summary: Statement of Deficiency - MHLCS Annual

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Division of Health Service Regulation

PRINTED: 04/01/2019
FORM APPROVED

10A NCAC 27G .0202 PERSONNEL
REQUIREMENTS

(f) Continuing education shall be documented.
(g) Employee training programs shall be
provided and, at a minimum, shall consist of the
following:

(1) general organizational orientation;

(2) training on client rights and confidentiality as
delineated in 10A NCAC 27C, 27D, 27E, 27F and
10A NCAC 26B;

(3) training to meet the mh/dd/sa needs of the
client as specified in the treatment/habilitation
plan; and

(4) training in infectious diseases and
bloodborne pathogens.

(h) Except as permitted under 10a NCAC 27G
.5602(b) of this Subchapter, at least one staff
member shall be available in the facility at all
times when a client is present. That staff
member shall be trained in basic first aid
including seizure management, currently trained
to provide cardiopulmonary resuscitation and
trained in the Heimlich maneuver or other first aid
techniques such as those provided by Red Cross,
the American Heart Association or their
equivalence for relieving airway obstruction.

(i) The governing body shall develop and
implement policies and procedures for identifying,
reporting, investigating and controlling infectious
and communicable diseases of personnel and

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

STATE FORM

809 COFL11

TITLE

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHLO013-195 03/27/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
9167 HYDRANGEA DRIVE
SMITH HOME
HARRISBURG, NC 28075
(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 survey was completed on 3/27/29.
Deficiencies were cited.
This facility is licensed for the folllowing service
category: 10A NCAC 27G .5600F Alternative
Family Living.
V 108] 27G .0202 (F-I) Personnel Requirements V 108

(X6) DATE

If continuation sheet 1 of 18

Division of Health Service Regulation

PRINTED: 04/01/2019
FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
MHLO013-195 03/27/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
9167 HYDRANGEA DRIVE
SMITH HOME
HARRISBURG, NC 28075
(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 108] Continued From page 1

clients.

This Rule is not met as evidenced by:

Based on interviews, observations and record
reviews, the facility failed to ensure all staff
completed trainings in general organizational
orientation, training in client rights and
confidentiality, training to meet the mh/dd/sa
needs of the client as specified in the
treatment/habilitation plan, training in infectious
diseases and bloodborne pathogens and the
facility also failed to ensure at least one staff
member trained in basic first aid including seizure
management, currently trained to provide
cardiopulmonary resuscitation and trained in the
Heimlich maneuver or other first aid techniques
was available in the facility at all times when
clients were present affecting 2 of 2 clients (#1,
#2) The findings are:

Observation on 3/25/19 at 3:00pm revealed a
male adult in the facility with staff #1.

Review on 3/22/19 of client #1's record revealed:
-admission date of 11/10/14 with diagnoses of
COPD, Encephalopathy, Osteoarthritis, Asthma,
Schizoaffective Disorder, Depressive Disorder,
Borderline Personality Disorder and Intellectual
Developmental Disabilities(IDD)-Moderate.

Review on 3/22/19 of client #2's record revealed:
-admission date of 4/5/18 with diagnoses of
PTSD, Personality Disorder, Bipolar Disorder,
Psychosis Disorder, Depression, Acid Reflux,
Hypothyroidism, Obesity, Anxiety, IDD-Moderate,
Migraines and Adjustment Disorder.

Division of Health Service Regulation
STATE FORM

V 108

809 COFL11

If continuation sheet 2 of 18

Division of Health Service Regulation

PRINTED: 04/01/2019

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

03/27/2019

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

(xs)
COMPLETE
DATE

Division of Health Service Regulation
STATE FORM

6809

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
A. BUILDING:
MHL013-195
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
9167 HYDRANGEA DRIVE
SMITH HOME
HARRISBURG, NC 28075
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG
V 108] Continued From page 2 V 108
Interview on 3/25/19 with client #1 revealed when
staff #1 goes places, "[the adult male] watches
them sometimes."
Interview on 3/25/19 with client #2 revealed if staff
#1 has to run an errand, "[the adult male]
watches them."
Interview with staff #1 revealed the adult male
was her boyfriend and watched client #1 and #2
sometimes if she has to run a quick errand.
Request on 3/27/19 to review the personnel
record and trainings of the adult male in the
facility providing care for clients #1 and #2 was
unsuccessful as there was not a personnel record
or trainings to review.
Interview on 3/27/19 with the Residential Director
revealed:
-staff #1's boyfriend does not live in the facility;
-he only visits from time to time;
-considered a "natural support;"
-can watch clients #1 and #2 up to three hours
per their policy and no training required;
-this policy was created by a former administrator
regarding an issue at another facility;
-do not have a personnel record on the adult
male in the facility;
-the adult male in the facility does not have any
completed trainings.
V 118| 27G .0209 (C) Medication Requirements Vv 118
10A NCAC 27G .0209 MEDICATION
REQUIREMENTS
(c) Medication administration:
(1) Prescription or non-prescription drugs shall

If continuation sheet 3 of 18

Division of Health Service Regulation

PRINTED: 04/01/2019
FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
MHLO013-195 03/27/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
9167 HYDRANGEA DRIVE
SMITH HOME
HARRISBURG, NC 28075
(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 118] Continued From page 3

only be administered to a client on the written
order of a person authorized by law to prescribe
drugs.

(2) Medications shall be self-administered by
clients only when authorized in writing by the
client's physician.

(3) Medications, including injections, shall be
administered only by licensed persons, or by
unlicensed persons trained by a registered nurse,
pharmacist or other legally qualified person and
privileged to prepare and administer medications.
(4) A Medication Administration Record (MAR) of
all drugs administered to each client must be kept
current. Medications administered shall be
recorded immediately after administration. The
MAR is to include the following:

(A) client's name;

(B) name, strength, and quantity of the drug;

(C) instructions for administering the drug;

(D) date and time the drug is administered; and
(E) name or initials of person administering the
drug.

(5) Client requests for medication changes or
checks shall be recorded and kept with the MAR
file followed up by appointment or consultation
with a physician.

This Rule is not met as evidenced by:
Based on records review, observation and
interviews, the facility failed to ensure
medications were administered as ordered
affecting 1 of 2 clients (#1). The findings are:

Review on 3/22/19 of client #1's record revealed:
-admission date of 11/10/14 with diagnoses of
COPD, Encephalopathy, Osteoarthritis, Asthma,

Division of Health Service Regulation
STATE FORM

V 118

809 COFL11

If continuation sheet 4 of 18

Division of Health Service Regulation

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

MHLO013-195

A. BUILDING:

(X2) MULTIPLE CONSTRUCTION

PRINTED: 04/01/2019

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

9167 HYDR:
HARRISBU!

SMITH HOME

ANGEA DRIVE
RG, NC 28075

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

03/27/2019

(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 118] Continued From page 4

Schizoaffective Disorder, Depressive Disorder,
Borderline Personality Disorder and Intellectual
Developmental Disabilities-Moderate;
-physicians' orders dated 1/9/19 for
Triamcinolone ointment apply twice daily to groin
and Ketoconazole cream apply once daily to right
groin.

Observation on 3/25/19 at 2:58pm of client #1's
medications on site revealed:

-Triamcinolone ointment apply twice daily to groin
not on site;

-Ketoconazole cream apply once daily to right
groin not on site.

Review on 3/22/19 and 3/25/19 of client #1's
MARS from 1/1/19-3/22/19 revealed:
-Triamcinolone ointment apply twice daily and
Ketoconazole cream apply once daily not listed
on MARs for 1/2019, 2/2019 and 3/2019;

-no documentation on the 1/2019, 2/2019 and
3/2019 MARs Triamcinolone ointment apply twice
daily and Ketoconazole cream apply once daily
was administered.

Interview on 3/25/19 with client #1 revealed she
was not aware of any missed medications.

Interview on 3/27/19 with the Nurse revealed:
-not sure why medications were not on MARs;
-not sure why medications were not administered;
-will ensure correct medications were listed on
MARS and medications administered as
prescribed.

V 131] G.S. 131E-256 (D2) HCPR - Prior Employment
Verification

G.S. §131E-256 HEALTH CARE PERSONNEL

Division of Health Service Regulation
STATE FORM

V 118

Vv 131

809 COFL11

If continuation sheet 5 of 18

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHLO013-195

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 04/01/2019

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

03/27/2019

REGISTRY

(d2) Before hiring health care personnel into a
health care facility or service, every employer at a
health care facility shall access the Health Care
Personnel Registry and shall note each incident
of access in the appropriate business files.

This Rule is not met as evidenced by:
Based on records review, observations and
interviews, the facility failed to access the
HCPR(Health Care Personnel Registry). The
findings are:

Observation on 3/25/19 at 3:00pm revealed a
male adult in the facility with staff #1.

Review on 3/22/19 of client #1's record revealed:
-admission date of 11/10/14 with diagnoses of
COPD, Encephalopathy, Osteoarthritis, Asthma,
Schizoaffective Disorder, Depressive Disorder,
Borderline Personality Disorder and Intellectual
Developmental Disabilities(IDD)-Moderate.

Review on 3/22/19 of client #2's record revealed:
-admission date of 4/5/18 with diagnoses of
PTSD, Personality Disorder, Bipolar Disorder,
Psychosis Disorder, Depression, Acid Reflux,
Hypothyroidism, Obesity, Anxiety, IDD-Moderate,
Migraines and Adjustment Disorder.

Interview on 3/25/19 with client #1 revealed when
staff #1 goes places, "[the adult male] watches
them sometimes."

Interview on 3/25/19 with client #2 revealed if staff

Division of Health Service Regulation
STATE FORM

6809

COFL11

9167 HYDRANGEA DRIVE
SMITH HOME
HARRISBURG, NC 28075
(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 131] Continued From page 5 Vv 131

If

continuation sheet 6 of 18

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

SMITH HOME

MHLO013-195

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION

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

PRINTED: 04/01/2019

STREET ADDRESS, CITY, STATE, ZIP CODE
9167 HYDRANGEA DRIVE
HARRISBURG, NC 28075

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

03/27/2019

(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

Vv 131

V 133|

Continued From page 6 Vv 131

#1 has to run an errand, "[the adult male]
watches them."

Interview with staff #1 revealed the adult male
was her boyfriend and watched client #1 and #2
sometimes if she has to run a quick errand.

Request on 3/27/19 to review the personnel
record and HCPR check of the adult male in the
facility providing care to clients #1 and #2 was
unsuccessful as there was not a personnel record
or HCPR check to review.

Interview on 3/27/19 with the Residential Director
revealed:

-staff #1's boyfriend does not live in the facility;
-he only visits from time to time;

-considered a "natural support;"

-can watch clients #1 and #2 up to three hours
per their policy;

-this policy was created by a former administrator
regarding an issue at another facility;

-do not have a personnel record on the adult
male in the facility;

-the adult male in the facility does not have a
HCPR check since he does not reside in the
facility.

G.S. 122C-80 Criminal History Record Check V 133

G.S. §122C-80 CRIMINAL HISTORY RECORD
CHECK REQUIRED FOR CERTAIN
APPLICANTS FOR EMPLOYMENT.

(a) Definition. - As used in this section, the term
"provider" applies to an area authority/county
program and any provider of mental health,
developmental disability, and substance abuse
services that is licensable under Article 2 of this
Chapter.

Division of Health Service Regulation
STATE FORM

6809

If continuation sheet 7 of 18

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHLO013-195

A. BUILDING:

(X2) MULTIPLE CONSTRUCTION

PRINTED: 04/01/2019

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

03/27/2019

(b) Requirement. - An offer of employment by a
provider licensed under this Chapter to an
applicant to fill a position that does not require the
applicant to have an occupational license is
conditioned on consent to a State and national
criminal history record check of the applicant. If
the applicant has been a resident of this State for
less than five years, then the offer of employment
is conditioned on consent to a State and national
criminal history record check of the applicant. The
national criminal history record check shall
include a check of the applicant's fingerprints. If
the applicant has been a resident of this State for
five years or more, then the offer is conditioned
on consent to a State criminal history record
check of the applicant. A provider shall not
employ an applicant who refuses to consent to a
criminal history record check required by this
section. Except as otherwise provided in this
subsection, within five business days of making
the conditional offer of employment, a provider
shall submit a request to the Department of
Justice under G.S. 114-19.10 to conduct a
criminal history record check required by this
section or shall submit a request to a private
entity to conduct a State criminal history record
check required by this section. Notwithstanding
G.S. 114-19.10, the Department of Justice shall
return the results of national criminal history
record checks for employment positions not
covered by Public Law 105-277 to the
Department of Health and Human Services,
Criminal Records Check Unit. Within five
business days of receipt of the national criminal
history of the person, the Department of Health
and Human Services, Criminal Records Check
Unit, shall notify the provider as to whether the
information received may affect the employability
of the applicant. In no case shall the results of the

Division of Health Service Regulation
STATE FORM

809 COFL11

9167 HYDRANGEA DRIVE
SMITH HOME
HARRISBURG, NC 28075
(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 133] Continued From page 7 V 133

If continuation sheet 8 of 18

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

(X2) MULTIPLE CONSTRUCTION

PRINTED: 04/01/2019

FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHLO013-195 03/27/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
9167 HYDRANGEA DRIVE
SMITH HOME
HARRISBURG, NC 28075
(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 133] Continued From page 8 V 133

national criminal history record check be shared
with the provider. Providers shall make available
upon request verification that a criminal history
check has been completed on any staff covered
by this section. A county that has adopted an
appropriate local ordinance and has access to
the Division of Criminal Information data bank
may conduct on behalf of a provider a State
criminal history record check required by this
section without the provider having to submit a
request to the Department of Justice. In such a
case, the county shall commence with the State
criminal history record check required by this
section within five business days of the
conditional offer of employment by the provider.
All criminal history information received by the
provider is confidential and may not be disclosed,
except to the applicant as provided in subsection
(c) of this section. For purposes of this
subsection, the term "private entity" means a
business regularly engaged in conducting
criminal history record checks utilizing public
records obtained from a State agency.

(c) Action. - If an applicant's criminal history
record check reveals one or more convictions of
a relevant offense, the provider shall consider all
of the following factors in determining whether to
hire the applicant:

(1) The level and seriousness of the crime.

(2) The date of the crime.

(3) The age of the person at the time of the
conviction.

(4) The circumstances surrounding the
commission of the crime, if known.

(5) The nexus between the criminal conduct of
the person and the job duties of the position to be
filled.

(6) The prison, jail, probation, parole,
rehabilitation, and employment records of the

Division of Health Service Regulation
STATE FORM

809 COFL11

If continuation sheet 9 of 18

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHLO013-195

A. BUILDING:

(X2) MULTIPLE CONSTRUCTION

PRINTED: 04/01/2019

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

03/27/2019

person since the date the crime was committed.
(7) The subsequent commission by the person of
a relevant offense.

The fact of conviction of a relevant offense alone
shall not be a bar to employment; however, the
listed factors shall be considered by the provider.
If the provider disqualifies an applicant after
consideration of the relevant factors, then the
provider may disclose information contained in
the criminal history record check that is relevant
to the disqualification, but may not provide a copy
of the criminal history record check to the
applicant.

(d) Limited Immunity. - A provider and an officer
or employee of a provider that, in good faith,
complies with this section shall be immune from
civil liability for:

(1) The failure of the provider to employ an
individual on the basis of information provided in
the criminal history record check of the individual.
(2) Failure to check an employee's history of
criminal offenses if the employee's criminal
history record check is requested and received in
compliance with this section.

(e) Relevant Offense. - As used in this section,
"relevant offense" means a county, state, or
federal criminal history of conviction or pending
indictment of a crime, whether a misdemeanor or
felony, that bears upon an individual's fitness to
have responsibility for the safety and well-being of
persons needing mental health, developmental
disabilities, or substance abuse services. These
crimes include the criminal offenses set forth in
any of the following Articles of Chapter 14 of the
General Statutes: Article 5, Counterfeiting and
Issuing Monetary Substitutes; Article 5A,
Endangering Executive and Legislative Officers;
Article 6, Homicide; Article 7A, Rape and Other
Sex Offenses; Article 8, Assaults; Article 10,

Division of Health Service Regulation
STATE FORM

809 COFL11

9167 HYDRANGEA DRIVE
SMITH HOME
HARRISBURG, NC 28075
(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 133] Continued From page 9 V 133

If continuation sheet 10 of 18

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHLO013-195

A. BUILDING:

(X2) MULTIPLE CONSTRUCTION

PRINTED: 04/01/2019

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

03/27/2019

Kidnapping and Abduction; Article 13, Malicious
Injury or Damage by Use of Explosive or
Incendiary Device or Material; Article 14, Burglary
and Other Housebreakings; Article 15, Arson and
Other Burnings; Article 16, Larceny; Article 17,
Robbery; Article 18, Embezzlement; Article 19,
False Pretenses and Cheats; Article 19A,
Obtaining Property or Services by False or
Fraudulent Use of Credit Device or Other Means;
Article 19B, Financial Transaction Card Crime
Act; Article 20, Frauds; Article 21, Forgery; Article
26, Offenses Against Public Morality and
Decency; Article 26A, Adult Establishments;
Article 27, Prostitution; Article 28, Perjury; Article
29, Bribery; Article 31, Misconduct in Public
Office; Article 35, Offenses Against the Public
Peace; Article 36A, Riots and Civil Disorders;
Article 39, Protection of Minors; Article 40,
Protection of the Family; Article 59, Public
Intoxication; and Article 60, Computer-Related
Crime. These crimes also include possession or
sale of drugs in violation of the North Carolina
Controlled Substances Act, Article 5 of Chapter
90 of the General Statutes, and alcohol-related
offenses such as sale to underage persons in
violation of G.S. 18B-302 or driving while
impaired in violation of G.S. 20-138.1 through
G.S. 20-138.5.

(f) Penalty for Furnishing False Information. - Any
applicant for employment who willfully furnishes,
supplies, or otherwise gives false information on
an employment application that is the basis for a
criminal history record check under this section
shall be guilty of a Class A1 misdemeanor.

(g) Conditional Employment. - A provider may
employ an applicant conditionally prior to
obtaining the results of a criminal history record
check regarding the applicant if both of the
following requirements are met:

Division of Health Service Regulation
STATE FORM

809 COFL11

9167 HYDRANGEA DRIVE
SMITH HOME
HARRISBURG, NC 28075
(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 133] Continued From page 10 V 133

If continuation sheet 11 of 18

Division of Health Service Regulation

PRINTED: 04/01/2019
FORM APPROVED

(1) The provider shall not employ an applicant
prior to obtaining the applicant's consent for
criminal history record check as required in
subsection (b) of this section or the completed
fingerprint cards as required in G.S. 114-19.10.
(2) The provider shall submit the request for a
criminal history record check not later than five
business days after the individual begins
conditional employment. (2000-154, s. 4;
2001-155, s. 1; 2004-124, ss. 10.19D(c), (h);
2005-4, ss. 1, 2, 3, 4, 5(a); 2007-444, s. 3.)

This Rule is not met as evidenced by:

Based on records review, observations and
interviews, the facility failed to request the
required criminal records check. The findings are:

Observation on 3/25/19 at 3:00pm revealed a
male adult in the facility with staff #1.

Review on 3/22/19 of client #1's record revealed:
-admission date of 11/10/14 with diagnoses of
COPD, Encephalopathy, Osteoarthritis, Asthma,
Schizoaffective Disorder, Depressive Disorder,
Borderline Personality Disorder and Intellectual
Developmental Disabilities(IDD)-Moderate.

Review on 3/22/19 of client #2's record revealed:
-admission date of 4/5/18 with diagnoses of
PTSD, Personality Disorder, Bipolar Disorder,
Psychosis Disorder, Depression, Acid Reflux,
Hypothyroidism, Obesity, Anxiety, IDD-Moderate,
Migraines and Adjustment Disorder.

Interview on 3/25/19 with client #1 revealed when
staff #1 goes places, "[the adult male] watches

Division of Health Service Regulation

STATE FORM

809 COFL11

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHLO013-195 03/27/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
9167 HYDRANGEA DRIVE
SMITH HOME
HARRISBURG, NC 28075
(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 133] Continued From page 11 V 133

If continuation sheet 12 of 18

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHLO013-195

9167 HYDR:
HARRISBU!

SMITH HOME

A. BUILDING:

ANGEA DRIVE
RG, NC 28075

(X2) MULTIPLE CONSTRUCTION

PRINTED: 04/01/2019

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

03/27/2019

(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 133

V 536|

Continued From page 12

them sometimes."

Interview on 3/25/19 with client #2 revealed if staff
#1 has to run an errand, "[the adult male]
watches them."

Interview with staff #1 revealed the adult male
was her boyfriend and watched client #1 and #2
sometimes if she has to run a quick errand.

Request on 3/27/19 to review the personnel
record and criminal records check of the adult
male providing care to clients #1 and #2 in the
facility was unsuccessful as there was not a
personnel record or criminal records check to
review.

Interview on 3/27/19 with the Residential Director
revealed:

-staff #1's boyfriend does not live in the facility;
-he only visits from time to time;

-considered a "natural support;"

-can watch clients #1 and #2 up to three hours
per their policy;

-this policy was created by a former administrator
regarding an issue at another facility;

-do not have a personnel record on the adult
male in the facility;

-the adult male in the facility does not have a
criminal records check since he does not reside
in the facility.

27E .0107 Client Rights - Training on Alt to Rest.
Int.

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

(a) Facilities shall implement policies and

Division of Health Service Regulation
STATE FORM

V 133

V 536

809 COFL11

If continuation sheet 13 of 18

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

(X2) MULTIPLE CONSTRUCTION

PRINTED: 04/01/2019

FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHLO013-195 03/27/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
9167 HYDRANGEA DRIVE
SMITH HOME
HARRISBURG, NC 28075
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 536 | Continued From page 13 V 536

practices that emphasize the use of alternatives
to restrictive interventions.

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

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

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

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

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

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

(1) knowledge and understanding of the
people being served;

(2) recognizing and interpreting human
behavior;

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

(4) strategies for building positive

relationships with persons with disabilities;

Division of Health Service Regulation
STATE FORM

809 COFL11

If continuation sheet 14 of 18

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

(X2) MULTIPLE CONSTRUCTION

PRINTED: 04/01/2019

FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHLO013-195 03/27/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
9167 HYDRANGEA DRIVE
SMITH HOME
HARRISBURG, NC 28075
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 536 | Continued From page 14 V 536

(5) recognizing cultural, environmental and
organizational factors that may affect people with
disabilities;

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

(7) skills in assessing individual risk for
escalating behavior;

(8) communication strategies for defusing
and de-escalating potentially dangerous behavior;
and

(9) positive behavioral supports (providing

means for people with disabilities to choose
activities which directly oppose or replace
behaviors which are unsafe).

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

(1) Documentation shall include:

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

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

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

review/request this documentation at any time.

(i) Instructor Qualifications and Training
Requirements:

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

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

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

Division of Health Service Regulation
STATE FORM

809 COFL11

If continuation sheet 15 of 18

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

(X2) MULTIPLE CONSTRUCTION

PRINTED: 04/01/2019

FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHLO013-195 03/27/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
9167 HYDRANGEA DRIVE
SMITH HOME
HARRISBURG, NC 28075
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 536 | Continued From page 15 V 536

failing the course.

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

(5) Acceptable instructor training programs
shall include but are not limited to presentation of:
(A) understanding the adult learner;

(B) methods for teaching content of the
course;

(C) methods for evaluating trainee
performance; and

(D) documentation procedures.

(6) Trainers shall have coached experience

teaching a training program aimed at preventing,
reducing and eliminating the need for restrictive
interventions at least one time, with positive
review by the coach.

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

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

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

(1) Documentation shall include:

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

(B) when and where attended; and

(C) instructor's name.

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

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

(1) Coaches shall meet all preparation
requirements as a trainer.
(2) Coaches shall teach at least three times

the course which is being coached.

Division of Health Service Regulation
STATE FORM

809 COFL11

If continuation sheet 16 of 18

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

(X2) MULTIPLE CONSTRUCTION

PRINTED: 04/01/2019

(X3) DATE SURVEY

FORM APPROVED

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHLO013-195 03/27/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
9167 HYDRANGEA DRIVE
SMITH HOME
HARRISBURG, NC 28075
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 536 | Continued From page 16 V 536

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

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

This Rule is not met as evidenced by:

Based on records review, observations and
interviews, the facility failed to ensure prior to
providing services, staff demonstrated
competence by successfully completing training
in alternatives to restrictive interventions. The
findings are:

Observation on 3/25/19 at 3:00pm revealed a
male adult in the facility with staff #1.

Review on 3/22/19 of client #1's record revealed:
-admission date of 11/10/14 with diagnoses of
COPD, Encephalopathy, Osteoarthritis, Asthma,
Schizoaffective Disorder, Depressive Disorder,
Borderline Personality Disorder and Intellectual
Developmental Disabilities(IDD)-Moderate.

Review on 3/22/19 of client #2's record revealed:
-admission date of 4/5/18 with diagnoses of
PTSD, Personality Disorder, Bipolar Disorder,
Psychosis Disorder, Depression, Acid Reflux,
Hypothyroidism, Obesity, Anxiety, IDD-Moderate,
Migraines and Adjustment Disorder.

Interview on 3/25/19 with client #1 revealed when
staff #1 goes places, "[the adult male] watches
them sometimes."

Division of Health Service Regulation
STATE FORM

6809

COFL11

If continuation sheet 17 of 18

Division of Health Service Re

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

NAME OF PROVIDER OR SUPPLIER

MHLO013-195

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 04/01/2019

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY
COMPLETED

FORM APPROVED

03/27/2019

Interview on 3/25/19 with client #2 revealed if staff
#1 has to run an errand, "[the adult male]
watches them."

Interview with staff #1 revealed the adult male
was her boyfriend and watched client #1 and #2
sometimes if she has to run a quick errand.

Request on 3/27/19 to review the personnel
record and completed training in alternatives to
restrictive interventions of the adult male in the
facility was unsuccessful as there was not a
personnel record or any trainings to review.

Interview on 3/27/19 with the Residential Director
revealed:

-staff #1's boyfriend does not live in the facility;
-he only visits from time to time;

-considered a "natural support;"

-can watch clients #1 and #2 up to three hours
per their policy;

-this policy was created by a former administrator
regarding an issue at another facility;

-do not have a personnel record on the adult
male in the facility;

-the adult male in the facility does not have a any
completed trainings since he does not reside in
the facility.

Division of Health Service Regulation
STATE FORM

6809

COFL11

9167 HYDRANGEA DRIVE
SMITH HOME
HARRISBURG, NC 28075
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 536 | Continued From page 17 V 536

If continuation sheet 18 of 18

document_type: Statement of Deficiency


state: NC

facility_name: Miller Home LLC

summary: Statement of Deficiency - MHLCS Annual

raw_content:
Division of Health Service Re

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

NAME OF PROVIDER OR SUPPLIER

MHL013-194

8455 BLUM
HARRISBU!

THE MILLER HOME

IE PARKWAY

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

RG, NC 28075

PRINTED: 08/28/2018

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

08/23/2018

An annual survey was completed on 8/23/18. No
deficiencies were cited.

This facility is licensed for the following service
category: 10A NCAC 27G .5600F Alternative
Family Living for Individuals with Developmental
Disabilities.

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

STATE FORM

6899

2C9G11

(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 Vv 000

TITLE

(X6) DATE

If continuation sheet 1 of 1

inspection_type: MHLCS Annual


facility_name: Alexander Youth Network - Charlotte Day Treatment

summary: Statement of Deficiency - MHLCS Follow-up

raw_content:
PRINTED: 07/07/2025

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-C
MHL060968 B. WING 06/30/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE 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 follow up survey was completed on June 30,
2025. No deficiencies were cited.

This facility is licensed for the following service
category: 10A NCAC 1400 Day Treatment For
Children And Adolescents With Emotional Or
Behavioral Disturbances.

This facility has a current census of 34.

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

STATE FORM 6899 KUZIN2 If continuation sheet 1 of 1

inspection_type: MHLCS Follow-up


summary: Statement of Deficiency - MHLCS Complaint

raw_content:
PRINTED: 06/09/2025

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL060968 06/03/2025
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

Acomplaint survey was completed on 6-3-25.
The complaint was unsubstantiated (Intake
#NC00230794). No deficiencies were cited.

This facility is licensed for the following service
category: 10ANCAC 1400 Day Treatment For
Children And Adolescents With Emotional Or
Behavioral Disturbances.

This facility has a current census of 34. The
survey sample consisted of audits of 1 former
client.

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

STATE FORM

6899

YDZ911

TITLE (X6) DATE

If continuation sheet 1 of 1

inspection_type: MHLCS Complaint


summary: Plan of Correction - MHLCS Complaint

raw_content:
PRINTED: 05/14/2025
FORM APPROVED

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER ’ COMPLETED
A. BUILDING: __
Cc
MHL060968 B. WING 04/30/2025

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

ALEXANDER YOUTH NETWORK-CHARLOTT —-220-D THERMAL RD
CHARLOTTE, NC 28211

xa) | 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 ORLSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
| DEFICIENCY)
u ee
—__|_
V 000 INITIAL COMMENTS Vv 000

A complaint survey was completed on April 30, R ECEIVED
2025. The complaints were substantiated (intake —

| #NC00228706 and #NC00228713). Deficiencies )
| were cited.

Pe DHSR-MH Licensure Sect
This facility is licensed for the following service
category: 10A NCAC 27G .1400 Day Treatment
for Children and adolescents with Emotional or
Behavioral Disturbances.

| This facility has a current census of 30 . The
| survey sample consisted of audits of 1 current

client.
V 132, G.S. 131£-256(G) HCPR-Notification v132 HR Director and Vice President for 5/23/2025
Allegations, & Protection , _ Performance Improvement reviewed and |
, updated procedure for internal reviews of

G.S. §131E-256 HEALTH CARE PERSONNEL allegations against staff. When there is an

| REGISTRY allegation of abuse, neglect or exploitation
(g) Health care facilities shall ensure that the against staff, HR and the Program Director
Department is notified of all allegations against will suspend the accused staff member from
health care personnel, including injuries of working with any clients in any program
unknown source, which appear to be related to pending the outcome of the agency’s
any act listed in subdivision (a)(1) of this section. investigation.
(which includes:

| a. Neglect or abuse of a resident in a healthcare Upon becoming aware of an allegation of

| facility or a person to whom home care services abuse against a staff member, the Program
as defined by G.S. 131E-136 or hospice services Director, HR Director and Vice President for

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.

Performance Improvement immediately will _
| meet to initiate the internal review. At this |
time, HR Director and Vice President for
Performance Improvement will ensure the
accused staff member is suspended and not

working in any program pending the

| c. Misappropriation of the property ofa outcome of the investigation.
healthcare facility.
d. Diversion of drugs belonging to a health care | The Vice President for Performance
facility or to a patient or client. Improvement will monitor this process

monthly for any allegations against staff to
| ensure it is followed as described.

PRINTED: 05/14/2025
FORM APPROVED

Division of Health Service Regulation

L I
Division of Health Service Regulation
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATUR! pr TTL Copeons —

STATE FORM E02 KUZI1 If continuati

5Y5/2085

sheet 1 of 11

PRINTED: 05/14/2025

FORM APPROVED

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING

(X3) DATE SURVEY
COMPLETED

Cc

MHL060968 B.WING. 04/30/2025

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

ALEXANDER YOUTH NETWORK - CHARLOTT £220-D THERMAL RD
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 CORRECTIVEACTION SHOULD BE COMPLETE
TAG REGULATORY ORLSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE. DATE
DEFICIENCY)
K__ ———
V 132) Continued From page 1 V 132

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:

Based on record reviews and interviews, the
facility failed to protect clients during an
investigation of abuse, neglect or exploitation.
The findings are:

Review on 4/21/25 of the Qualified Professional's
(QP) personnel record revealed:
-Date of hire 2/28/22
-Job Title QP. |

Record Review on 4/21/25 at 12:00pm of the |
Facility's Video Footage dated 3/14/25 revealed:
-Client #1 was in the classroom standing in a
chair yelling, "Dummy! Dummy! Dummy!"

-The QP said, "Don't start with me today, I'm the
wrong one."

-Staff #2 walked over to Client #1 and asked him
to sit in the chair but he continued standing in the
chair.

-There was an unintelligible exchange of words |
between Client #1 and the QP. |
-The QP got up from her seat, walked over to
Client #1, grabbed both of his shoulders and
pushed him to the floor then walked back over to
her seat.

-Client #1 fell over to the right out of his chair on
to the floor.

-Client #1 got up off the floor, sat in his chair and |
Division of Health Service Regulation

STATE FORM 6899 KUZI11 If continuation sheet 2 of 11

NAME OF PROVIDER OR SUPPLIER
ALEXANDER YOUTH NETWORK - CHARLOTT

PRINTED: 05/14/2025
FORM APPROVED

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA

AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
MHL060968

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

B. WING

(X3) DATE SURVEY
COMPLETED

Cc
04/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

6220-D THERMAL RD
CHARLOTTE, NC 28211

(X4) 1D
PREFIX
TAG

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

V 132)

Continued From page 2

made an unintelligible comment to the QP then |
Client #1 said, "Do something about it." in which
| the QP replied, "I just did."

Review on 4/16/25 of the North Carolina Incident
Response Improvement System (IRIS) revealed:
| -On 3/19/25 while reviewing video footage in
reference to another incident, the Program
Supervisor saw the QP walk over to Client #1 and
pushed him out of his chair on 3/14/25.

-Client #1 fell to the floor.

-The QP walked back over to her seat and Client
#1 got up and sat in his chair.

Review on 4/21/25 of the facility's document titled

"Internal Review Findings of Fact Summary-

| 3.31.24: Incident 3.19.25" revealed:

-"Allegation: While reviewing video for another

Internal Investigation, program manager saw staff

(QP) pull client (Client #1) off a desk and ‘throw

the to the floor.'"

-"The video shows the staff member (QP)

| approaching the youth (Client #1) after an

exchange of words and then the youth is on the

floor. The video is dark.”

| -"The youth (Client #1) is repeatedly saying

‘dummy.' The staff member (QP) can be heard

| Saying 'Don't start with me today, I'm the wrong
one.' After the physical exchanged the youth
challenged the staff verbally to which she stated,
‘| just did something about it.'"
-"The cause of the incident is seen as staff
member (QP) exacting revenge on the youth
(Client #1) for challenging her. Staff was
reactionary."
-"Recommendations: It is recommended that the |
staff member (QP) be on a 60-day Performance
Improvement Plan during which time she
completed TCI (therapeutic crisis intervention)

| refresher training with a concentration on Handle

ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH CORRECTIVEACTION SHOULD BE | COMPLETE
TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

———
V 132

—_—

Division of Health Service Regulation

STATE FORM

ese KUZI11

If continuation sheet 3 of 11

PRINTED: 05/14/2025
FORM APPROVED

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES. (X1) PROVIDER/SUPPLIERI/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
Cc
MHL060968 B.WING 04/30/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

6220-D THERMAL RD

CHARLOTTE, NC 28211

ALEXANDER YOUTH NETWORK - CHARLOTT

(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 ORLSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY) |

‘ rs
V 132) Continued From page 3 V1320—O| |

with Care concepts that assist with being
proactive and utilizing verbal de-escalation
techniques as well as positive engagement
strategies."

Interview on 4/21/25 with the Program Supervisor
revealed:

-On 3/19/25 he was reviewing video footage in |
reference to another incident when he came upon
footage of the QP pushing Client #1 out of his |
chair on 3/14/25.

-Completed the NC IRIS report and reported the
incident to Human Resources (HR) on 3/20/25.
-HR did the internal investigation (3/27/25-

| 3/31/25).

-Did not question the QP.

| -Did not know the outcome of the internal
investigation.

-Client #1 did not sustain any injuries.

| Attempted interview on 4/25/25 with Client #1
revealed:

-His legal guardian would not consent to an
interview because Client #1 "does not speak
good english and he has trouble following

| conversations."

Interview on 4/28/25 with Staff #2 revealed:
-Did not remember a lot of the details of the
incident between the QP and Client #1 on |
3/14/25. |
-Remembered Client #1 was disrupting the other |
clients and "talking back, calling staff names like
black B**ch."
-"Whatever you saw on the video is what

| happened. | think she (QP) just lost her cool for a |
minute. That kid (Client #1) would push and push
and push.”

| -Did not hear the QP and Client #1 arguing with

| each other.

Division of Health Service Regulation

STATE FORM 6899 KUZI11 If continuation sheet 4 of 11

PRINTED: 05/14/2025

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

Cc
MHL060968 B. WING ____________ 04/30/2025

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

ALEXANDER YOUTH NETWORK - CHARLOTT 6220-D THERMAL RD
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 ORLSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

[ | —___|
V 132| Continued From page 4 V 132

Interview on 4/28/25 the QP revealed:
-On 3/14/25 Client #1 kept using the saying "clock
that tea" and in a jokingly way she said "I will."
-"| walked over to his desk and tickled him and he
wiggled out of his chair. | was playing with him, |
wasn't trying to harm him."
-"I'm not that kind of person to harm children."
-"It was a playful interaction.”
-Denied telling Client #1 "Don't start with me
| today, I'm the wrong one."
-Denied Client #1 was standing in his chair yelling
"Dummy."
-Did not pull Client #1 out of his chair on to the
| floor.
-Could not recall which days she worked between |
3/27/25 and 3/31/25.

Interview on 4/22/25 with the HR Director
revealed: |
-The QP was suspended from the day program
pending investigation on 3/27/25.

-The QP worked with another program while
under investigation.

-The internal investigation took place from | |
3/27/25 to 3/31/25. |
-Did not know the QP was not supposed to work
with any clients while under investigation.

-"| thought the suspension was just for the day

| program."

| Interview on 4/29/25 with the Vice President of

| Performance Improvement revealed:
-Did not have a lot of details about the incident
between the QP and Client #1.

| -Verified the QP was allowed to work in another
Program while under investigation for abusing | |
Client #1. |
-The internal investigation was 3/27/25 through

| 3/31/25.

Division of Health Service Regulation

STATE FORM 6899 KUZI11 If continuation sheet 5 of 11

Division of Health Service Regulation

PRINTED: 05/14/2025
FORM APPROVED

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

B. WING
MHL060968

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

Cc
04/30/2025

——
NAME OF PROVIDER OR SUPPLIER

ALEXANDER YOUTH NETWORK - CHARLOTT

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

CHARLOTTE, NC 28211

PROVIDER'S PLAN OF CORRECTION (x6)
(EACH CORRECTIVE ACTION SHOULD BE COMPLETE
CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

-The QP was terminated on 4/29/25.
|

V 512 27D .0304 Client Rights - Harm, Abuse, Neglect V 512

10A NCAC 27D .0304 =PROTECTION FROM
HARM, ABUSE, NEGLECT OREXPLOITATION
(a) Employees shall protect clients from harm,
abuse, neglect and exploitation in accordance
with G.S. 122C-66.

(b) Employees shall not subject a client to any |
sort of abuse or neglect, as defined in 10ANCAC |
27C .0102 of this Chapter.

| (c) Goods or services shall not be sold toor

| purchased from a client except through
established governing body policy.

(d) Employees shall use only that degree of force
necessary to repel or secure a violent and
aggressive client and which is permitted by

| governing body policy. The degree of force that
is necessary depends upon the individual
characteristics of the client (such as age, size
and physical and mental health) and the degree
of aggressiveness displayed by the client. Use of
intervention procedures shall be compliance with
| Subchapter 10A NCAC 27E of this Chapter.

(e) Any violation byan employee of Paragraphs

| (a) through (d) of this Rule shall be grounds for
dismissal of the employee.

This Rule is not met as evidenced by:
| Based on record reviews and interviews, 1 of 1
| Qualified Professional (QP) abused 1 of 14 client
(#1). The findings are:

Review on 4/16/25 of Client #1's record revealed:
| - 9 years old

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID
PREFIX | (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX
TAG REGULATORY ORLSC IDENTIFYING INFORMATION) TAG
V 132) Continued From page 5 V 132

The Day Treatment Program Manager will 5/23/2025
continue to have staffing meetings with each
staff member. In this meeting the program
manager will reiterate the importance of
appropriate therapeutic interventions. The
program staff will conduct frequent check-ins|
with each client, especially with children that
have a tendency or history of constantly
antagonizing others for long periods of time.
When staff become frustrated staff will tag
out, reach out to the supervisor, and step
away to take a break outside away from the
escalated client.

The program manager will use the model of
care (MOC) observation forms monthly to
monitor each staff member regardless of the |
staff's credentials of QP, AP or |
paraprofessional, to prevent the problem
from occurring again. The Program Manager
will use the MOC Observation Forms to
ensure the staff are engaging in therapeutic |
interventions, effectively regulating their
own emotions and following effective
classroom guidelines and expectations. The
Program Manager will give feedback to each
staff member after the observation.

The Program Manager will routinely monitor
each classroom throughout the days to
provide oversight and support as needed.

The Regional Director will review compliance
and quality of the MOC forms monthly to
ensure monitoring is completed.

Division of Health Service Regulation
STATE FORM 6899

KUZI11

If continuation sheet 6 of 11

PRINTED: 05/14/2025
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 ee

(X3) DATE SURVEY
COMPLETED

Cc
04/30/2025

MHL060968 B. WING

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

ALEXANDER YOUTH NETWORK-CHARLOTT —-220-D THERMAL RD
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 ORLSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
T
V 512) Continued From page 6 V 512

-Diagnoses of Oppositional Defiant Disorder and
Posttraumatic Stress Disorder

Review on 4/21/25 of the QP's personnel record
| revealed:

-Date of hire 2/28/22

-Job Title QP.

-Abuse training on 9/18/24.

Review on 4/21/25 at 12:00pm of the Facility's
Video Footage dated 3/14/25 revealed:

-Client #1 was in the classroom standing ina
chair yelling, "Dummy! Dummy! Dummy!"

-The QP said, "Don't start with me today, I'm the
wrong one." |
-Staff #2 walked over to Client #1 and asked him
to sit in the chair but he continued standing in the
| chair.

-There was an unintelligible exchange of words
between Client #1 and the QP.

-The QP got up from her seat, walked over to

| Client #1, grabbed both of his shoulders and
pulled him to the floor then walked back overto
her seat.

-Client #1 fell over to the right of the chair on to
the floor. |
-Client #1 got up off the floor, sat in his chair then
made an unintelligible comment to the QP and
challenged the QP to "Do something about it" in |
which the QP replied, "I just did."

Review on 4/16/25 of the North Carolina Incident |
Response Improvement System (IRIS) revealed: |
-On 3/19/25 while reviewing video footage in
reference to another incident, the Program
Supervisor saw the QP walk over to Client #1 and
| pushed him out of his chair on 3/14/25.

-Client #1 fell to the floor.

-The QP walked back over to her seat and Client |
#1 got up and sat in his chair.
Division of Health Service Regulation

STATE FORM se Kuzi11 If continuation sheet 7 of 11

PRINTED: 05/14/2025
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
Cc
MHLO60968 B..WING 04/30/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

6220-D THERMAL RD
CHARLOTTE, NC 28211

ALEXANDER YOUTH NETWORK - CHARLOTT

(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 ORLSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
i DEFICIENCY) |
i i
Vv 512| Continued From page 7 V 512

Review on 4/21/25 of the facility's document titled
“Internal Review Findings of Fact Summary-

| 3.31.24: Incident 3.19.25 revealed:

-"Allegation: While reviewing video for another
Internal Investigation, program manager
(Program Supervisor) saw staff (QP) pull client
(Client #1) off a desk and throw the to the floor.
-The video shows the staff member (QP)
approaching the youth (Client #1) after an
exchange of words and then the youth is on the
floor. The video is dark.

-The youth (Client #1) is repeatedly saying
dummy. The staff member (QP) can be heard
saying ‘Don't start with me today, I'm the wrong
one.’ After the physical exchanged the youth
challenged the staff verbally to which she stated,
‘| just did something about it.'

-The cause of the incident is seen as staff
member (QP) exacting revenge on the youth
(Client #1) for challenging her. Staff was
reactionary.

-Recommendations: It is recommended that the
staff member (QP) be on a 60-day Performance
Improvement Plan during which time she
completed TCI (therapeutic crisis intervention)

| refresher training with a concentration on Handle
with Care concepts that assist with being
proactive and utilizing verbal de-escalation
techniques as well as positive engagement
strategies."

Interview on 4/21/25 with the Program Supervisor
revealed: |
-On 3/19/25 he was reviewing video footage in |

reference to another incident when he came upon
footage of the QP pushing Client #1 out of his
chair on 3/14/25.

-Completed the NC IRIS report and reported the

| incident to Human Resources (HR) on 3/20/25.
Division of Health Service Regulation

STATE FORM 6899 KUZI11 if continuation sheet 8 of 11

$$ $$ __

PRINTED: 05/14/2025
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

Cc
04/30/2025

MHLO60968 BaWING

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

ALEXANDER YOUTH NETWORK-CHARLOTT —-©220-D THERMAL RD
CHARLOTTE, NC 28211

SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION

(x4) ID (5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY ORLSCIDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
| DEFICIENCY)

V 512) Continued From page 8 V51I20 | |

-HR did the internal investigation (3/27/25-
3/31/25).

-Did not question the QP.

-Did not know the outcome of the internal |
investigation. |

-Client #1 did not sustain any injuries.

Attempted interview on 4/25/25 with Client #1 |
revealed:

-His legal guardian would not consent to an
interview because Client #1 "does not speak
good english and he has trouble following

| conversations."

Interview on 4/28/25 with Staff #2 revealed:
| -Did not remember a lot of the details of the |
incident between the QP and Client #1 on |
3/14/25. |

-Remembered Client #1 was disrupting the other
clients and "talking back, calling staff names like
black B***h."

-"Whatever you saw on the video is what |
happened. | think she (QP) just lost her cool for a
minute. That kid (Client #1) would push and push
and push."

| -Did not hear the QP and Client #1 arguing with
each other.

-Did not know if Client #1 sustained any injuries. |

Interview on 4/28/25 the QP revealed:

-On 3/14/25, Client #1 kept using the saying
"clock that tea" and in a jokingly way she said "!
will." | |
-"| walked over to his desk and tickled him and he
wiggled out of his chair. | was playing with him, |
wasn't trying to harm him."

-"I'm not that kind of person to harm children.”
-"It was a playful interaction." |
-Denied telling Client #1 "Don't start with me
| today, I'm the wrong one.

Division of Health Service Regulation

STATE FORM 6899 KUZI11 If continuation sheet 9 of 11

PRINTED: 05/14/2025
FORM APPROVED

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
Cc
MHL060968 B. WING 04/30/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

6220-D THERMAL RD
CHARLOTTE, NC 28211

ALEXANDER YOUTH NETWORK - CHARLOTT

(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 ORLSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 512) Continued From page 9 vVs12 | |
-Denied Client #1 was standing in his chair yelling
"Dummy."
-Did not pull Client #1 out of his chair on to the
| floor.

Interview on 4/22/25 with the HR Director
revealed:

-The QP was suspended from the day program
pending investigation on 3/27/25.

-The QP worked with another program while
under investigation.

-The internal investigation took place from
3/27/25 to 3/31/25.

-The QP was put on a 60 day performance plan.
| -The QP had to retake TCI training, "Handle with
Care" on 3/31/25. |

Interview on 4/29/25 with the Vice President of
Performance Improvement revealed:

-Did not have a lot of details about the incident
between the QP and Client #1.

-Verified the QP was allowed to work in another | |
Program while under investigation for abusing |

Client #1.

-The internal investigation was 3/27/25 through
| 3/31/25.

-The QP was terminated on 4/30/25.

Review on 4/30/25 of the Plan of Protection dated
4/30/25 signed by the Vice President of |
Performance Improvement revealed:
-"What immediate action will the facility take to |
ensure the safety of the consumers in your care?

[QP] was terminated from employment with
[Licensee] on 4/29/2025 and has not worked with |
any children since 4/4/2025.

Describe your plans to make sure the above
| happens.

Division of Health Service Regulation
STATE FORM 6899 KUZI11 If continuation sheet 10 of 11

PRINTED: 05/14/2025

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED
Cc
MHLO60968 BeWING) 04/30/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
ALEXANDER YOUTH NETWORK-CHARLOTT —-9#20-D THERMAL RD
CHARLOTTE, NC 28211
(x4) 1D | SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION | os)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY ORLSCIDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY) |
ee ee
v 512| Continued From page 10 V5120
| Human Resources has removed [QP] access to
| all systems and locations effective 4/29/2025."
| Client #1 was 9 years old with diagnoses of
Oppositional Defiant Disorder and PostTraumatic
Stress Disorder. On 3/19//25, Client #1 was seen
on a video from 3/14/25 standing in his chair and
yelling the word dummy. The QP told Client #1, |
don't start with me today, I'm the wrong one. The
_ QP walked over to Client #1, grabbed both of his
shoulders, pulled him to the floor. Client #1 |
ended up on the floor beside the chair. This
| Deficiency constitutes a Type A1 rule violation for
serious abuse and must be corrected with in 23
days.
|
|
ee —

Division of Health Service Regulation
STATE FORM 6699 KUZI11 If continuation sheet 11 of 11

document_type: Plan of Correction


raw_content:
PRINTED: 05/14/2025
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA. (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
c
MHL060968 B. WING _____ 04/30/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE 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

Acomplaint survey was completed on April 30,
2025. The complaints were substantiated (intake
#NC00228706 and #NC002287 13). 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.

This facility has a current census of 30 . The
survey sample consisted of audits of 1 current
client.

V 132) G.S. 131E-256(G) HCPR-Notification, V 132
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.

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

STATE FORM 6899 KUZI11 If continuation sheet 1 of 11

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL060968 B. WING

NAME OF PROVIDER OR SUPPLIER

6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE CHARLOTTE, NC 28211

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/14/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
04/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

(X4) ID
PREFIX
TAG

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

CROSS-REFERENCED TO THE APPROPRIATE

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

(x5)
COMPLETE
DATE

DEFICIENCY)

V 132] Continued From page 1 V 132

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:

Based on record reviews and interviews, the
facility failed to protect clients during an
investigation of abuse, neglect or exploitation.
The findings are:

Review on 4/21/25 of the Qualified Professional's
(QP) personnel record revealed:

-Date of hire 2/28/22

-Job Title QP.

Record Review on 4/21/25 at 12:00pm of the
Facility's Video Footage dated 3/14/25 revealed:
-Client #1 was in the classroom standing in a
chair yelling, "Dummy! Dummy! Dummy!"

-The QP said, "Don't start with me today, I'm the
wrong one."
-Staff #2 walked over to Client #1 and asked him
to sit in the chair but he continued standing in the
chair.
-There was an unintelligible exchange of words
between Client #1 and the QP.

-The QP got up from her seat, walked over to
Client #1, grabbed both of his shoulders and
pushed him to the floor then walked back over to
her seat.

-Client #1 fell over to the right out of his chair on
to the floor.

-Client #1 got up off the floor, sat in his chair and
Division of Health Service Regulation

STATE FORM

6899 KUZI11

If continuation sheet 2 of 11

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL060968 B. WING

NAME OF PROVIDER OR SUPPLIER
6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE CHARLOTTE, NC 28211

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/14/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
04/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

made an unintelligible comment to the QP then
Client #1 said, "Do something about it." in which
the QP replied, "I just did.”

Review on 4/16/25 of the North Carolina Incident
Response Improvement System (IRIS) revealed:
-On 3/19/25 while reviewing video footage in
reference to another incident, the Program
Supervisor saw the QP walk over to Client #1 and
pushed him out of his chair on 3/14/25.

-Client #1 fell to the floor.

-The QP walked back over to her seat and Client
#1 got up and sat in his chair.

Review on 4/21/25 of the facility's document titled
"Internal Review Findings of Fact Summary-
3.31.24: Incident 3.19.25" revealed:
-"Allegation: While reviewing video for another
Internal Investigation, program manager saw staff
(QP) pull client (Client #1) off a desk and ‘throw
the to the floor.'"

-"The video shows the staff member (QP)
approaching the youth (Client #1) after an
exchange of words and then the youth is on the
floor. The video is dark."

-"The youth (Client #1) is repeatedly saying
‘dummy.’ The staff member (QP) can be heard
saying 'Don't start with me today, I'm the wrong
one.' After the physical exchanged the youth
challenged the staff verbally to which she stated,
‘| just did something about it.’ "

-"The cause of the incident is seen as staff
member (QP) exacting revenge on the youth
(Client #1) for challenging her. Staff was
reactionary.”

-"Recommendations: It is recommended that the
staff member (QP) be on a 60-day Performance
Improvement Plan during which time she
completed TCI (therapeutic crisis intervention)
refresher training with a concentration on Handle
Division of Health Service Regulation

STATE FORM

6899 KUZI11

(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 11

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL060968 B. WING

NAME OF PROVIDER OR SUPPLIER
6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE CHARLOTTE, NC 28211

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/14/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
04/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

with Care concepts that assist with being
proactive and utilizing verbal de-escalation
techniques as well as positive engagement
strategies."

Interview on 4/21/25 with the Program Supervisor
revealed:

-On 3/19/25 he was reviewing video footage in
reference to another incident when he came upon
footage of the QP pushing Client #1 out of his
chair on 3/14/25.

-Completed the NC IRIS report and reported the
incident to Human Resources (HR) on 3/20/25.
-HR did the internal investigation (3/27/25-
3/31/25).

-Did not question the QP.

-Did not know the outcome of the internal
investigation.

-Client #1 did not sustain any injuries.

Attempted interview on 4/25/25 with Client #1
revealed:

-His legal guardian would not consent to an
interview because Client #1 "does not speak
good english and he has trouble following
conversations."

Interview on 4/28/25 with Staff #2 revealed:

-Did not remember a lot of the details of the
incident between the QP and Client #1 on
3/14/25.

-Remembered Client #1 was disrupting the other
clients and "talking back, calling staff names like
black B**ch."

-"Whatever you saw on the video is what
happened. | think she (QP) just lost her cool for a
minute. That kid (Client #1) would push and push
and push."

-Did not hear the QP and Client #1 arguing with
each other.

Division of Health Service Regulation

STATE FORM

6899 KUZI11

(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

If continuation sheet 4 of 11

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: 05/14/2025

FORM APPROVED
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
A. BUILDING: COMPLETED
c
B.WING 04/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

6220-D THERMAL RD
CHARLOTTE, NC 28211

ALEXANDER YOUTH NETWORK - CHARLOTTE

Interview on 4/28/25 the QP revealed:

-On 3/14/25 Client #1 kept using the saying "clock
that tea" and in a jokingly way she said "I will."

-"| walked over to his desk and tickled him and he
wiggled out of his chair. | was playing with him, |
wasn't trying to harm him."

-"I'm not that kind of person to harm children."

-"It was a playful interaction."

-Denied telling Client #1 "Don't start with me
today, I'm the wrong one."

-Denied Client #1 was standing in his chair yelling
"Dummy."

-Did not pull Client #1 out of his chair on to the
floor.

-Could not recall which days she worked between
3/27/25 and 3/31/25.

Interview on 4/22/25 with the HR Director
revealed:

-The QP was suspended from the day program
pending investigation on 3/27/25.

-The QP worked with another program while
under investigation.

-The internal investigation took place from
3/27/25 to 3/31/25.

-Did not know the QP was not supposed to work
with any clients while under investigation.

-"| thought the suspension was just for the day
program."

Interview on 4/29/25 with the Vice President of
Performance Improvement revealed:

-Did not have a lot of details about the incident
between the QP and Client #1.

-Verified the QP was allowed to work in another
Program while under investigation for abusing
Client #1.

-The internal investigation was 3/27/25 through
3/31/25.

Division of Health Service Regulation
STATE FORM

(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 4 V 132

6899 KUZI11 If continuation sheet 5 of 11

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL060968 B. WING

NAME OF PROVIDER OR SUPPLIER
6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE CHARLOTTE, NC 28211

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/14/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
04/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

10A NCAC 27D .0304 PROTECTION FROM
HARM, ABUSE, NEGLECT OR EXPLOITATION
(a) Employees shall protect clients from harm,
abuse, neglect and exploitation in accordance
with G.S. 122C-66.

(b) Employees shall not subject a client to any
sort of abuse or neglect, as defined in 10A NCAC
27C .0102 of this Chapter.

(c) Goods or services shall not be sold to or
purchased from a client except through
established governing body policy.

(d) Employees shall use only that degree of force
necessary to repel or secure a violent and
aggressive client and which is permitted by
governing body policy. The degree of force that
is necessary depends upon the individual
characteristics of the client (such as age, size
and physical and mental health) and the degree
of aggressiveness displayed by the client. Use of
intervention procedures shall be compliance with
Subchapter 10A NCAC 27E of this Chapter.

(e) Any violation by an employee of Paragraphs
(a) through (d) of this Rule shall be grounds for
dismissal of the employee.

This Rule is not met as evidenced by:

Based on record reviews and interviews, 1 of 1
Qualified Professional (QP) abused 1 of 1 client
(#1). The findings are:

Review on 4/16/25 of Client #1's record revealed:
- 9 years old

Division of Health Service Regulation

STATE FORM 6899

KUZI11

(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 5 V 132
-The QP was terminated on 4/29/25.
V 512) 27D .0304 Client Rights - Harm, Abuse, Neglect V 512

If continuation sheet 6 of 11

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL060968 B. WING

NAME OF PROVIDER OR SUPPLIER
6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE CHARLOTTE, NC 28211

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/14/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
04/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

-Diagnoses of Oppositional Defiant Disorder and
Posttraumatic Stress Disorder

Review on 4/21/25 of the QP's personnel record
revealed:

-Date of hire 2/28/22

-Job Title QP.

-Abuse training on 9/18/24.

Review on 4/21/25 at 12:00pm of the Facility's
Video Footage dated 3/14/25 revealed:

-Client #1 was in the classroom standing in a
chair yelling, "Dummy! Dummy! Dummy!"

-The QP said, "Don't start with me today, I'm the
wrong one."

-Staff #2 walked over to Client #1 and asked him
to sit in the chair but he continued standing in the
chair.

-There was an unintelligible exchange of words
between Client #1 and the QP.

-The QP got up from her seat, walked over to
Client #1, grabbed both of his shoulders and
pulled him to the floor then walked back over to
her seat.

-Client #1 fell over to the right of the chair on to
the floor.

-Client #1 got up off the floor, sat in his chair then
made an unintelligible comment to the QP and
challenged the QP to "Do something about it" in
which the QP replied, "I just did."

Review on 4/16/25 of the North Carolina Incident
Response Improvement System (IRIS) revealed:
-On 3/19/25 while reviewing video footage in
reference to another incident, the Program
Supervisor saw the QP walk over to Client #1 and
pushed him out of his chair on 3/14/25.

-Client #1 fell to the floor.

-The QP walked back over to her seat and Client
#1 got up and sat in his chair.

Division of Health Service Regulation

STATE FORM

6899 KUZI11

(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 512} Continued From page 6 V 512

If continuation sheet 7 of 11

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL060968 B. WING

NAME OF PROVIDER OR SUPPLIER
6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE CHARLOTTE, NC 28211

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/14/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
04/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Review on 4/21/25 of the facility's document titled
"Internal Review Findings of Fact Summary-
3.31.24: Incident 3.19.25 revealed:

-"Allegation: While reviewing video for another
Internal Investigation, program manager
(Program Supervisor) saw staff (QP) pull client
(Client #1) off a desk and throw the to the floor.
-The video shows the staff member (QP)
approaching the youth (Client #1) after an
exchange of words and then the youth is on the
floor. The video is dark.

-The youth (Client #1) is repeatedly saying
dummy. The staff member (QP) can be heard
saying 'Don't start with me today, I'm the wrong
one.' After the physical exchanged the youth
challenged the staff verbally to which she stated,
‘| just did something about it."

-The cause of the incident is seen as staff
member (QP) exacting revenge on the youth
(Client #1) for challenging her. Staff was
reactionary.
-Recommendations: It is recommended that the
staff member (QP) be on a 60-day Performance
Improvement Plan during which time she
completed TCI (therapeutic crisis intervention)
refresher training with a concentration on Handle
with Care concepts that assist with being
proactive and utilizing verbal de-escalation
techniques as well as positive engagement
strategies."

Interview on 4/21/25 with the Program Supervisor
revealed:

-On 3/19/25 he was reviewing video footage in
reference to another incident when he came upon
footage of the QP pushing Client #1 out of his
chair on 3/14/25.

-Completed the NC IRIS report and reported the
incident to Human Resources (HR) on 3/20/25.
Division of Health Service Regulation

STATE FORM

6899 KUZI11

(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 512} Continued From page 7 V 512

If continuation sheet 8 of 11

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL060968 B. WING

NAME OF PROVIDER OR SUPPLIER
6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE CHARLOTTE, NC 28211

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/14/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
04/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

-HR did the internal investigation (3/27/25-
3/31/25).

-Did not question the QP.

-Did not know the outcome of the internal
investigation.

-Client #1 did not sustain any injuries.

Attempted interview on 4/25/25 with Client #1
revealed:

-His legal guardian would not consent to an
interview because Client #1 "does not speak
good english and he has trouble following
conversations."

Interview on 4/28/25 with Staff #2 revealed:

-Did not remember a lot of the details of the
incident between the QP and Client #1 on
3/14/25.

-Remembered Client #1 was disrupting the other
clients and "talking back, calling staff names like
black B***h."

-"Whatever you saw on the video is what
happened. | think she (QP) just lost her cool for a
minute. That kid (Client #1) would push and push
and push."

-Did not hear the QP and Client #1 arguing with
each other.

-Did not know if Client #1 sustained any injuries.

Interview on 4/28/25 the QP revealed:

-On 3/14/25, Client #1 kept using the saying
"clock that tea" and in a jokingly way she said "I
will."

-"| walked over to his desk and tickled him and he
wiggled out of his chair. | was playing with him, |
wasn't trying to harm him."

-"I'm not that kind of person to harm children."
-"It was a playful interaction."

-Denied telling Client #1 "Don't start with me
today, I'm the wrong one."

Division of Health Service Regulation

STATE FORM

6899 KUZI11

(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 512} Continued From page 8 V 512

If continuation sheet 9 of 11

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL060968 B. WING

NAME OF PROVIDER OR SUPPLIER
6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE CHARLOTTE, NC 28211

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/14/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
04/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Interview on 4/22/25 with the HR Director
revealed:
-The QP was suspended from the day program
pending investigation on 3/27/25.

-The QP worked with another program while
under investigation.
-The internal investigation took place from
3/27/25 to 3/31/25.
-The QP was put on a 60 day performance plan.
-The QP had to retake TCI training, "Handle with
Care" on 3/31/25.

Interview on 4/29/25 with the Vice President of
Performance Improvement revealed:

-Did not have a lot of details about the incident
between the QP and Client #1.

-Verified the QP was allowed to work in another
Program while under investigation for abusing
Client #1.

-The internal investigation was 3/27/25 through
3/31/25.

-The QP was terminated on 4/30/25.

Review on 4/30/25 of the Plan of Protection dated
4/30/25 signed by the Vice President of
Performance Improvement revealed:

-"What immediate action will the facility take to
ensure the safety of the consumers in your care?

[QP] was terminated from employment with
[Licensee] on 4/29/2025 and has not worked with
any children since 4/4/2025.

Describe your plans to make sure the above
happens.

Division of Health Service Regulation

STATE FORM

6899 KUZI11

(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 512} Continued From page 9 Vv 512
-Denied Client #1 was standing in his chair yelling
"Dummy."
-Did not pull Client #1 out of his chair on to the
floor.

If continuation sheet 10 of 11

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

ALEXANDER YOUTH NETWORK - CHARLOTTE

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

MHL060968

(X2) MULTIPLE CONSTRUCTION

A. BUILDING:

B. WING

6220-D THERMAL RD

CHARLOTTE, NC 28211

PRINTED: 05/14/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
04/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

PROVIDER'S PLAN OF CORRECTION

Human Resources has removed [QP] access to
all systems and locations effective 4/29/2025."

Client #1 was 9 years old with diagnoses of
Oppositional Defiant Disorder and Post Traumatic
Stress Disorder. On 3/19//25, Client #1 was seen
on a video from 3/14/25 standing in his chair and
yelling the word dummy. The QP told Client #1,
don't start with me today, I'm the wrong one. The
QP walked over to Client #1, grabbed both of his
shoulders, pulled him to the floor. Client #1
ended up on the floor beside the chair. This
Deficiency constitutes a Type A1 rule violation for
serious abuse and must be corrected with in 23
days.

Division of Health Service Regulation
STATE FORM

6899

KUZI11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID (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 512] Continued From page 10 Vv 512

If continuation sheet 11 of 11