continuation sheet 14 of 20

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/11/2020
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL004-016 09/08/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY
WADESBORO, NC 28170
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 536 | Continued From page 14 V 536

request and review this documentation any time.
(k) Qualifications of Coaches:

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

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

(3) Coaches shall demonstrate
competence by completion of coaching or
train-the-trainer instruction.

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

This Rule is not met as evidenced by:

Based on record review and interview, the facility
failed to ensure 2 of 13 audited staff (#8 and
#13) received recertification training in Alternative
to Restrictive Interventions. The findings are:

Review on 9/8/20 of Staff #8 personnel record
revealed:

-Hire date of 8/12/18.

-Employed as Residential Mental - 2nd shift.
-Crisis Prevention Intervention expired 8/6/20.
-There was no current CPI training certification in
the personnel record.

Review on 9/8/20 of Staff #13 personnel record
revealed:

-Hire date of 9/1/19.

-Employed as Residential Mental - 2nd and 3rd
shift.

-Crisis Prevention Intervention expired 8/3/20.
-There was no current CPI training certification in

Division of Health Service Regulation
STATE FORM

6809

G4HJ11

If continuation sheet 15 of 20

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/11/2020
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED
Cc
MHL004-016 09/08/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY
WADESBORO, NC 28170
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 536 | Continued From page 15 V 536
the personnel record.
Interview on 9/8/20 with the Executive Director
revealed:
-The agency trained staff on CPI and facilitated
by the facility's first responder and senior first
responder..
-The administrative assistant was supposed to
keep track when it was time for recertifications.
-Confirmed staff #8 and #13 CPI training expired.
V 537] 27E .0108 Client Rights - Training in Sec Rest & V 537

ITO

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

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

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

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

(d) The training shall be competency-based,

Division of Health Service Regulation
STATE FORM

6809

G4HJ11

If continuation sheet 16 of 20

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/11/2020
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL004-016 09/08/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY
WADESBORO, NC 28170
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 537] Continued From page 16 V 537

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

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

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

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

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

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

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

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

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

(6) prohibited procedures;

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

(8) documentation methods/procedures.

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

(1) Documentation shall include:

Division of Health Service Regulation
STATE FORM

6809

G4HJ11

If continuation sheet 17 of 20

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/11/2020
FORM APPROVED

(X3) DATE SURVEY

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

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

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

(i) Instructor Qualification and Training
Requirements:

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

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

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

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

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

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

(A) understanding the adult learner;

(B) methods for teaching content of the
course;

(C) evaluation of trainee performance; and

(D) documentation procedures.
(7) Trainers shall be retrained at least
annually and demonstrate competence in the use

Division of Health Service Regulation
STATE FORM

6809

G4HJ11

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL004-016 09/08/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY
WADESBORO, NC 28170
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 537] Continued From page 17 V 537

If continuation sheet 18 of 20

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/11/2020
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL004-016 09/08/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY
WADESBORO, NC 28170
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 537 Continued From page 18 V 537

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

Rule.

(8) Trainers shall be currently trained in
CPR.

(9) Trainers shall have coached experience

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

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

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

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

(1) Documentation shall include:

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

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

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

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

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

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

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

This Rule is not met as evidenced by:

Division of Health Service Regulation
STATE FORM

6809

G4HJ11

If continuation sheet 19 of 20

Division of Health Service Regulation

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

MHL004-016

NAME OF PROVIDER OR SUPPLIER

A. BUILDING:

129 WALLCE ROAD
WADESBORO, NC 28170

CORNERSTONE TREATMENT FACILITY

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/11/2020

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

Cc
09/08/2020

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

Based on record review and interview the facility
failed to ensure 2 of 13 audited staff (#8 and #13)
had training in seclusion, physical restraint and
isolation time-out. The finding are:

Review on 9/8/20 of Staff #8 personnel record
revealed:

-Hire date of 8/12/18.

-Employed as Residential Mental - 2nd shift.
-Crisis Prevention Intervention expired 8/6/20.
-There was no current CPI training certification in
the personnel record.

Review on 9/8/20 of Staff #13 personnel record
revealed:

-Hire date of 9/1/19.

-Employed as Residential Mental - 2nd and 3rd
shift.

-Crisis Prevention Intervention expired 8/3/20.
-There was no current CPI training certification in
the personnel record.

Interview on 9/8/20 with the Executive Director
revealed:

-The agency trained staff on CPI and facilitated
by the facility's first responder and senior first
responder.

-The administrative assistant was supposed to
keep track when it was time for recertifications.
-Confirmed staff #8 and #13 CPI training expired.

Division of Health Service Regulation
STATE FORM

6809

G4HJ11

If continuation sheet 20 of 20

inspection_type: MHLCS Complaint

document_type: Statement of Deficiency


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

raw_content:
PRINTED: 02/05/2020
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:
MHL004-016 B. WING ____ 01/29/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

129 WALLCE ROAD

CORNERSTONE TREATMENT FACILITY WADESBORO, NC 28170

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

DEFICIENCY)
V 000} INITIAL COMMENTS V 000

An annual, complaints and follow-up survey was
completed on January 29, 2020. The complaint
#NC00160490 was substantiated. Complaints
#NC00160181and #NC00160438 were
unsubstantiated. Deficiencies were cited.

This facility is licensed for the following service
category: 10A NCAC 27G .1900 Psychiatric
Residential Treatment for Children and
Adolescents.

V 364] G.S. 122C- 62 Additional Rights in 24 Hour V 364
Facilities

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

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

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

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

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

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

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

(1) Make and receive confidential telephone
calls. All long distance calls shall be paid for by

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

STATE FORM 6899 KEGH11 If continuation sheet 1 of 10

PRINTED: 02/05/2020

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
MHL004-016 B. WING ____ 01/29/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY
WADESBORO, NC 28170
(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

V 364] Continued From page 1 V 364

the client at the time of making the call or made
collect to the receiving party;

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

(3) Communicate and meet under appropriate
supervision with individuals of his own choice
upon the consent of the individuals;

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

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

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

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

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

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

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

(7) Participate in religious worship;

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

(9) Retain a driver's license, unless otherwise

Division of Health Service Regulation
STATE FORM 6899 KEGH11 If continuation sheet 2 of 10

PRINTED: 02/05/2020
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:
MHL004-016 B. WING ____ 01/29/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

129 WALLCE ROAD

CORNERSTONE TREATMENT FACILITY WADESBORO, NC 28170

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

DEFICIENCY)
V 364] Continued From page 2 V 364
prohibited by Chapter 20 of the General Statutes;
and

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

(c) In addition to the rights enumerated in G.S.
122C-51 through G.S. 122C-57 and G.S.
122C-59 through G.S. 122C-61, each minor client
who is receiving treatment or habilitation in a
24-hour facility has the right to have access to
proper adult supervision and guidance. In
recognition of the minor's status as a developing
individual, the minor shall be provided
opportunities to enable him to mature physically,
emotionally, intellectually, socially, and
vocationally. In view of the physical, emotional,
and intellectual immaturity of the minor, the
24-hour facility shall provide appropriate
structure, supervision and control consistent with
the rights given to the minor pursuant to this Part.
The facility shall also, where practical, make
reasonable efforts to ensure that each minor
client receives treatment apart and separate from
adult clients unless the treatment needs of the
minor client dictate otherwise.

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

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

The rights specified in this subsection may not be
restricted by the facility and each minor client

Division of Health Service Regulation
STATE FORM 6899 KEGH11 If continuation sheet 3 of 10

PRINTED: 02/05/2020

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
MHL004-016 B. WING ____ 01/29/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY
WADESBORO, NC 28170
(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

V 364] Continued From page 3 V 364

may exercise these rights at all reasonable times.
(d) Except as provided in subsections (e) and (h)
of this section, each minor client who is receiving
treatment or habilitation in a 24-hour facility has
the right to:

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

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

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

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

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

(7) Participate in religious worship;

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

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

(10)Retain a driver's license, unless otherwise
prohibited by Chapter 20 of the General Statutes.
(e) No right enumerated in subsections (b) or (d)
of this section may be limited or restricted except
by the qualified professional responsible for the
formulation of the client's treatment or habilitation

Division of Health Service Regulation
STATE FORM 6899 KEGH11 If continuation sheet 4 of 10

PRINTED: 02/05/2020

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
MHL004-016 B. WING ____ 01/29/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY
WADESBORO, NC 28170
(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

V 364] Continued From page 4 V 364

plan. Awritten statement shall be placed in the
client's record that indicates the detailed reason
for the restriction. The restriction shall be
reasonable and related to the client's treatment or
habilitation needs. A restriction is effective for a
period not to exceed 30 days. An evaluation of
each restriction shall be conducted by the
qualified professional at least every seven days,
at which time the restriction may be removed.
Each evaluation of a restriction shall be
documented in the client's record. Restrictions on
rights may be renewed only by a written
statement entered by the qualified professional in
the client's record that states the reason for the
renewal of the restriction. In the case of an adult
client who has not been adjudicated incompetent,
in each instance of an initial restriction or renewal
of a restriction of rights, an individual designated
by the client shall, upon the consent of the client,
be notified of the restriction and of the reason for
it. In the case of a minor client or an incompetent
adult client, the legally responsible person shall
be notified of each instance of an initial restriction
or renewal of a restriction of rights and of the
reason for it. Notification of the designated
individual or legally responsible person shall be
documented in writing in the client's record.

This Rule is not met as evidenced by:

Based on interviews, and observation, the facility
failed to: a) Ensure clients were allowed to keep
and use personal clothing under appropriate
supervision affecting 3 of 3 clients (Clients #1, #2,
and #3) and b). Ensure that clients have the
opportunity to make and receive confidential
telephone calls affecting 3 of 3 clients (Clients #1,
Division of Health Service Regulation

STATE FORM 6899 KEGH11 If continuation sheet 5 of 10

PRINTED: 02/05/2020
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:
MHL004-016 B. WING ____ 01/29/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

129 WALLCE ROAD

CORNERSTONE TREATMENT FACILITY WADESBORO, NC 28170

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

DEFICIENCY)
V 364] Continued From page 5 V 364

#2, and #3). The findings are:

Review on 1/29/20 of Client #1's record revealed:
-Admission date of 10/14/19.

-Diagnoses of Post Traumatic Stress Disorder;
Unspecified Disruptive Impulsive Control;
Conduct Disorder; Attention Deficit Hyperactivity
Disorder, Combined Presentation; Child Physical
Abuse; Child Neglect.

-Current treatment plan dated 12/17/19 does not
indicate the removal or refrain from using
personal clothing.

Review on 1/29/20 of Client #2's record revealed:
-Admission date of 12/21/18.

-Diagnoses of Disruptive Mood Disregulation
Disorder; Rule Out Post Traumatic Stress
Disorder; Attention Deficit Hyperactivity Disorder,
Combined Presentation (per history); Child
Physical Abuse; Child Neglect.

-Current treatment plan dated 1/7/20 does not
indicate the removal or refrain from using
personal clothing.

Review on 1/29/20 of Client #3's record revealed:
-Admission date of 11/19/19.

-Diagnoses of Disruptive Mood Dysregulation
Disorder; Conduct Disorder, Childhood Onset
Type; Attention Deficit Hyperactivity Disorder,
Combined Presentation; Child Sexual Abuse;
Child Neglect (per history).

-Current treatment plan dated 1/6/20 does not
indicate the removal or refrain from using
personal clothing.

Review on 1/29/20 of the agency's website's
Questions and Answers revealed

Q- What items do | need to bring for my child on
the day of admission?

A-The facility provides uniform clothing,

Division of Health Service Regulation

STATE FORM 6899 KEGH11 If continuation sheet 6 of 10

PRINTED: 02/05/2020

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
MHL004-016 B. WING ____ 01/29/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY
WADESBORO, NC 28170
(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

V 364] Continued From page 6 V 364

underwear, slippers and hygiene items.

Q: Are residents allowed to make and receive
phone calls?

A: Yes. Communication with our residents is
encouraged. You will be provided with a phone
call schedule shortly after admission to ensure
each resident has an opportunity to call loved
ones.

Interview on 1/29/20 with Client #1 revealed:
-She had to wear uniforms during education time.
-She was allowed to change into her regular
clothes after education time.

-She was only able to use the phone on certain
days of the week and at certain times.

Interview on 1/29/20 with Client #2 revealed:
-She had to wear uniforms during education time.
-She was allowed to change into her regular
clothes after education time.

-She was able to use the telephone, but she had
nobody to call.

-Other girls were able to call their family on
certain days of the week and at certain times.

Interview on 1/29/20 with Client #3 revealed:
-She had to wear uniforms during education time.
-She was allowed to change into her regular
clothes after education time.

-She was only able to use the phone on certain
days of the week and at certain times.

Observation on 1/29/20 at approximately 1:15 PM
of the facility revealed:
-All students were wearing uniforms.

Interview on 1/29/20 with the Executive Director
revealed:

-All students worn their uniforms during education
time.

Division of Health Service Regulation

STATE FORM 6899 KEGH11 If continuation sheet 7 of 10

PRINTED: 02/05/2020

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
MHL004-016 B. WING ____ 01/29/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY
WADESBORO, NC 28170
(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

V 364] Continued From page 7 V 364

-Students were able to change into their regular
clothes afterwards.

-Person from Disability Rights had come and
explained the general statutes regarding client
rights in a 24 hour facility.

-Schedules to use the telephone was
implemented in order to not allow disruption of
education time and for clients not to use it all at
the same time.

-lf a student really needed to use the phone, they
were allowed by the staff at any time.

-She acknowledged that students had to wear
their uniform during education time and that they
were able to make use of the telephone only at
their scheduled times.

V 736| 27G .0303(c) Facility and Grounds Maintenance | V 736

10A NCAC 27G .0303 LOCATION AND
EXTERIOR REQUIREMENTS

(c) Each facility and its grounds shall be
maintained in a safe, clean, attractive and orderly
manner and shall be kept free from offensive
odor.

This Rule is not met as evidenced by:

Based on observation and interview, the facility
failed to ensure facility grounds were maintained
in a clean, safe and attractive manner. The
findings are:

Observation on 1/29/20 between 1:17 p.m. and
1:30 p.m. of the facility revealed:

-Hallway- There was a large section of paint
chipping away from wall outside of bedroom #2.
There was a golf size hole on the wall next to

Division of Health Service Regulation
STATE FORM 6899 KEGH11 If continuation sheet 8 of 10

PRINTED: 02/05/2020

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
MHL004-016 B. WING ____ 01/29/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY
WADESBORO, NC 28170
(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 736 | Continued From page 8 V 736

bathroom #1.

-Bedroom #1- Edges between flooring and walls
were dark and stained in brown color.
-Bedroom #2- Edges between flooring and walls
were dark and stained in brown color.
-Bedroom #3- Edges between flooring and walls
were dark and stained in brown color. There was
a large crack inside the closet.
-Bedroom #4- Edges between flooring and walls
were dark and stained in brown color.
-Bedroom #5- Edges between flooring and walls
were dark and stained in brown color.
-Bedroom #6- Edges between flooring and walls
were dark and stained in brown color. There were
several sections of paint peeled off on the
wall and repaired patches on the wall needed to
be repainted.
-Bedroom #7- Edges between flooring and walls
were dark and stained in brown color. There were
sections of paint peeled off from the
wall next to the light switch.
-Bedroom #8- Edges between flooring and walls
were dark and stained in brown color. Scratches
on the wall.
-Bedroom #9- Edges between flooring and walls
were dark and stained in brown color. Patches of

paint were peeled off near the window.
-Bathroom #B- Paint was peeled off by the light
switch.

-Bathroom #C- Handle from faucet came off.
-Activity Room- Several stains/markings observed
on the ceiling. Walls were dirty/stained.

Interview on 1/29/20 with the Executive Director
revealed:

-She was aware that the facility needed to be
repainted at certain places.

-Indicated that the paint was being peeled off
from the residents at the facility.

-She was aware of floorings being stained along
Division of Health Service Regulation

STATE FORM 6899 KEGH11 If continuation sheet 9 of 10

PRINTED: 02/05/2020

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
MHL004-016 B. WING 01/29/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

129 WALLCE ROAD

CORNERSTONE TREATMENT FACILITY WADESBORO, NC 28170

(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 736 | Continued From page 9 V 736

the edges that meet the walls. Attributed it to wax
being built up after floors get waxed.

-She was not aware that the handle from
bathroom #C had come off.

-Maintenance staff was present on premises and
making needed repairs.

-Maintenance staff was to replace handle from
faucet in bathroom #C and touch up on places
needing paint.

-She confirmed the facility failed to ensure facility
grounds were maintained in a clean, safe and
attractive manner.

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

Division of Health Service Regulation
STATE FORM 6899 KEGH11 If continuation sheet 10 of 10

inspection_type: MHLCS Annual, Complaint, and Follow-up


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

raw_content:
Division of Health Service Regulation

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

MHL004-016

CORNERSTONE TREATMENT FACILITY

A. BUILDING:

B. WING

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
WADESBORO, NC 28170

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

PRINTED: 05/24/2019
FORM APPROVED

COMPLETED

05/23/2019

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

ID
PREFIX
TAG

PROVIDER'S PLAN OF CORRECTION (x5)
(EACH CORRECTIVE ACTION SHOULD BE COMPLETE

CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

V 000} INITIAL COMMENTS

An annual and follow-up survey was completed
on May 23, 2019. Deficiencies were cited.

This facility is licensed for the following services
category: 10A NCAC 27G 1900 Psychiatric
Residential Treatment for Children and
Adolescents.

V 736] 27G .0303(c) Facility and Grounds Maintenance

10A NCAC 27G .0303 LOCATION AND
EXTERIOR REQUIREMENTS

(c) Each facility and its grounds shall be
maintained in a safe, clean, attractive and orderly
manner and shall be kept free from offensive
odor.

This Rule is not met as evidenced by:

Based on observation and interview, the facility
failed to ensure facility grounds were maintained
in a clean, safe and attractive manner. The
findings are:

Observation on 5/23/19 between 12:00 p.m. and
12:20 p.m. of the facility revealed:

-Inside of door leading to education room- Paint
was chipping off.

-Hallway- There was a large section of paint
chipping away from wall outside of bedroom #2.
There was a golf size hole on the wall next to
bathroom #1.

-Bedroom #2- Paint on bottom of window was
peeled off.

-Bedroom #3- Paint in closet had spots that were
peeled off.

-Bedroom #4- Paint on wall by window and near
Division of Health Service Regulation

V 000

V 736

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

STATE FORM

TITLE (X6) DATE

6899 A2L011 If continuation sheet 1 of 2

PRINTED: 05/24/2019

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL004-016 B. WING ____ 05/23/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
129 WALLCE ROAD
CORNERSTONE TREATMENT FACILITY
WADESBORO, NC 28170
(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 736 | Continued From page 1 V 736

the door had sections peeled off.

-Bedroom #5- Paint was peeling off on left corner
of the room.

-Bedroom #6- There were several sections of
paint peeled off on the wall and repaired patches
on the wall needed to be repainted.

-Bedroom #7- There were sections of paint
peeled off from the door.

-Bedroom #8- Blinds on the window were
tangled/broken.

-Bedroom #9- Patches of paint were peeled off
near the window and next to the door.
-Bathroom #2- Shower was missing the level
handle.

nterview on 5/23/19 with the Executive Director
revealed:

-She was aware that the facility needed to be
repainted.

-She was aware of the paint being peeled off from
he residents at the facility.

-She was aware that the shower in bathroom #2
was missing the level handle.

-Request had been made to corporate to paint
acility over and do necessary repairs, but
approval was pending.

-She was waiting for corporate agency to have
‘olks over to paint facility over.

-She would make another request corporate
office to have facility repainted.

-She confirmed the facility failed to ensure facility
grounds were maintained in a clean, safe and
attractive manner.

Division of Health Service Regulation
STATE FORM 6899 A2L011 If continuation sheet 2 of 2

inspection_type: MHLCS Annual and Follow-up


raw_content:
Division of Health Service Regulation

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

MHL004-016

CORNERSTONE TREATMENT FACILITY

A. BUILDING:

B. WING

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

129 WALLCE ROAD
WADESBORO, NC 28170

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

PRINTED: 05/25/2018
FORM APPROVED

COMPLETED

05/24/2018

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

ID
PREFIX
TAG

PROVIDER'S PLAN OF CORRECTION (x5)
(EACH CORRECTIVE ACTION SHOULD BE COMPLETE

CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

V 000} INITIAL COMMENTS

An annual and follow-up survey was completed
on May 24, 2018. Deficiencies were cited.

This facility is licensed for the following services
category: 10A NCAC 27G 1900 Psychiatric
Residential Treatment for Children and
Adolescents.

V 315} 27G .1902 Psych. Res. Tx. Facility - Staff

10A NCAC 27G .1902 STAFF

(a) Each facility shall be under the direction a
physician board-eligible or certified in child
psychiatry or a general psychiatrist with
experience in the treatment of children and
adolescents with mental illness.

(b) At all times, at least two direct care staff
members shall be present with every six children
or adolescents in each residential unit.

(c) If the PRTF is hospital based, staff shall be
specifically assigned to this facility, with
responsibilities separate from those performed on
an acute medical unit or other residential units.
(d) Apsychiatrist shall provide weekly
consultation to review medications with each child
or adolescent admitted to the facility.

(e) The PRTF shall provide 24 hour on-site
coverage by a registered nurse.

This Rule is not met as evidenced by:

Based on record reviews and interviews the
facility failed to provide 24 hour on-site coverage
by a registered nurse. The findings are:

Division of Health Service Regulation

V 000

V 315

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

STATE FORM

TITLE (X6) DATE

6899 4WUH11 If continuation sheet 1 of 2

PRINTED: 05/25/2018
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:
MHL004-016 B. WING _____ 05/24/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

129 WALLCE ROAD

CORNERSTONE TREATMENT FACILITY WADESBORO, NC 28170

(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 315] Continued From page 1 V 315

Review on 5/23/18 of the facility's personnel files
revealed nurses employed by the facility included
hree full time Registered Nurses and one
ull-time Licensed Practical Nurse.

nterview with Nurse #3 on 5/26/18 revealed:
-She had been employed with the agency since
December 2016.

-She was a Licensed Practical Nurse.

-She normally worked a 12 hour shift alone.

nterview on 5/23/18 with the Vice President of
Administration revealed:

-The facility uses Licensed Practical Nurses and
Registered Nurses.

-The licensure waiver was not approved by the
local Management Care Organization.

-The waiver would allow a Licensed Practical
Nurse to provide the required 24 hour on-site
coverage.

-She was told they would have to apply for the
waiver again because they applied over a year
ago.

-She confirmed the facility did not have 24 hour
on-site coverage by a registered nurse.

Division of Health Service Regulation
STATE FORM 6899 4WUH11 If continuation sheet 2 of 2