raw_content:
Division of Health Service Regulation

PRINTED: 02/28/2022
FORM APPROVED

This Rule is not met as evidenced by:

Based on record reviews and interviews, the
facllity failed to hold fire and disaster drills at least
quarterly and for each shift. The findings are:

L Review on 2-7-22 of facility fire and disaster drill

STATEMENT OF DEFICIENCIES. (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED
R
MHL002-028 EWING 02/10/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
243 LILEDOUN ROAD
LUCA'S HORE! TAYLORSVILLE, NC 28681
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES iD PROVIDER'S PLAN OF CORRECTION 0%)
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 Vv 000
An annual, complaint and follow up survey was
completed on February 10, 2022. The complaint | ca .
was unsubstantiated (Intake #NCO0 184216). Lucas Wome wi \ setup @
Deficiencies were cited. MOA Monitotrn System +o
AVE ri ba aon Ley
The facility is licensed for the following service rev Weed & + ule ¥. 2 bal aby
category: 10A NCAC 27G .1300 Residential FO SANSA Arak Whe Factity 1S al
Treatment for Children or Adolescents. hordia EiAe + dSa Ser cht Ns quect 4
“Fh The Dae
The survey sample consisted of audits of two | Gnd Le) ea th ee: cle: ¥
current clients and one former client. sW\ be res@on Sole weces é
‘a « 5 Cnrer
CROAT Wis ee Sor fud{
V 114 27G .0207 Emergency Plans and Supplies V114 a rhe Sah stm Aement a. Quart 7
pace e . 4 1 cludes Fit]
10A NCAC 27G .0207 EMERGENCY PLANS Check. list rat an
AND SUPPLIES 4 AS Sten be ulls,
(a) Awritten fire plan for each facility and
area-wide disaster plan shall be developed and
Shall be approved by the appropriate local
authority. | DHSR Mental Health
(b) The plan shall be made available to all staff
and evacuation procedures and routes shall be 022
Posted in the facility. MAR 9 a
(c) Fire and disaster drills in a 24-hour facility .
shall be held at least quarterly and shall be lic. & Cart Saction
repeated for each shift. Drills shall be conducted ~
under conditions that simulate fire emergencies.
(d) Each iacility shall have basic first aid supplies
accessible for use.

Division of Heaith Service Regulation
LABORATORY DIRECTOR'S OR PROVIDER/SUPP,

Ufa.

‘SENTATIVE'S SIGNATURE

E Xecahi

TITLE

wD ibector

(x6) DATE

STATE FORM

pa

89FO11

I continuation sheet 1 of 9

PRINTED: 02/28/2022

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (x1) PROVIDERISUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY.
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A BUILDING: COMPLETED
R
MHL002-028 9B. WANG 02/10/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
243 LILEDOUN ROAD
JCA'S HOPE III
LUCAS HOP TAYLORSVILLE, NC 28681
(x4) ID. SUMMARY STATEMENT OF DEFICIENCIES 1D 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 114. Continued From page 1 Uv V \ % on
records revealed: |
Pil i quarter 2021 (January, February, and Lutes Pope toAN Corduck a C\ass
arch): 2 — .
-Fire drills were not completed for 2nd and Gk AWE Nek Sar E mech -F
3rd shifts. ba bls, aA & elu cating al { ar
Disaster drills were not completed for 1st ? ae. DE Ane putes , 4
shift. are @ - ret
-For the third quarter 2021 (July, August, and Ay +o the Beal Care Pas
September): | af" . “
Fire drills were not completed for 2nd and R og shays HE Fac ALY wo \\ documer
3rd shifts. ° $e ANvVestigatials Comphe
-Disaster drills were not completed for 1st ive Win BS . ‘
ssfic . admin’ ratio. Sd Vat this
-For the fourth quarter 2021 (October, November, ¢ a PEE Ww
and December): Ww ( be ONE Jalle FoR Wed
Fire drills were not completed for 1st shift. ae anytime Show 4 as ? ;
-Disaster drills were not completed for 2nd ( \V he at Dal
shift. | dhat an m* RING ‘a es rg
has been Condubded, THE
Interview on 2-7-22 and 2-8-22 with the Director Mal RA Ww. \\ b &
revealed: rackiow / ANG: ~ Ste 5
-There are three shifts: first, second, and third. e500 Se hle For ASsudeat TW
ae facility was closed the first two months of ¥ er erent ac pine Face WY
ke
-It has been hard to get staff and "we just do what § CASUAL Yneak a tnt. dents
we can". wa iIN © Ac\n Pe Rue AMOS
-May have the missing drills at the office. There is Nar me i)
some paperwork that has to be filed. Ly reply an wwe (RSS)
| Loti Ane Pe Gr Med im Flac
V 132 G.S. 131E-256(G) HCPR-Notification, Lvigg tora UN : fandes Luce’S
Allegations, & Protection Ho remains MN ( “ Z i\ i
: reat 2
4 dire alle a
G.S. §131£-256 HEALTH CARE PERSONNEL Hope has © FOES wiSoiviel
REGISTRY Ao | (he 0? A SONIN]G
(g) Health care facilities shall ensure that the oO € H ca Me F
Department is notified of all allegations against oq sha SAC nis SuAve
health care personnel, including injuries of a . j in
unknown source, which appear to be related to | Eom O P) ‘a nad ye ev Co yo
any act listed in subdivision (a)(1) of this section. |
} ii

Division of Health Service Regulation

STATE FORM 6699

89FO11

If continuation sheet 2 of 9

Division of Health Service Regulation

PRINTED: 02/28/2022
FORM APPROVED

V 132 Continued From page 2

(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
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:

STATEMENT OF DEFICIENCIES, (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: _ COMPLETED
R
MHL002-028 Er WING: - — 02/10/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
243 LILEDOUN ROAD
LUCA'S HOPE lil
TAYLORSVILLE, NC 28681
(x4) 1D. 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

Division of Health Service Regulation
STATE FORM

e290

89FO11

Ii continuation sheet 3 of 9

PRINTED: 02/28/2022

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
MHL002-028 B. WING _____ 02/10/2022
NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE
243 LILEDOUN ROAD
LUCA'S HOPE Ill
TAYLORSVILLE, NC 28681
(x4) 1D. SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 132. Continued From page 3 Vv 132

Based on record reviews and interviews, the
facility failed to notify the Department of
allegations and report results of investigation of

findings are:

Interview on 2-8-22 with Department of Social
Services (DSS) Social Worker regarding
allegation of neglect of a client for improper
discipline by a staff person revealed:

-The Director knew the allegations against the
specific staff when the DSS report was initiated
-DSS did not make the recommendation that
Staff #1 not work in the facility but had

no physical discipline for the clients.

initially made the allegation recanted his story.
-The DSS case was closed with Services Not
Recommended.

Interview on 2-9-22 with the Qualified
Professional (QP) revealed:

-Was not aware that a report to Health Care
Personnel Registry (HCPR) had to be made for
an allegation.

~"In the past we have made the report to DSS.

revealed
-The Director was aware of the DSS report and
the allegations that a staff had whipped a client.

report.

-She was able to figure out which staff the
allegation was about after the clients were
interviewed.

-A report to HCPR was not done as the Director
was waiting for Division of Health Service

an allegation against health care personnel. The

discussions with the Director and Staff #1 about

-All clients denied allegations and the client who

That is all we were told we were supposed to do."

Interview on 2-7-22 and 2-8-22 with the Director

-No specific staff was mentioned initially from the

Division of Health Service Regulation
STATE FORM

see B9FO11

Hf continuation sheet 4 of 9

Division of Health Service Regulation

PRINTED: 02/28/2022
FORM APPROVED

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

MHL002-028

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

(X3) DATE SURVEY
COMPLETED

R
BWING 02/10/2022

NAME OF PROVIDER OR SUPPLIER

LUCA'S HOPE Ill

STREET ADDRESS, CITY, STATE, ZIP CODE

243 LILEDOUN ROAD
TAYLORSVILLE, NC 28681

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

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

V 132 Continued From page 4

Regulation (DHSR) to come out to complete an
investigation.

-"| didn't want to report someone to HCPR if the
allegations were not true.”

-She had spoken to Staff #1 but had not
documented any conversations.

-"I'm not even sure how to make a report to
HCPR."

-Did not complete a North Carolina Incident
Response Improvement System (IRIS) report or
any formal internal investigation. "I talked with her
(Staff #1) about it."

-"DSS didn't tell me that she (Staff #1) couldn't
work but | wouldn't let her work until DHSR came
out to complete the investigation and say she
could return to work."

Record review on 2-7-22 and 2-8-22 revealed:
-No documentation of a report made to the
HCPR.

-No documentation of an internal investigation.

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

V 367 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 Il 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

V 132

V 367

Division of Health Service Regulation
STATE FORM

809 89FO11 If continuation sheet 5 of 9

PRINTED: 02/28/2022

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (K1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER. REUENS COMPLETED
R
MHL002-028 8. WING ____ 02/10/2022
_ OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) 10 SUMMARY STATEMENT OF DEFICIENCIES io PROVIDER'S PLAN OF CORRECTION (x8)
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
OEFICIENCY)
V 367 Continued From page 5 V 367

becoming aware of the incident. The report shall
be submitted on a form provided by the
Secretary. The report may be submitted via mail,
in person, facsimile or encrypted electronic
means. The report shall include the following

information

(1) reporting provider contact and
identification information;

(2) client identification information;

(3) type of incident;

(4) description of incident;

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

(6) other individuals or authorities notified

or responding.

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

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

(c) Category A and B providers shall submit, |
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 Il 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

Division of Health Service Regulation
STATE FORM ‘Sees: 89FO11 If continuation sheet 6 of 9

Division of Health Service Regulation

PRINTED: 02/28/2022
FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA

(X2) MULTIPLE CONSTRUCTION

(x3) DATE SURVEY

V 367 Continued From page 6

incidents involving a client death to the Division of
Health Service Regulation within 72 hours of
becoming aware of the incident. In cases of
client death within seven days of use of seclusion
or restraint, the provider shall report the death
immediately, as required by 10A NCAC 26C
-0300 and 10A NCAC 27E .0104(e)(18).

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

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

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

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

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

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

This Rule is not met as evidenced by:

Based on record reviews and interviews, the
facility failed to report all level 2 incidents that
occurred during the provision of billable services.

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED
R
MHL002-028 SAWING 02/10/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
WWeAS ROPER 243 LILEDOUN ROAD
TAYLORSVILLE, NC 28681
(X4) 1D. 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

V 367

Luca's Pope SlLensuce thet cat |
Thcideats OF AWrtptucd Levels
be reputed Documented accel
4o We rules ‘eae +o anid
reathian , The Facty as(\ also
reece Prot Hae “crac |
Trwestigakions GA] documented
and Bled 50 frat Sot abs
Tnwestrgecton Gar be Quai (able
for 0 eNi eu + Luca‘S Hee wi \
designate he QP (amH?P)
as the Pessonnel bein, repn
and Nhe process oF Completes
bircidenck TePLES Folms, “ute
fe will Conduct an acd
pepoctiny Retleshed Class es
Ol SPE, reviewing (He hu
land phats reguitdd Foc c (l
Leute Is or cacidents

be

Division of Health Service Regulation
STATE FORM

999

89F011 if continuation sheet 7 of 9

Division of Health Service Requlation

PRINTED: 02/28/2022

FORM APPROVED

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

MHL002-028

(%2) MULTIPLE CONSTRUCTION

A, BUILDING:

B. WING

(x3) DATE SURVEY

COMPLETED

R
02/10/2022

NAME OF PROVIDER OR SUPPLIER

243 LILEDOUN ROAD
TAYLORSVILLE, NC 28681

LUCA'S HOPE Ill

STREET ADDRESS, CITY, STATE, ZIP CODE

(xa) 1D
PREFIX
TAG

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

ie}
PREFIX
TAG

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

(x5)
COMPLETE
DATE

V 367

V 736

Continued From page 7

The findings are:

Review of records on 2-7-22 and 2-8-22 revealed:

-No evidence of an incident report related to the
allegations against staff #1.

-No evidence of an internal investigation
completed by the facility.

Interview on 2-8-22 with Department of Social
Services (DSS) Social Worker revealed:

-the Director knew the allegations against the
specific staff when the DSS report was initiated.
-DSS did not make the recommendation that
Staff #1 not work in the facility but had
discussions with the Director and Staff #1 about
no physical discipline for the clients.

Interview on 2-9-22 with the Qualified
Professional (QP) revealed:

-Documentation was completed in the form of
monthly supervision notes with staff #1

-She believed an incident report had been
completed. The Director should have completed
it.

Interview on 2-7-22 and 2-8-22 with the Director
revealed:

-She had spoken with Staff #1 but had not
documented any conversations.

-Did not complete a North Carolina Incident
Response Improvement System (IRIS) report or
any formal internal investigation. "| talked with her
(Staff #1) about it."

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

27G .0303(c) Facility and Grounds Maintenance

V 367

V 736

Division of Health Service Regulation

STATE FORM

6899

89FO11

If continuation sheet 8 of 9

Division of Health Service Regulation

PRINTED: 02/28/2022
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
MHL002-028 8. WING 02/10/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Ue SHORE 243 LILEDOUN ROAD
TAYLORSVILLE, NC 28681
(x4) 10 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

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 observations and interviews, the facility
failed to be maintained in a safe, clean, attractive
and orderly manner. The findings are:

Observations on 2-7-22 at 12:30 pm and 2-8-22
at 10:15 am revealed:

-Blinds in the client bathroom were missing 3-4
slats.

-Blinds in the living room covering 3 windows had
multiple slats that were broken and hanging in the
holding strings and some slats were missing.
-Blinds in one of the kitchen windows had 2
broken slats.

Interview on 2-8-22 with the Director revealed:
-One of the clients like to "snap the blinds." The
clients look out of the window between the slats.
-Would have to replace the blinds every two
months due to how often the clients break them.
-Need to get something more durable that will
last.

Luce’s Hee wi\\ do @ monthly
Jtnhouse Checid OF \liads
to ensure Wetdhey ace
rePlaced TE Needed. the
Director &'\\ be telson sc ble
Khe Facility Kas reacted
Luca's |4qpe Cranyed all
bands QuAacha Sha a mne

dutable AYype oF blinds Yaa
“mont be so CaSy XO Drak

e hone anstalled the
aad Qlastic tye blinds
Hou gout @ home.

Division of Health Service Regulation
STATE FORM

6390 89FO11 lf continuation sheet 9 of 9

» NC DEPARTMENT OF ROY COOPER * Governor

HEALTH AND , + Seer
HUMAN SERVICES KODY H. KINSLEY - Secretary

DHSR - Mental Health

war § 2022

March 1, 2022 MAK
Valarie Stanback Lic. & Cert. Section
Luca’s Hope, LLC

PO Box 442

Suite 307

Sherrills Ford, NC 28673

Re: Annual, Complaint, and Follow up Survey completed February 10, 2022
Luca’s Hope III, 243 Liledoun Road, Taylorsville, NC 28681
MHL # 002-028
E-mail Address: valariestanback@yahoo.com
Intake #NC00182216

Dear Ms. Stanback:

Thank you for the cooperation and courtesy extended during the Annual, Complaint,
and Follow up survey completed February 10, 2022. The complaint was
unsubstantiated.

As a result of the follow up survey, it was determined that some of the deficiencies are
now in compliance, which is reflected on the enclosed Revisit Report. Additional
deficiencies were cited during the survey.

Enclosed you will find all deficiencies cited listed on the Statement of Deficiencies Form.
The purpose of the Statement of Deficiencies is to provide you with specific details of
the practice that does not comply with state regulations. You must develop one Plan of
Correction that addresses each deficiency listed on the State Form, and return it to our
office within ten days of receipt of this letter. Below you will find details of the type of
deficiencies found, the time frames for compliance plus what to include in the Plan of
Correction.

Type of Deficiencies Found

e Re-cited standard level deficiencies.
e Allother tags cited are standard level deficiencies.

Time Frames for Compliance

e Re-cited standard level deficiencies must be corrected within 30 days from the
exit of the survey, which is March 12, 2022.
MENTAL HEALTH LICENSURE & CERTIFICATION SECTION
NC DEPARTMENT OF HEALTH AND HUMAN SERVICES - DIVISION OF HEALTH SERVICE REGULATION

LOCATION: 1800 Umstead Drive, Williams Building, Raleigh, NC 27603
MAILING ADDRESS: 2718 Mail Service Center, Raleigh, NC 27699-2718
www.nedhhs.gow/dhsr + TEL: 919-855-3795 + Fax: 919-715-8078

AN EQUAL OPPORTUNITY / AFFIRMATIVE ACTION EMPLOYER

MARK PAYNE » Director, Division of Health Service Regulation

March 1, 2022

Luca’s Hope III

Valarie Stanback

e Standard level deficiencies must be corrected within 60 days from the exit of the
survey, which is April 11, 2022.

What to include in the Plan of Correction

e Indicate what measures will be put in place to correct the deficient area of
practice (i.e. changes in policy and procedure, staff training, changes in staffing
patterns, etc.).

e Indicate what measures will be put in place to prevent the problem from
occurring again.

e Indicate who will monitor the situation to ensure it will not occur again.

e Indicate how often the monitoring will take place.

e Sign and date the bottom of the first page of the State Form.

Make a copy of the Statement of Deficiencies with the Plan of Correction to retain for
your records. Please do not include confidential information in your plan of
correction and please remember never to send confidential information
(protected health information) via email.

Send the original completed form to our office at the following address within 10 days of
receipt of this letter.

Mental Health Licensure and Certification Section
NC Division of Health Service Regulation
2718 Mail Service Center
Raleigh, NC 27699-2718

A follow up visit will be conducted to verify all violations have been corrected. If we can
be of further assistance, please call Sonia Eldridge at 828-665-9911.

Sincerely,

Benjamin Robinson
Facility Compliance Consultant |
Mental Health Licensure & Certification Section

Cc: dhhs@vayahealth.com

Pam Pridgen, Administrative Assistant


state: NC

facility_name: Luca's Hope III

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

raw_content:
Division of Health Service Regulation

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

MHLO002-028

NAME OF PROVIDER OR SUPPLIER

A. BUILDING:

243 LILEDOUN ROAD
TAYLORSVILLE, NC 28681

LUCA'S HOPE III

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 02/28/2022

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R
02/10/2022

(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 000} INITIAL COMMENTS

An annual, complaint and follow up survey was
completed on February 10, 2022. The complaint
was unsubstantiated (Intake #NC00184216).
Deficiencies were cited.

The facility is licensed for the following service
category: 10A NCAC 27G .1300 Residential
Treatment for Children or Adolescents.

The survey sample consisted of audits of two
current clients and one former client.

V 114) 27G .0207 Emergency Plans and Supplies

10A NCAC 27G .0207 EMERGENCY PLANS
AND SUPPLIES

(a) Awritten fire plan for each facility and
area-wide disaster plan shall be developed and
shall be approved by the appropriate local
authority.

(b) The plan shall be made available to all staff
and evacuation procedures and routes shall be
posted in the facility.

(c) Fire and disaster drills in a 24-hour facility
shall be held at least quarterly and shall be
repeated for each shift. Drills shall be conducted
under conditions that simulate fire emergencies.
(d) Each facility shall have basic first aid supplies
accessible for use.

This Rule is not met as evidenced by:

Based on record reviews and interviews, the
facility failed to hold fire and disaster drills at least
quarterly and for each shift. The findings are:

Review on 2-7-22 of facility fire and disaster drill

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

STATE FORM

V 000

Vv 114

6899

89FO11

TITLE

(X6) DATE

If continuation sheet 1 of 9

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHLO002-028

A. BUILDING:

243 LILEDOUN ROAD
TAYLORSVILLE, NC 28681

LUCA'S HOPE III

(X2) MULTIPLE CONSTRUCTION

PRINTED: 02/28/2022

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R
02/10/2022

(x4) ID
PREFIX
TAG

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

ID
PREFIX
TAG

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

(xs)
COMPLETE
DATE

V114

V 132|

Continued From page 1

records revealed:
-For first quarter 2021 (January, February, and
March):

-Fire drills were not completed for 2nd and
3rd shifts.

-Disaster drills were not completed for 1st
shift.
-For the third quarter 2021 (July, August, and
September):

-Fire drills were not completed for 2nd and
3rd shifts.

-Disaster drills were not completed for 1st
shift.
-For the fourth quarter 2021 (October, November,
and December):

-Fire drills were not completed for 1st shift.

-Disaster drills were not completed for 2nd
shift.

Interview on 2-7-22 and 2-8-22 with the Director
revealed:

-There are three shifts: first, second, and third.
-The facility was closed the first two months of
2021.

-It has been hard to get staff and "we just do what
we can".

-May have the missing drills at the office. There is
some paperwork that has to be filed.

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.

Division of Health Service Regulation
STATE FORM

Vv 114

V 132

6809

89FO11

If continuation sheet 2 of 9

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHLO002-028

A. BUILDING:

243 LILEDOUN ROAD

(X2) MULTIPLE CONSTRUCTION

PRINTED: 02/28/2022

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R
02/10/2022

(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
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:

Division of Health Service Regulation

STATE FORM

6809

89FO11

LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 132] Continued From page 2 V 132

If continuation sheet 3 of 9

Division of Health Service Regulation

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

MHLO002-028

NAME OF PROVIDER OR SUPPLIER

A. BUILDING:

243 LILEDOUN ROAD

(X2) MULTIPLE CONSTRUCTION

PRINTED: 02/28/2022

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R
02/10/2022

LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 132] Continued From page 3 V 132

Based on record reviews and interviews, the
facility failed to notify the Department of
allegations and report results of investigation of
an allegation against health care personnel. The
findings are:

Interview on 2-8-22 with Department of Social
Services (DSS) Social Worker regarding
allegation of neglect of a client for improper
discipline by a staff person revealed:

-The Director knew the allegations against the
specific staff when the DSS report was initiated.
-DSS did not make the recommendation that
Staff #1 not work in the facility but had
discussions with the Director and Staff #1 about
no physical discipline for the clients.

-All clients denied allegations and the client who
initially made the allegation recanted his story.
-The DSS case was closed with Services Not
Recommended.

Interview on 2-9-22 with the Qualified
Professional (QP) revealed:

-Was not aware that a report to Health Care
Personnel Registry (HCPR) had to be made for
an allegation.

-"In the past we have made the report to DSS.
That is all we were told we were supposed to do."

Interview on 2-7-22 and 2-8-22 with the Director
revealed:

-The Director was aware of the DSS report and
the allegations that a staff had whipped a client.
-No specific staff was mentioned initially from the
report.

-She was able to figure out which staff the
allegation was about after the clients were
interviewed.

-A report to HCPR was not done as the Director
was waiting for Division of Health Service

Division of Health Service Regulation
STATE FORM

6809

89FO11

If continuation sheet 4 of 9

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHLO002-028

A. BUILDING:

243 LILEDOUN ROAD
TAYLORSVILLE, NC 28681

LUCA'S HOPE III

(X2) MULTIPLE CONSTRUCTION

PRINTED: 02/28/2022

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R
02/10/2022

(x4) ID
PREFIX
TAG

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

ID
PREFIX
TAG

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

(xs)
COMPLETE
DATE

V 132

V 367|

Continued From page 4

Regulation (DHSR) to come out to complete an
investigation.

-"| didn't want to report someone to HCPR if the
allegations were not true."

-She had spoken to Staff #1 but had not
documented any conversations.

-"I'm not even sure how to make a report to
HCPR."

-Did not complete a North Carolina Incident
Response Improvement System (IRIS) report or
any formal internal investigation. "I talked with her
(Staff #1) about it.”

-"DSS didn't tell me that she (Staff #1) couldn't
work but | wouldn't let her work until DHSR came
out to complete the investigation and say she
could return to work."

Record review on 2-7-22 and 2-8-22 revealed:
-No documentation of a report made to the
HCPR.

-No documentation of an internal investigation.

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

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

Division of Health Service Regulation
STATE FORM

V 132

V 367

6809

89FO11

If continuation sheet 5 of 9

Division of Health Service Regulation

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

MHLO002-028

NAME OF PROVIDER OR SUPPLIER

A. BUILDING:

243 LILEDOUN ROAD

(X2) MULTIPLE CONSTRUCTION

PRINTED: 02/28/2022

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R
02/10/2022

LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(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

becoming aware of the incident. The report shall
be submitted on a form provided by the
Secretary. The report may be submitted via mail,
in person, facsimile or encrypted electronic
means. The report shall include the following

information:

(1) reporting provider contact and
identification information;

(2) client identification information;

(3) type of incident;

(4) description of incident;

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

(6) other individuals or authorities notified

or responding.

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

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

(c) Category A and B providers shall submit,
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

Division of Health Service Regulation
STATE FORM

6809

89FO11

If continuation sheet 6 of 9

Division of Health Service Regulation

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

MHLO002-028

NAME OF PROVIDER OR SUPPLIER

A. BUILDING:

243 LILEDOUN ROAD

(X2) MULTIPLE CONSTRUCTION

PRINTED: 02/28/2022

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R
02/10/2022

LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(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 6 V 367

incidents involving a client death to the Division of
Health Service Regulation within 72 hours of
becoming aware of the incident. In cases of
client death within seven days of use of seclusion
or restraint, the provider shall report the death
immediately, as required by 10A NCAC 26C.
.0300 and 10A NCAC 27E .0104(e)(18).

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

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

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

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

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

(6) a statement indicating that there have

been no reportable incidents whenever no
incidents have occurred during the quarter that
meet any of the criteria as set forth in Paragraphs
(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 reviews and interviews, the
facility failed to report all level 2 incidents that
occurred during the provision of billable services.

Division of Health Service Regulation
STATE FORM

6809

89FO11

If continuation sheet 7 of 9

Division of Health Service Regulation

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

MHLO002-028

NAME OF PROVIDER OR SUPPLIER

A. BUILDING:

243 LILEDOUN ROAD
TAYLORSVILLE, NC 28681

LUCA'S HOPE III

(X2) MULTIPLE CONSTRUCTION

PRINTED: 02/28/2022

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

R
02/10/2022

(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 367] Continued From page 7

The findings are:

Review of records on 2-7-22 and 2-8-22 revealed:
-No evidence of an incident report related to the
allegations against staff #1.

-No evidence of an internal investigation
completed by the facility.

Interview on 2-8-22 with Department of Social
Services (DSS) Social Worker revealed:

-the Director knew the allegations against the
specific staff when the DSS report was initiated.
-DSS did not make the recommendation that
Staff #1 not work in the facility but had
discussions with the Director and Staff #1 about
no physical discipline for the clients.

Interview on 2-9-22 with the Qualified
Professional (QP) revealed:

-Documentation was completed in the form of
monthly supervision notes with staff #1.

-She believed an incident report had been
completed. The Director should have completed
it.

Interview on 2-7-22 and 2-8-22 with the Director
revealed:

-She had spoken with Staff #1 but had not
documented any conversations.

-Did not complete a North Carolina Incident
Response Improvement System (IRIS) report or
any formal internal investigation. "I talked with her
(Staff #1) about it.”

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

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

V 367

V 736

Division of Health Service Regulation
STATE FORM

6809

89FO11

If continuation sheet 8 of 9

Division of Health Service Regulation

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

MHLO002-028

NAME OF PROVIDER OR SUPPLIER

A. BUILDING:

243 LILEDOUN ROAD

(X2) MULTIPLE CONSTRUCTION

PRINTED: 02/28/2022

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

R
02/10/2022

LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(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

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 observations and interviews, the facility
failed to be maintained in a safe, clean, attractive
and orderly manner. The findings are:

Observations on 2-7-22 at 12:30 pm and 2-8-22
at 10:15 am revealed:

-Blinds in the client bathroom were missing 3-4
slats.

-Blinds in the living room covering 3 windows had
multiple slats that were broken and hanging in the
holding strings and some slats were missing.
-Blinds in one of the kitchen windows had 2
broken slats.

Interview on 2-8-22 with the Director revealed:
-One of the clients like to "snap the blinds." The
clients look out of the window between the slats.
-Would have to replace the blinds every two
months due to how often the clients break them.
-Need to get something more durable that will
last.

Division of Health Service Regulation
STATE FORM

6809

89FO11

If continuation sheet 9 of 9

inspection_type: MHLCS Annual, Complaint, and Follow-up

document_type: Statement of Deficiency


summary: Statement of Deficiency - MHLCS Complaint

raw_content:
PRINTED: 08/14/2020

FORM APPROVED
Division of Health Service Re
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHLO002-028 08/14/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
\ 243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(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 August 14,
2020. The complaints were unsubstantiated
(intake #NC00167242, #NC00167515, and
#NC00167755). No deficiencies were cited.

This facility is licensed for the following service
category: 10A NCAC 27G .1300 Residential
Treatment for Children or Adolescents.

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

STATE FORM

6899

60HW11

TITLE (X6) DATE

If continuation sheet 1 of 1

inspection_type: MHLCS Complaint


summary: Statement of Deficiency - MHLCS Follow-up

raw_content:
Division of Health Service Regulation

PRINTED: 12/20/2019
FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHLO002-028 B. WING 12/13/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
' 243 LILEDOUN ROAD
LUGA'S HOPE Il TAYLORSVILLE, NC 28681
(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 rule
violation was completed on December 13, 2019.
This was a limited follow up survey, only 10A
NCAC 27E .0108 Training in Seclusion, Physical
Restraint and Isolation Time-Out (V537) was
reviewed for compliance. The following was
brought back into compliance: 10A NCAC 27E
.0108 Training in Seclusion, Physical Restraint
and Isolation Time-Out (V537). No deficiencies
were cited.
This facility is licensed for the following service
category: 10A NCAC 27G .1300 Residential
Treatment for Children or Adolescents.
Division of Health Service Regulation
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
STATE FORM 6899 2O0RR11 If continuation sheet 1 of 1

inspection_type: MHLCS Follow-up