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

raw_content:
PRINTED: 03/13/2020

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
R
MHL060968 03/10/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1
CHARLOTTE, NC 28211
(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, follow up and complaint survey was
completed on 3-10-20. The complaints were
substantiated (HNC00160961, #NC00161079,
#NC00160996). No deficiencies were cited.

This facility is licensed for the following service
category: 10A NCAC 27G. 1400 Day Treatment
for Children and Adolescents With Emotional or
Behavioral Disturbances.

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

STATE FORM

6899

AGPQ11

TITLE (X6) DATE

If continuation sheet 1 of 1

inspection_type: MHLCS Annual, Complaint, and Follow-up


state: NC

facility_name: Alexander Youth Network - Charlotte Day Treatment

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

raw_content:
Division of Health Service Regulation

PRINTED: 10/04/2019
FORM APPROVED

Allegations, & Protection

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

(g) Health care facilities shall ensure that the
Department is notified of all allegations against
health care personnel, including injuries of
unknown source, which appear to be related to
any act listed in subdivision (a)(1) of this section.
(which includes:

a. Neglect or abuse of a resident in a healthcare
facility or a person to whom home care services
as defined by G.S. 131E-136 or hospice services
as defined by G.S. 131E-201 are being provided.
b. Misappropriation of the property of a resident
in a health care facility, as defined in subsection
(b) of this section including places where home
care services as defined by G.S. 131E-136 or
hospice services as defined by G.S. 131E-201
are being provided.

c. Misappropriation of the property of a
healthcare facility.

d. Diversion of drugs belonging to a health care
facility or to a patient or client.

e. Fraud against a health care facility or against
a patient or client for whom the employee is
providing services).

Facilities must have evidence that all alleged

Division of Health Service Regulation

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

STATE FORM

6899

NUNC11

TITLE

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
R
MHL060968 10/02/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1
CHARLOTTE, NC 28211
(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
A complaint and follow up survey was completed
on October 2, 2019. The complaint was
unsubstantiated (Intake #NC 00156517).
Deficiencies were cited.
The facility is licensed for the following service
category: 10A NCAC 27G .1400 Day Treatment
for Children and Adolescents with Emotional or
Behavioral Disturbances.
V 132} G.S. 131E-256(G) HCPR-Notification, V 132

(X6) DATE

If continuation sheet 1 of 12

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/04/2019
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL060968 10/02/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1
CHARLOTTE, NC 28211
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 132] Continued From page 1 V 132

acts are investigated and must make every effort
to protect residents from harm while the
investigation is in progress. The results of all
investigations must be reported to the
Department within five working days of the initial
notification to the Department.

This Rule is not met as evidenced by:

Based on interview and record review, the facility
failed to investigate all allegations of abuse and
failed to protect clients from harm while the
investigation was in progress affecting 2 of 3
audited staff.

Review on 10/2/19 of Client #1's record revealed:
-Admission date of 3/14/19;

-Diagnoses of Attention Deficit Hyperactivity
Disorder, Disruptive Mood Dysregulation
Disorder, and Oppositional Defiant Disorder;

-11 years old.

Review on 10/2/19 of a Level | Incident Report
dated 8/1/19 revealed:

-Client #1 made an allegation against Staff #5
regarding Staff #5 using a choke hold while on
the van.

Interview on 10/2/19 with Client #1 revealed:
-Was brought into the library by Staff #4 who
grabbed his shirt and pushed him against the

Division of Health Service Regulation
STATE FORM

6809

NUNC11

If continuation sheet 2 of 12

Division of Health Service Regulation

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

MHL060968

NAME OF PROVIDER OR SUPPLIER

A. BUILDING:

6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1

CHARLOTTE, NC 28211

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/04/2019

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R
10/02/2019

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

(xs)
COMPLETE
DATE

V 132] Continued From page 2

wall;

-Was put in a choke hold by Staff #5 while on the
van ride home;

-Dates of the incidents are unknown.

Interview on 10/2/19 with the Supervisor
revealed:

-Had a meeting with Client #1's grandmother at
the end of September, 2019 during which the
grandmother reported the allegations involving
Staff #4 and Staff #5;

-Did not complete an internal investigation and
did not suspend either staff;

-Will ensure to complete an internal investigation
on any allegations of abuse in the future.

Interview on 10/2/19 with the Executive Director
revealed:

-Will work closely with the Supervisor and will
discuss a possible re-arrangement of supervisory
duties to increase the Executive Director's time at
the Day Treatment.

V 318) 130 .0102 HCPR - 24 Hour Reporting

10A NCAC 130 .0102 INVESTIGATING AND
REPORTING HEALTH CARE PERSONNEL

The reporting by health care facilities to the
Department of all allegations against health care
personnel as defined in G.S. 131E-256 (a)(1),
including injuries of unknown source, shall be
done within 24 hours of the health care facility
becoming aware of the allegation. The results of
the health care facility's investigation shall be
submitted to the Department in accordance with
G.S. 131E-256(g).

V 132

V 318

Division of Health Service Regulation
STATE FORM

6809

NUNC11

If

continuation sheet 3 of 12

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/04/2019
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL060968 10/02/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1
CHARLOTTE, NC 28211
(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 318] Continued From page 3 V 318

This Rule is not met as evidenced by:

Based on interview and record review, the facility
failed to notify the Department within 24 hours of

becoming aware of an allegation of abuse against
staff affecting 2 of 3 audited staff.

Review on 10/2/19 of Client #1's record revealed:
-Admission date of 3/14/19;

-Diagnoses of Attention Deficit Hyperactivity
Disorder, Disruptive Mood Dysregulation
Disorder, and Oppositional Defiant Disorder;

-11 years old.

Review on 10/2/19 of a Level | Incident Report
dated 8/1/19 revealed:

-Client #1 made an allegation against Staff #5
regarding Staff #5 using a choke hold while on
the van.

Interview on 10/2/19 with Client #1 revealed:
-Was brought into the library by Staff #4 who
grabbed his shirt and pushed him against the
wall;

-Was put in a choke hold by Staff #5 while on the
van ride home;

-Dates of the incidents are unknown.

Interview on 10/2/19 with the Supervisor
revealed:

-Had a meeting with Client #1's grandmother at
the end of September, 2019 during which the
grandmother reported the allegations involving
Staff #4 and Staff #5;

-Did not complete incident reporting or notification
of the allegations of abuse;

-Will ensure proper notification and
documentation in the future.

Division of Health Service Regulation
STATE FORM

6809

NUNC11

If continuation sheet 4 of 12

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL060968

6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1
CHARLOTTE, NC 28211

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 10/04/2019

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R
10/02/2019

10A NCAC 27G .0603 INCIDENT
RESPONSE REQUIREMENTS FOR

CATEGORY AAND B PROVIDERS

(a) Category A and B providers shall develop and
implement written policies governing their
response to level |, Il or Ill incidents. The policies
shall require the provider to respond by:

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

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

measures according to provider specified
timeframes not to exceed 45 days;

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

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

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

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

(c) In addition to the requirements set forth in

Division of Health Service Regulation
STATE FORM

6809

NUNC11

(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 318] Continued From page 4 V 318
Interview on 10/2/19 with the Executive Director
revealed:
-Will work closely with the Supervisor and will
discuss a possible re-arrangement of supervisory
duties to increase the Executive Director's time at
the Day Treatment.
V 366} 27G .0603 Incident Response Requirments V 366

If continuation sheet 5 of 12

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/04/2019
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL060968 10/02/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1
CHARLOTTE, NC 28211
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 366 | Continued From page 5 V 366

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

by:

(1) immediately securing the client record
by:

(A) obtaining the client record;

(B) making a photocopy;

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

(2) convening a meeting of an internal

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

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

(B) gather other information needed;

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

(D) issue a final written report signed by the
owner within three months of the incident. The
final report shall be sent to the LME in whose
catchment area the provider is located and to the

Division of Health Service Regulation
STATE FORM

6809

NUNC11

If continuation sheet 6 of 12

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/04/2019
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL060968 10/02/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1
CHARLOTTE, NC 28211
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 366 | Continued From page 6 V 366

LME where the client resides, if different. The
final written report shall address the issues
identified by the internal review team, shall
include all public documents pertinent to the
incident, and shall make recommendations for
minimizing the occurrence of future incidents. If
all documents needed for the report are not
available within three months of the incident, the
LME may give the provider an extension of up to
three months to submit the final report; and

(3) immediately notifying the following:

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

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

(C) the provider agency with responsibility

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

(D) the Department;

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

(F) any other authorities required by law.

This Rule is not met as evidenced by:

Based on interview and record review, the facility
failed to implement their written policy governing
their response to incidents

Review on 10/2/19 of Client #1's record revealed:
-Admission date of 3/14/19;

-Diagnoses of Attention Deficit Hyperactivity
Disorder, Disruptive Mood Dysregulation

Division of Health Service Regulation
STATE FORM

6809

NUNC11

If continuation sheet 7 of 12

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL060968

A. BUILDING:

6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1
CHARLOTTE, NC 28211

PRINTED: 10/04/2019
FORM APPROVED

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

COMPLETED

R
10/02/2019

STREET ADDRESS, CITY, STATE, ZIP CODE

(x4) ID
PREFIX
TAG

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

ID
PREFIX
TAG

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

CROSS-REFERENCED TO THE APPROPRIATE, DATE
DEFICIENCY)

V 366

V 367|

Continued From page 7

Disorder, and Oppositional Defiant Disorder;
-11 years old.

Interview on 10/2/19 with Client #1 revealed:
-Was brought into the library by Staff #4 when he
attempted to elope and Staff #4 who grabbed his
shirt and pushed him against the wall;

-Dates of the incident is unknown.

Interview on 10/2/19 with the Supervisor
revealed:

-Completed a disciplinary write-up for Staff #4's
failure to complete an incident report when Client
#1 attempted to elope and Staff #4 brought Client
#1 to the library to calm down.

Interview on 10/2/19 with the Executive Director
revealed:

-Will work closely with the Supervisor and will
discuss a possible re-arrangement of supervisory
duties to increase the Executive Director's time at
the Day Treatment.

27G .0604 Incident Reporting Requirements

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

Division of Health Service Regulation
STATE FORM

V 366

V 367

6809

NUNC11

If continuation sheet 8 of 12

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/04/2019
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL060968 10/02/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1
CHARLOTTE, NC 28211
(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

Secretary. The report may be submitted via mail,
in person, facsimile or encrypted electronic
means. The report shall include the following

information:

(1) reporting provider contact and
identification information;

(2) client identification information;

(3) type of incident;

(4) description of incident;

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

(6) other individuals or authorities notified

or responding.

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

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

(c) Category A and B providers shall submit,
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

Division of Health Service Regulation
STATE FORM

6809

NUNC11

If continuation sheet 9 of 12

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/04/2019
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL060968 10/02/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1
CHARLOTTE, NC 28211
(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

becoming aware of the incident. In cases of
client death within seven days of use of seclusion
or restraint, the provider shall report the death
immediately, as required by 10A NCAC 26C.
.0300 and 10A NCAC 27E .0104(e)(18).

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

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

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

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

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

(6) a statement indicating that there have

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

This Rule is not met as evidenced by:

Based on interview and record review, the facility
failed to report all Level III incidents to the LME
responsible for the catchment area where
services are provided within 72 hours of
becoming aware of the incident.

Review on 10/2/19 of Client #1's record revealed:
-Admission date of 3/14/19;
-Diagnoses of Attention Deficit Hyperactivity

Division of Health Service Regulation
STATE FORM

6809

NUNC11

If continuation sheet 10 of 12

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/04/2019
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL060968 10/02/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1
CHARLOTTE, NC 28211
(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

Disorder, Disruptive Mood Dysregulation
Disorder, and Oppositional Defiant Disorder;
-11 years old.

Review on 10/2/19 of a Level | Incident Report
dated 8/1/19 revealed:

-Client #1 made an allegation against Staff #5
regarding Staff #5 using a choke hold while on
the van.

Review on 10/2/19 of the North Carolina Incident
Response Improvement System revealed:

-No Level Ill incident reports completed on the
allegations of abuse made by Client #1.

Interview on 10/2/19 with Client #1 revealed:
-Was brought into the library by Staff #4 who
grabbed his shirt and pushed him against the
wall;

-Was put in a choke hold by Staff #5 while on the
van ride home;

-Dates of the incidents are unknown.

Interview on 10/2/19 with the Supervisor
revealed:

-Had a meeting with Client #1's grandmother at
the end of September, 2019 during which the
grandmother reported the allegations involving
Staff #4 and Staff #5;

-No Level Ill incident reports were completed
regarding the allegations of abuse.

-Will ensure to complete Level III incident reports
on all allegations of abuse in the future.

Interview on 10/2/19 with the Executive Director
revealed:

-Will work closely with the Supervisor and will
discuss a possible re-arrangement of supervisory
duties to increase the Executive Director's time at
the Day Treatment.

Division of Health Service Regulation
STATE FORM

6809

NUNC11

If continuation sheet 11 of 12

PRINTED: 10/04/2019

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
R
MHL060968 — 10/02/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1
CHARLOTTE, NC 28211
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

V 367] Continued From page 11 V 367

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

Division of Health Service Regulation
STATE FORM 6809 NUNC11 If continuation sheet 12 of 12

inspection_type: MHLCS Complaint and Follow-up

document_type: Statement of Deficiency


summary: Plan of Correction - MHLCS Complaint and Follow-up

raw_content:
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

MHL060968

PRINTED: 10/04/2019
FORM APPROVED
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
‘A. BUILDING: COMPLETED
R
B. WING 40/02/2019

6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1

(x4) 10
PREFIX
TAG

V 000;

V 132)

CHARLOTTE, NC 28211

STREET ADDRESS, CITY, STATE, ZIP CODE

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

INITIAL COMMENTS

Acompiaint and follow up survey was completed
on October 2, 2019. The complaint was
unsubstantiated (Intake #NC 00156517).
Deficiencies were cited.

The facility is licensed for the following service
category: 10A NCAC 27G .1400 Day Treatment
for Children and Adolescents with Emotional or
Behavioral Disturbances.

G.S. 131E-256(G) HCPR-Notification,
Allegations, & Protection

G.S. §131E-256 HEALTH CARE PERSONNEL
REGISTRY
(g) Health care facilities shall ensure that the
Department is notified of all allegations against
health care personnel, including injuries of
unknown source, which appear to be related to
any act listed in subdivision (a)(1) of this section.
(which includes:
a. Neglect or abuse of a resident in a healthcare
facility or a person to whom home care services
as defined by G.S. 131E-136 or hospice services
as defined by G.S. 131E-201 are being provided.
b, Misappropriation of the property of a resident
in a health care facility, as defined in subsection
(b) of this section including places where home
care services as defined by G.S. 131E-136 or
hospice services as defined by G.S. 131E-201
are being provided.

c. Misappropriation of the property of a
healthcare facility.

d. Diversion of drugs belonging to a health care
facility or to a patient or client.

e. Fraud against a health care facility or against
a patient or client for whom the employee is
providing services).

Facilities must have evidence that all alleged

Division of Health Service Regulation

LABORATORY DIRECTOR'S

STATE FORM

PROVIDER/SUPPLIER REPRESENTJATIVE'S SIGNATURE

1D
PREFIX
TAG

Vv 000

V 132

Executive Divectr Day Ti

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

RECEIVED

By psammons at 5:57 am, Oct 20, 2019

V132

What measures will be put in place to correct the
deficient area of practice.

. At the end of each day, Program Manager
will meet face to face with a staff member from each
group and inquire about any incidents that occurred
during the day. This will be documented on a daily log
. Program Manager will notify Executive
Director of all incidents within 12 hour timeframe.

. Program Manager will receive coaching in
reporting when an incident occurs to the Executive
Director to ensure proper escalation of procedures.

. If any incidents occur Program manager will
check to ensure documents are complete, and
determine what level the incident should be under.

. If the incident rises to a level 2 or 3 Program}
Manager wilf ensure that critical incident information is,
complete.

. Program manager will ensure that
the proper authorities have been contacted and
notified of the incident.

TITLE

NUNC11 If continual

(x8)
COMPLETE
DATE

1016/19

10/16/19

10/14/19

10/14/19

101419

10/149

(Xe) DATE

tion sheet 1 of 12

PRINTED: 10/04/2019
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

R
MHLo60968 8. WING —______________ 10/02/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
CHARLOTTE, NC 28211

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION
PREFIX. (BACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE

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

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1

Continued From page 1 Vv 132 132 Continued From page 1
. Describe your plans to make sure the above happens.
acts are investigated and must make every effort

to protect residents from harm while the . On 10/4/19, Executive director discussed
investigation is in progress. The results of all
investigations must be reported to the
Department within five working days of the initial
notification to the Department.

with Program Manager the prevention steps above,
and reviewed the policy and procedures for
documenting incidents and reported allegations of
abuse.

. Training and Program Improvement team
will provide day treatment staff with refresher training
on Incident Reporting policies and procedures. 10/2119
+ Program Manager will complete coaching
and other progressive documentation in situations in
which the correct documentation procedures are

not followed. 10/1619

Who will monitor the situation to ensure it will not
occur again.

This Rule is not met as evidenced by: . The Executive Director will provide
Based on interview and record review, the facility monitoring to ensure that the interventions about
failed to investigate all allegations of abuse and are being met.

failed to protect clients from harm while the
investigation was in progress affecting 2 of 3
audited staff.

Review on 10/2/19 of Client #1's record revealed:
-Admission date of 3/14/19;

-Diagnoses of Attention Deficit Hyperactivity
Disorder, Disruptive Mood Dysregulation
Disorder, and Oppositional Defiant Disorder;

-11 years old.

Review on 10/2/19 of a Level | incident Report
dated 8/1/19 revealed:

-Client #1 made an allegation against Staff #5
regarding Staff #5 using a choke hold while on
the van.

Interview on 10/2/19 with Client #1 revealed:
-Was brought into the library by Staff #4 who
grabbed his shirt and pushed him against the
Division of Health Service Regulation

STATE FORM 000 NUNC11 continuation sheet 2 of 12

PRINTED: 10/04/2019
FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED

R
MHL060968 Be WING —_______—_W. 10/02/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
CHARLOTTE, NC 28211

x4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE

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

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1

Continued From page 2

wall;

-Was put in a choke hold by Staff #5 while on the
van ride home;

-Dates of the incidents are unknown.

Interview on 10/2/19 with the Supervisor
revealed:

-Had a meeting with Client #1's grandmother at
the end of September, 2019 during which the
grandmother reported the allegations involving
Staff #4 and Staff #5;

-Did not complete an internal investigation and
did not suspend either staff;

-Will ensure to complete an internal investigation
on any allegations of abuse in the future.

Interview on 10/2/19 with the Executive Director
revealed:

-Will work closely with the Supervisor and will
discuss a possible re-arrangement of supervisory
duties to increase the Executive Director's time at
the Day Treatment.

130 .0102 HCPR - 24 Hour Reporting V318

What measures will be put in place to correct the
10A NCAC 130 .0102 INVESTIGATING AND
REPORTING HEALTH CARE PERSONNEL deficient area of practice.

The reporting by health care facilities to the . At the end of each day, Program Manager

Department of all allegations against health care
personnel as defined in G.S. 131E-256 (a)(1) will meet face to face with a staff member from each

including injuries of unknown source, shall be group and inquire about any incidents that occurred
done within 24 hours of the health care facility
becoming aware of the allegation. The results of
the health care facility's investigation shall be . Program Manager will notify Executive
submitted to the Department in accordance with
G.S. 131E-256(g).

during the day. This will be documented on a daily log] 10/16/19

Director of ali incidents within 12 hour timeframe. 10/16/19
. Program Manager will receive coaching in

reporting when an incident occurs to the Executive

Director to ensure proper escalation of procedures. | 10/14/19

Division of Health Service Regulation
STATE FORM cd NUNC11 Hf continuation sheet 3 of 12

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIERICLIA,
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

MHL060968
NAME OF PROVIDER OR SUPPLIER
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 17

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

B. WING

Continued From page 3

This Rule is not met as evidenced by:

Based on interview and record review, the facility
failed to notify the Department within 24 hours of
becoming aware of an allegation of abuse against
staff affecting 2 of 3 audited staff.

Review on 10/2/19 of Client #1's record revealed:
-Admission date of 3/14/19;

-Diagnoses of Attention Deficit Hyperactivity
Disorder, Disruptive Mood Dysregulation
Disorder, and Oppositional Defiant Disorder;

-11 years old.

Review on 10/2/19 of a Level | Incident Report
dated 8/1/19 revealed:

-Client #1 made an allegation against Staff #5
regarding Staff #5 using a choke hold while on
the van.

Interview on 10/2/19 with Client #1 revealed:
-Was brought into the library by Staff #4 who
grabbed his shirt and pushed him against the
wall;

-Was put in a choke hold by Staff #5 while on the
van ride home;

-Dates of the incidents are unknown.

Interview on 10/2/19 with the Supervisor
revealed:

-Had a meeting with Client #1's grandmother at
the end of September, 2019 during which the
grandmother reported the allegations involving
Staff #4 and Staff #5;

-Did not complete incident reporting or notification
of the allegations of abuse;

-Will ensure proper notification and
documentation in the future.

Division of Health Service Regulation
STATE FORM

PRINTED:
FORM

10/04/2019
APPROVED

(X3) DATE SURVEY

COMPLETED

R

10/02/2019

STREET ADDRESS, CITY, STATE, ZIP CODE

6220-D THERMAL RD
CHARLOTTE, NC 28211

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

(x8)
COMPLETE
DATE

318 continued from page 3

. If any incidents occur Program manager
will check to ensure documents are complete, and
determine what level the incident should be under,

. If the incident rises to a level 2 or 3
Program Manager will ensure that critical incident
information is complete.

. Program manager will ensure that the
proper authorities have been contacted and notified
of the incident.

Describe your plans to make sure the above happens]
. On 10/4/19, Executive director discussed
with Program Manager the prevention steps above,
and reviewed the policy and procedures for
documenting incidents and reported allegations of
abuse.

. Training and Program Improvement team
will provide day treatment staff with refresher training
on Incident Reporting policies and procedures.

. Program Manager will complete coaching
and other progressive documentation in situations in
which the correct documentation procedures are not
followed.

‘Who will monitor the situation to ensure it will not
occur again.

. The Executive Director will provide
monitoring to ensure that the interventions about are
being met.

NUNC11 if continuat

10/1419

10/1419

10/14/19

10/21/19

1ON6N9

tion sheet 4 of 12

PRINTED: 10/04/2019
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (1) PROVIDER/SUPPLIERICLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED

R
MHL060968 B. WING ___________ 40/02/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
CHARLOTTE, NC 28211

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES: PROVIDER'S PLAN OF CORRECTION (X8)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE. COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1

Continued From page 4

Interview on 10/2/19 with the Executive Director
revealed:

-Will work closely with the Supervisor and will
discuss a possible re-arrangement of supervisory
duties to increase the Executive Director's time at
the Day Treatment.

27G .0603 Incident Response Requirments V366

What measures will be put in place to correct the
10A NCAC 27G .0603 INCIDENT deficient area of practice.

RESPONSE REQUIREMENTS FOR . At the end of each day, Program Manager
CATEGORY AAND B PROVIDERS will meet face to face with a staff member from each
(a) Category A and B providers shall develop and group and inquire about any incidents that occurred
implement written policies governing their during the day. This will be documented on a daily log| 10/16/19
response to level |, Il or Ill incidents. The policies . Program Manager will notify Executive

oy require the Provieer © respond oy ty need Director of all incidents within 12 hour timeframe. ‘| 10/16/19
attending to the health and safety needs Program Manager will receive coaching in
of individuals involved in the incident; . og rae o ng
(2) determining the cause of the incident: reporting when an incident occurs to the Executive
re) developing and implementing corrective Director to ensure proper escalation of procedures. 10/14/19
measures according to provider specified . . If any incidents occur Program manager
will check to ensure documents are complete, and

timeframes not to exceed 45 days;
(4) developing and implementing measures determine what level the incident should be under. 1014/19

to prevent similar incidents according to provider . If the incident rises to a level 2 or 3
specified timeframes not to exceed 45 days; Program Manager will ensure that critical incident
(5) assigning person(s) to be responsible information is complete. 10/1419
for implementation of the corrections and . Program manager will ensure that the
preventive measures; proper authorities have been contacted and notified
(6) adhering to confidentiality requirements of the incident, 10/14/19
set forth in G.S. 75, Article 2A, 10A NCAC 26B, Describe your plans to make sure the above happens. |
42 CFR Parts 2 and 3 and 45 CFR Parts 160 and . On 10/4/19, Executive director discussed
164; and with Program Manager the prevention steps above,
(7) maintaining documentation regarding and reviewed the policy and procedures for
Subparagraphs (a)(1) through (a)(6) of this Rule. documenting incidents and reported allegations of

(b) In addition to the requirements set forth in abuse.

Paragraph (a) of this Rule, ICF/MR providers .
shall address incidents as required by the federal
regulations in 42 CFR Part 483 Subpart I.

(c) In addition to the requirements set forth in

Training and Program Improvement team
will provide day treatment staff with refresher training
on Incident Reporting policies and procedures. 10/21 19

Division of Health Service Regulation
STATE FORM 030 NUNC1 If continuation sheet 5 of 12

PRINTED: 10/04/2019
FORM APPROVED.

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIERICLIA,
AND PLAN OF CORRECTION IDENTIFICATION NUMBER;

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
A. BUILDING: COMPLETED

R
Be WING 10/02/2019

MHLO060968

STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
CHARLOTTE, NC 28211

NAME OF PROVIDER OR SUPPLIER

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 7

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

DEFICIENCY)

V 366 366 Continued From page 5
+ Program Manager will complete coaching
and other progressive documentation in situations in
which the correct documentation procedures are not

followed. 10/16/19

Continued From page 5

Paragraph (a) of this Rule, Category A and B
providers, excluding ICF/MR providers, shall
develop and implement written policies governing
their response to a level Ill incident that occurs
while the provider is delivering a billable service
or while the client is on the provider's premises.

Who will monitor the situation to ensure it will not

The policies shall require the provider to respond occur again.

by: . The Executive Director will provide

(1) immediately securing the client record monitoring to ensure that the interventions about are
by: being met.

(A) obtaining the client record;

(B) making a photocopy;

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

(2) convening a meeting of an internal

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

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

(B) gather other information needed;

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

(D) issue a final written report signed by the
owner within three months of the incident. The
final report shall be sent to the LME in whose
catchment area the provider is located and to the

Division of Health Service Regulation
STATE FORM aid NUNC11 If continuation sheet 6 of 12

PRINTED: 10/04/2019
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

R
MHL060968 B. WING _____. 10/02/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
CHARLOTTE, NC 28211

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION ny
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)

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1

Continued From page 6 V 366

LME where the client resides, if different. The
final written report shall address the issues
identified by the internal review team, shall
include all public documents pertinent to the
incident, and shall make recommendations for
minimizing the occurrence of future incidents. If
all documents needed for the report are not
available within three months of the incident, the
LME may give the provider an extension of up to
three months to submit the final report; and

(3) immediately notifying the following:

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

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

(C) the provider agency with responsibility
for maintaining and updating the client's
treatment plan, if different from the reporting
provider;

(D) the Department;

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

(F) any other authorities required by law.

This Rule is not met as evidenced by:

Based on interview and record review, the facility
failed to implement their written policy governing
their response to incidents

Review on 10/2/19 of Client #1's record revealed:
-Admission date of 3/14/19;

-Diagnoses of Attention Deficit Hyperactivity
Disorder, Disruptive Mood Dysregulation

Division of Health Service Regulation

STATE FORM $800 NUNC11 If continuation sheet 7 of 12

PRINTED: 10/04/2019
FORM APPROVED
Division of Health Service Regulation

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

R

MHLo60968 B. WING 10/02/2019

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

6220-D THERMAL RD
. LOTTE DAY
ALEXANDER YOUTH NETWORK - CHARI Y 1 CHARLOTTE, NC 28211

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

PROVIDER'S PLAN OF CORRECTION (x8)
(EACH CORRECTIVE ACTION SHOULD BE COMPLETE
CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

V 366) Continued From page 7

Disorder, and Oppositional Defiant Disorder;
-11 years old.

Interview on 10/2/19 with Client #1 revealed:
-Was brought into the library by Staff #4 when he
attempted to elope and Staff #4 who grabbed his
shirt and pushed him against the wall;

-Dates of the incident is unknown.

Interview on 10/2/19 with the Supervisor
revealed:

-Completed a disciplinary write-up for Staff #4's
failure to complete an incident report when Client
#1 attempted to elope and Staff #4 brought Client
#1 to the library to calm down.

Interview on 10/2/19 with the Executive Director
revealed:

-Will work closely with the Supervisor and will
discuss a possible re-arrangement of supervisory
duties to increase the Executive Director's time at
the Day Treatment.

27G .0604 Incident Reporting Requirements V367

What measures will be put in place to correct the
10A NCAC 27G .0604 INCIDENT deficient area of practice.

REPORTING REQUIREMENTS FOR . At the end of each day, Program Manager

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

Division of Health Service Regulation

STATE FORM

NUNC11

will meet face to face with a staff member from each
group and inquire about any incidents that occurred
during the day. This will be documented on a daily log,
. Program Manager will notify Executive
Director of all incidents within 12 hour timeframe.

. Program Manager will receive coaching in
reporting when an incident occurs to the Executive
Director to ensure proper escalation of procedures.
. If any incidents occur Program manager
will check to ensure documents are complete, and
determine what level the incident should be under.

106/19

10/6/19

10/14/19

10/14/19

Ifcontinuation sheet 8 of 12

PRINTED: 10/04/2019
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

R
MHL060968 BAWING —____—_______ 10/02/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE.
6220-D THERMAL RD
CHARLOTTE, NC 28211

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL {EACH CORRECTIVE ACTION SHOULD BE

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

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1

Continued From page 8 367 Continued From page 8

. If the incident rises to a level 2 or 3
Program Manager will ensure that critical incident
information is complete. 10/14/19
. Program manager will ensure that the
proper authorities have been contacted and notified
of the incident. 10/14/19
(2) client identification information; Describe your plans to make sure the above happens,
(3) type of incident; . On 10/4/19, Executive director discussed
(4) description of incident; with Program Manager the prevention steps above,
(5) status of the effort to determine the and reviewed the policy and procedures for

cause of the incident; and documenting incidents and reported allegations of

(6) other individuals or authorities notified abuse.

or responding. . Training and Program Improvement team
(b) Category A and B providers shall explain any will provide day treatment staff with refresher training
missing or incomplete information. The provider on Incident Reporting policies and procedures. 10/219
shall submit an updated report to all required . Program Manager will complete coaching
report recipients by the end of the next business and other progressive documentation in situations in
day whenever: which the correct documentation procedures are not
(1) the provider has reason to believe that followed. 10/16/19
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 Ill 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

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;

Who will monitor the situation to ensure it will not
occur again.

. The Executive Director will provide
monitoring to ensure that the interventions about are
being met.

Division of Health Service Regulation
STATE FORM eee NUNC11 If continuation sheet 9 of 12

PRINTED: 10/04/2019
FORM APPROVED

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED

R
MHL060968 B. WING —___—_____. 40/02/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE.
6220-D THERMAL RD
CHARLOTTE, NC 28211

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

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 7

V 367| Continued From page 9

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 fevel 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 Ili
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 interview and record review, the facility
failed to report all Level Ill incidents to the LME
responsible for the catchment area where
services are provided within 72 hours of
becoming aware of the incident.

Review on 10/2/19 of Client #1's record revealed:
-Admission date of 3/14/19;

~Diagnoses of Attention Deficit Hyperactivity
Division of Health Service Regulation

STATE FORM ease NUNC11 Hf continuation sheet 10 of 12

PRINTED: 10/04/2019
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED

R
MHL060968 B. WING _____.__ 10/02/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
CHARLOTTE, NC 28211

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

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1

Continued From page 10

Disorder, Disruptive Mood Dysregulation
Disorder, and Oppositional Defiant Disorder;
-11 years old.

Review on 10/2/19 of a Level | Incident Report
dated 8/1/19 revealed:

-Client #1 made an allegation against Staff #5
regarding Staff #5 using a choke hold while on
the van,

Review on 10/2/19 of the North Carolina Incident
Response Improvement System revealed:

-No Level II incident reports completed on the
allegations of abuse made by Client #1.

Interview on 10/2/19 with Client #1 revealed:
-Was brought into the library by Staff #4 who
grabbed his shirt and pushed him against the
wall;

-Was put in a choke hold by Staff #5 while on the
van ride home;

-Dates of the incidents are unknown.

Interview on 10/2/19 with the Supervisor
revealed:

-Had a meeting with Client #1's grandmother at
the end of September, 2019 during which the
grandmother reported the allegations involving
Staff #4 and Staff #5;

-No Level [Il incident reports were completed
regarding the allegations of abuse.

-Will ensure to complete Level Ill incident reports
on all allegations of abuse in the future.

Interview on 10/2/19 with the Executive Director
revealed:

-Will work closely with the Supervisor and will
discuss a possible re-arrangement of supervisory
duties to increase the Executive Director's time at
the Day Treatment.

Division of Health Service Regulation
STATE FORM os00 NUNC1I If continuation sheet 11 of 12

PRINTED: 10/04/2019
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

R
MHLo60968 8, WING ££ ______ 40/02/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
CHARLOTTE, NC 28211

(X4) (1D SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE

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

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1

Continued From page 11 V 367

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

Division of Health Service Regulation
STATE FORM S008 NUNC11 If continuation sheet 12 of 12

document_type: Plan of Correction


summary: Statement of Deficiency - MHLCS Follow-up

raw_content:
PRINTED: 07/11/2019

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
R
MHL060968 07/11/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1
CHARLOTTE, NC 28211
(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

A limited follow up survey for the Type B was
completed on July 11, 2019. This was a limited
follow up survey, only 10A NCAC 27G .0209
Medication Requirements (V120) was reviewed
for compliance. The following was brought back
into compliance: 10A NCAC 27G .0209
Medication Requirements (V120). No
deficiencies were cited.

This facility is licensed for the following service
category: 10A NCAC 27G .1400 Day Treatment
for Children and Adolescents with Emotional or
Behavioral Disturbances.

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

STATE FORM

6899

S5KDE11

TITLE (X6) DATE

If continuation sheet 1 of 1

inspection_type: MHLCS Follow-up