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

raw_content:
PRINTED: 02/25/2019
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
R-C
MHL011-371 B. WING ____ 02/06/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE

GREEN LEVEL Il ASHEVILLE, NC 28806

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

DEFICIENCY)
V 000} INITIAL COMMENTS V 000

Acomplaint and limited follow up survey was
completed on February 6, 2019. The complaint
was unsubstantiated (#NC00147475). This was
also a limited follow up survey, only 10A NCAC.
27G .0404 Operations (V138), 10A NCAC 27G
-1708 Transfer or Discharge (V300), 10A NCAC
27G .1701 Scope (V293) and 10A NCAC 27G
.0205 Assessment and Treatment, Habilitation or
Service Plan (V112) were reviewed for
compliance. The following were brought back
into compliance: 10A NCAC 27G .0404
Operations (V138), 10A NCAC 27G .1708
Transfer or Discharge (V300), 10A NCAC 27G
-1701 Scope (V293) and 10A NCAC 27G .0205
Assessment and Treatment, Habilitation or
Service Plan (V112). Deficiencies were cited.

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

V 110} 27G .0204 Training/Supervision Vv 110
Paraprofessionals

10A NCAC 27G .0204 COMPETENCIES AND
SUPERVISION OF PARAPROFESSIONALS

(a) There shall be no privileging requirements for
paraprofessionals.

(b) Paraprofessionals shall be supervised by an
associate professional or by a qualified
professional as specified in Rule .0104 of this
Subchapter.
(c) Paraprofessionals shall demonstrate
knowledge, skills and abilities required by the
population served.

(d) At such time as a competency-based
employment system is established by rulemaking,
then qualified professionals and associate

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

STATE FORM 6899 7GFZ11 If continuation sheet 1 of 11

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Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
R-C
MHL011-371 B. WING ____ 02/06/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE

GREEN LEVEL Il ASHEVILLE, NC 28806

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

DEFICIENCY)
V 110} Continued From page 1 V 110

professionals shall demonstrate competence.
(e) Competence shall be demonstrated by
exhibiting core skills including:

(1) technical knowledge;

(2) cultural awareness;

(3) analytical skills;

(4) decision-making;

(5) interpersonal skills;

(6) communication skills; and

(7) clinical skills.

(f) The governing body for each facility shall
develop and implement policies and procedures
for the initiation of the individualized supervision
plan upon hiring each paraprofessional.

This Rule is not met as evidenced by:

Based on record review and interviews, 1 of 5
audited paraprofessionals (Staff #2) failed to
demonstrate knowledge, skills and abilities
required by the population served. The findings
are:

Review on 1/31/19 of the personnel record for
Staff #2 revealed:

-Hired on 6/4/18 as a Residential Counselor.
-On 12/26/18 Staff #2 met with the Residential
Director and assistant residential director for
coaching. They met to address appropriate
student/staff boundaries. Dress code and ratio
expectations were reviewed. The documentation
indicated that reports were made about
inappropriate dress and for playing inappropriate
music in front of students.

Interview on 1/31/19 with Staff #2 revealed:
Division of Health Service Regulation
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Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
R-C
MHL011-371 B. WING ____ 02/06/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE

GREEN LEVEL Il ASHEVILLE, NC 28806

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 110| Continued From page 2 V 110

-She wore leggings and knew she wasn't
supposed to.

-The residential director had met with her and had
her sign a "boundary plan".

-Client #1 had a pre-planned visit with his family
scheduled for Christmas. She had to supervise
the visit because there were no other staff to
facilitate the visit. She indicated she had no idea
how to do that.

-The other students of the facility had to gone to a
sister facility. She remained in the facility from
8:00PM to approximately 10:00Pm alone with
Client #1.

nterview on 1/31/19 with Staff #3 revealed:
-Staff #2 did not display good boundaries with the
students. Students would request music that she
would play for them.

-A student had reported to her the Staff #2 wore
ight clothing and would sit with her legs open.

nterview on 2/4/19 with Staff #4 revealed:
-Client #1 was alone in the cottage with Staff #2
or a couple of hours.
-Staff were never to be alone with students.
-Staff #2 would play music in the van that "was
ilthy and racist". He indicated she was in the
back of the van dancing like "one of them". He
reported this behavior to leadership.
-Staff #2 would hang out with 2 students like
“hanging out with her buddies". He felt her
interactions with students was like "buddies"
-There were “a lot of red flags".

Interview on 2/5/19 on Staff #5 revealed:

-Staff #2 seemed hyper focused on Client #1.
She felt that Staff #2 showed favoritism to Client
#1.

-Staff #2 always wore leggings. She was told not
to wear them.

Division of Health Service Regulation

STATE FORM 6899 7GFZ11 If continuation sheet 3 of 11

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Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHLO011-374 B. WING 02/06/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE
GREEN LEVEL Ill
ASHEVILLE, NC 28806
(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

V 110| Continued From page 3 V 110

-Other students reported to her that Staff #2 wore
"see through leggings" and would sit with her legs
open. The students also said that she would play
inappropriate music in the van.

Interview on 2/4/19 with the Cottage Supervisor
revealed:

-She wore exercise pants to work which was
against policy. This was addressed with her but
she continued to wear them.

-If music is not played on the radio then it should
not be played in front of students.

-Client #1 had a visit with family but they did not
show up. Staff #2 remained in the cottage with
Client #1. No other staff were present. No
supervisor was notified of this event. Staff #2
was counseled about this event.

Interview on 2/1/19 with the Residential Director
revealed:

-It was reported to him that Staff #2 played
sexually explicit music in front of students. He
and the assistant director addressed this with her.
They reviewed the boundary protocol with
students and had her sign it. Staff #2 said that
"they are in the real world" and would hear that
kind of music. This issue was included in the
boundary plan.

-He stated that Staff #2 pushed the envelope to
do things. Limits were set with her and she was
redirected.

-He was not aware at the time that Staff #2 was
alone in the cottage with Client #1. She should
have called a supervisor.

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

10A NCAC 27G .1704. MINIMUM STAFFING

Division of Health Service Regulation
STATE FORM 6899 7GFZ11 If continuation sheet 4 of 11

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Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHLO011-374 B. WING 02/06/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE
GREEN LEVEL Ill
ASHEVILLE, NC 28806
(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

V 296 | Continued From page 4 V 296

REQUIREMENTS

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

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

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

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

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

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

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

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

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

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

Division of Health Service Regulation
STATE FORM 6899 7GFZ11 If continuation sheet 5 of 11

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Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
R-C
MHL011-371 B. WING ____ 02/06/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE

GREEN LEVEL Il ASHEVILLE, NC 28806

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

DEFICIENCY)
V 296 | Continued From page 5 V 296

needs as specified in the treatment plan.

This Rule is not met as evidenced by:

Based on observation and interview the facility
failed to ensure that two direct care staff are
present for one, two, three, or four children. The
findings are:

Review on 1/31/19 of video tape for 12/25/18
revealed:

-Staff #2 was in the cottage at 8:30PM with Client
#1. There were no other staff present. At
10:06PM the 2nd staff member was observed to
enter the facility.

Review on 1/31/19 of the personnel record for
Staff #2 revealed:
-Hired on 6/4/18 as a Residential Counselor.

Record review on 1/31/19 for Client #1 revealed:
-Admitted on 12/5/18 with diagnosis of Conduct
Disorder, adolescent onset type.

nterview on 1/31/19 with Staff #2 revealed:
-Client #1 had a pre-planned visit with his family
scheduled for Christmas. She had to supervise
he visit because there were no other staff to
acilitate the visit. She indicated she had no idea
how to do that.

-The other students of the facility had to gone to a
sister facility. She remained in the facility from
8:00PM to approximately 10:00Pm alone with
Client #1.

-She did not contact leadership to indicate that
Division of Health Service Regulation

STATE FORM 6899 7GFZ11 If continuation sheet 6 of 11

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Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
R-C
MHL011-371 B. WING ____ 02/06/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE

GREEN LEVEL Il ASHEVILLE, NC 28806

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 296 | Continued From page 6 V 296

she was alone in the facility with a student.
-She indicated that the cottages "combine pretty
consistently". Cottages combined on first shift
when school was out and around the holidays.

Interview on 1/31/19 with Staff #3 revealed:
-She was working recently when cottages had
combined and had 6 students and 3 staff. This
had occurred for a couple of hours.

Interview on 2/4/19 with Staff #4 revealed:

-He had worked alone in the cottage for short
time periods if his co-worker was late.

-He had transported students alone while his
co-worker was alone in the cottage with other
students.

-There were holes in staffing that happened a lot.
-Nurses were pulled to do shifts and then if a
medical emergency occurred they would have to
leave which would leave the facility out of ratio.
-They were told not to combine cottages, then
told could combine if 6 students or less, and then
told could combine if kept at 4 students.
-Combining cottages was frequent on weekends
and after school.

-Client #1 was alone in the cottage with Staff #2
for a couple of hours.

-Staff were never to be alone with students.

Interview on 2/5/19 on Staff #5 revealed:

-There were times she worked alone with 3 or 4
students. This would be for an hour or so.

-Staff may be pulled out of ratio temporarily which
made her feel uncomfortable.

Interview on 2/4/19 with the Cottage Supervisor
revealed:

-Client #1 had a visit with family on Christmas but
they did not show up. Staff #2 remained in the
cottage with Client #1. No other staff were
Division of Health Service Regulation

STATE FORM 6899 7GFZ11 If continuation sheet 7 of 11

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FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
R-C
MHL011-371 B. WING ____ 02/06/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE

GREEN LEVEL Il ASHEVILLE, NC 28806

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 296] Continued From page 7 V 296
present.

-Cottages combined of the census was down in a
cottage. For example, if one level 3 had 3
students and another level 3 had 3 students they
may take 2 students from another level 3 to add
to each facility census to make 4 in each cottage.
This occurred during the day shift on weekends
and after school until approximately 8:30PM.
-The only reason they combined cottages was
due to a lack of staff.

-At times they would combine and have 5
students at the weight barn with 3 staff.

Interview on 2/1/19 with the Residential Director
revealed:

-He was not aware at the time that Staff #2 was
alone in the cottage with Client #1. She should
have called a supervisor.

-There is never 1 student with 1 staff.

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

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 Ill
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

Division of Health Service Regulation
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FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL011-371 B. WING ____ 02/06/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE
GREEN LEVEL Ill ASHEVILLE, NC 28806
(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 367 | Continued From page 8 V 367

information:

(1) reporting provider contact and

identification information;

(2) client identification information;

(3) type of incident;

(4) description of incident;

(5) status of the effort to determine the

cause of the incident; and

(6) other individuals or authorities notified

or responding.
(b) Category A and B providers shall explain any
missing or incomplete information. The provider
shall submit an updated report to all required
report recipients by the end of the next business
day whenever:
(1) he provider has reason to believe that
information provided in the report may be
erroneous, misleading or otherwise unreliable; or
(2) he 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) he 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

Division of Health Service Regulation
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FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
R-C
MHL011-371 B. WING ____ 02/06/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE

GREEN LEVEL Il ASHEVILLE, NC 28806

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

DEFICIENCY)
V 367 | Continued From page 9 V 367

immediately, as required by 10A NCAC 26C.
.0300 and 10A NCAC 27E .0104(e)(18).

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

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

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

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

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

(6) a statement indicating that there have

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

This Rule is not met as evidenced by:

Based on record review and interview the facility
failed to ensure Level III incidents were reported

fo the Local Management Entity (LME) within 72

hours of becoming aware of the incident effecting
2 of 3 audited clients (#1, #2). The findings are:

Record review on 1/31/19 for Client #1 revealed:
-Admitted on 12/5/18 with diagnosis of Conduct
Disorder, adolescent onset type.

-Age 17.

Record review on 1/31/19 for Client #2 revealed:
Division of Health Service Regulation
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FORM APPROVED

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

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER ‘A. BUILDING: COMPLETED
R-C
MHL011-371 B. WING 02/06/2019

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

2 COMPTON DRIVE

GREEN LEVEL Il ASHEVILLE, NC 28806

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

DEFICIENCY)
V 367 | Continued From page 10 V 367

-Admitted on 9/13/18 with diagnoses of
Post-Traumatic Stress Disorder and Adjustment
Disorder with mixed anxiety and depressed
mood.

-Age 16.

Review on 1/31/19 of incident reports revealed:

-On 1/22/19" ...Staff arrived a
a couple of minutes late to pic!
Staff continued to wait around
administration at school ...had

[local high school]
up [Client #2].
...Staff notified
them page [Client

#2] ...Staff informed [Client #2's] guardian that
she was missing from school and that they had

filed a report with [local law en

orcementi] ..."

-On 1/6/19" ...Staff did the 12:20am check and

[Client #1] was in his room. At 12:31am staff
checked in with [Client #1] then left his room. At
12:37am staff went back to ask [Client #1] a
question. When staff open the door [Client #1]
appeared to be in his bed sleep, but staff called
his name 2 times and he didn't answer ...staff
went in [Client #1's] room to check on him and
realized he was not in his bed ...Supervisor made
a report with [local police] ...at 5:15am, staff did a
check in [Client #1's] room and noticed he was
back in his bed ..." IRIS (Incident Response
Improvement System) report completed and
submitted on 1/11/19.

Review on 1/31/19 of reports in the IRIS system
revealed:

-No IRIS report for the incident on 1/22/19.
-Incident on 1/6/19 was submitted on 1/11/19.

Interview on 2/6/19 with the Director of
Performance/Quality Improvement revealed:
-She was aware that the IRIS reports were
submitted late for the level II incidents. This was
an oversight.

Division of Health Service Regulation

STATE FORM 6899

7GFZ11 If continuation sheet 11 of 11