summary: Statement of Deficiency - MHLCS Complaint

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PRINTED: 08/20/2018

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL011-371 — 08/03/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE
GREEN LEVEL Ill
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

V 000} INITIAL COMMENTS Vv 000

Acomplaint survey was completed on 8/3/18.
The complaint was substantiated (Intake
#NC00140645). Deficiencies were cited.

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

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

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 interviews and record reviews one of

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

STATE FORM 6609 1W3011 If continuation sheet 1 of 12

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/20/2018
FORM APPROVED

(X3) DATE SURVEY

one former staff (Former Staff #1) exploited and
two of two Associate Professionals (Program
Manager #1 and the Lead Night Residential
Counselor) failed to protect one of one client
(Client #1) from exploitation and neglect. The
findings are:

Review on 7/19/18 of Former Client (FC) #1's
record revealed:

-Admission 4/10/18

-17 years old

-Diagnoses: Conduct Disorder, Unspecified
Onset and Unspecified Trauma and Stressor
Related Disorder .

Review on 7/19/18 of an assessment for FC #1
dated 3/1/18 and completed by the Qualified
Professional revealed:

-FC #1 was beat up and left for dead by a gang
she belonged to;

-she was physically abused by her father and
witnessed domestic abuse.

Review on 7/19/18 of FC #1's Person-Centered
Profile revealed:
-"CHARACTERISTICS/OBSERVATION/JUSTIFI
CATION FOR THIS GOAL: Client was assaulted
by former friends in gang-related activity,
seriously injured in attack, family dynamics
putting stress on the family unit."

-FC #1 "will demonstrate an improvement in post
traumatic stress symptoms, as evidenced by: ...
2. Elimination of intrusive recollections

3. Increased trust

4. Decrease in experiences of dissociation,
depersonalization, derealization

5. Increase in age-appropriate behaviors ...

7. Decreased irritability

8. Increased optimism ..."

-"Date Goal was reviewed ...4/10/18 ...[FC #1]

Division of Health Service Regulation

STATE FORM

6809

1W3011

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHLO011-371 08/03/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE
GREEN LEVEL Ill
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 512] Continued From page 1 V 512

If continuation sheet 2 of 12

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/20/2018
FORM APPROVED

(X3) DATE SURVEY

talked to her case manager about having to learn
to trust new staff. It takes a little time for [FC #1]
to trust somebody. She continues to have
flashbacks about her being attacked. She
continues to work through this trauma ..."

-"Date Goal was reviewed ...5/8/18 ...[FC #1] has
some difficulty trusting new staff. She continues
to have some flashbacks and nightmares ..."

Review on 7/19/18 of FC #1's Individual Crisis
Management Plan updated 4/8/18 revealed:
-"Current Issues - Potential Triggers: trauma
involving her father ...talk about physical abuse

Review on 7/19/18 of Former Staff #1's (FS #1)
personnel record revealed:
-position - Night Residential Counselor (NRC)
-date of hire 4/2/18

-date of termination 6/29/18

Interview on 7/20/18 with FC #1 revealed:

-FS #1 was hired sometime in April and they
immediately started a "growing bond" as they
talked about their tattoos and shared music;
-they gave each other their snap chat (social
media) information and she talked to him while at
school;

-when they were in the kitchen of the cottage FS
#1 showed her a nude video of him on his phone;
-FS #1 told her he came to work just to be with
her;

-he flirted with her and she would request
"“support-walks" just to have some alone time with
him;

-FS #1 talked with her about having a family;
-they spent time together in the office of the
cottage with the door shut - the clients were
allowed to call their family and had to have a staff
present while making these calls;

Division of Health Service Regulation

STATE FORM

6809

1W3011

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHLO011-371 08/03/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE
GREEN LEVEL Ill
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 512] Continued From page 2 V 512

If continuation sheet 3 of 12

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHLO011-371

A. BUILDING:

2 COMPTON DRIVE
ASHEVILLE, NC 28806

GREEN LEVEL Ill

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/20/2018
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
08/03/2018

STREET ADDRESS, CITY, STATE, ZIP CODE

-FS #1 asked her to have sex with him while they
were in this office but she declined; they did touch
each other on the outside of their clothes while in
the office;

-they had codes to communicate with each other
while in the cottage; if FS #1 came to the door
and stood in the doorway that meant he wanted a
hug;

-they knew to never do anything in front of the
camera;

-they started "claiming" each other by the end of
April; "He [FS #1] hadn't even been here a
month."

Interview on 7/20/18 with the Residential Director
revealed:

-as he walked FC #1 back to the cottage after
speaking to the surveyor, FC #1 revealed she
and FS #1 had oral sex while in the office of the
cottage;

-this was the first time FC #1 admitted she and
FS #1 had sex.

Interview on 7/26/18 with FS #1 revealed:
-nothing happened with FC #1;

-he was told "basically that | showed favoritism
toward her, that's about it";

-he denied sharing social media contact, or
videos to FC #1.

Record review on 7/26/18 of Staff #2's interview
with the local Department of Social Services
(DSS) revealed :

-she felt FS #1 was not appropriate in that he
"catered" to FC #1's needs more than other
clients;

-he would "check-in" with FC #1 for up to two
hours when check-ins were to be a maximum of
20 minutes;

-she confronted FS #1 about two months ago

Division of Health Service Regulation

STATE FORM

6809

1W3011

(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 3 V 512

If continuation sheet 4 of 12

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHLO011-371

A. BUILDING:

2 COMPTON DRIVE

GREEN LEVEL Ill
ASHEVILLE, NC 28806

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/20/2018

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

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08/03/2018

concerning frequent " ...contact with [FC #1] and
her concerns that it was inappropriate";

-she reported these concerns about FS #1 to her
Program Manager (PM #1) " ...on three
occasions: 2 months ago, 1 month ago, and on
Thursday [6/28/18]";

-on 6/28/18 FC #1 disclosed to her she was in a
relationship with FS #1 and had been for about
three months.

Interview on 7/31/18 with the local DSS revealed:
-FC #1 disclosed she and FS #1 had sex, but she
would not disclose where this occurred;
-a friend of FS #1's gave FC #1 Plan B.

Interview on 7/26/18 and 7/30/18 with Program
Manager (PM #1) revealed:

-on 6/22/18 Staff #2 reported to her she saw
some "Red Flags" concerning FS #1;

-Staff #2 reported FS #1 seemed alittle "too
friendly" with the clients’, that he was doing a lot
of "check-ins" and "support walks" with the
female clients';

-she intentionally scheduled herself to work with
FS #1 the following day, 6/23/18;

-she noticed FS #1 was doing constant
"check-ins" with FC #1, that he was lenient and
friendly with the clients’, and he was very quick to
do "support walks";

-on 6/23/18 she provided FS #1 instantaneous
verbal feedback by discussing these concerns;
-she realized there were a couple of "serious
flags";

-she " ...knew he needed corrective action
immediately ...coaching ..." but felt it was not her
place as she was not his direct supervisor;

-she voiced Staff #2's concerns in the next PM
meeting, 6/26/18 ;

-the Assistant Residential Director asked her to
have Staff #2 write an email about her

Division of Health Service Regulation
STATE FORM

6809

1W3011

(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 4 V 512

If continuation sheet 5 of 12

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHLO011-371

A. BUILDING:

2 COMPTON DRIVE
ASHEVILLE, NC 28806

GREEN LEVEL Ill

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/20/2018

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

Cc
08/03/2018

observations of FS #1;

-an email was not received from Staff #2 until
6/29/18, the day FS #1 was terminated;

-once the email was received from Staff #2, the
plan was for FS #1 to receive coaching and/or
corrective action concerning his behavior .

Review on 7/27/18 of the PM Meeting Minutes
dated 6/26/18 revealed:
-"Staff Concerns ...[PM #1] will email [Staff #2]."

Review on 7/27/18 of Staff #2's email dated
6/29/18 revealed:

-"| have some concerns about staff [FS #1] and
student [FC #1]. About a month an half ago |
notice a closeness between [FS #1] and [FC #1],
and | had a talk with [FS #1] that the closeness
I'm seeing was inappropriate and he needed to
back away from [FC #1]."

-"Then | talked to some male staff and told them
what | was seeing and told them because they
was male could they have a talk with [FS#1] ..."
-" ... Yesterday 06/28/2018 [FC #1] came to me as
soon as | got to work and said she wanted to
check in with me ...Then she said, Yes, [Staff #2]
me and [FS #1] have been in a relationship for
about 3 months now and we had sex..."

Interview on 7/20/18 and 7/30/18 with PM #2
revealed:

-she was FS #1's direct supervisor;

-the first she heard of "concerns" regarding FS
#1's work was at the PM meeting on 6/26/18;
-nothing specifically was mentioned about those
concerns and she felt like more information was
needed;

-she did not remember PM #1 mentioning any
direct observations she made of FS #1's "red
flags";

-PM #1 mentioned Staff #2 had concerns and she

Division of Health Service Regulation
STATE FORM

6809

1W3011

(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 5 V 512

If continuation sheet 6 of 12

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/20/2018
FORM APPROVED

(X3) DATE SURVEY

felt like more information was needed so she
asked PM #1 to have Staff #2 send an email
detailing her observations;

-Staff #2 did not send the email right away.

Interview on 7/27/18 with Staff #3 revealed:

-she worked with FS #1 shortly after he was hired
in April and noticed he was conducting extended
"check-ins" and advised him to keep these to five
minutes;

-she felt like he was new and just did not know
the procedures well, or "didn't know any better";
-she could not remember who she reported this
to but said it was "Lead Staff."

Interview on 7/31/18 with the Lead Night
Residential Counselor ( NRC) revealed:

-in approximately April or May Staff #2 came to
him regarding her concerns of FS #1's
boundaries with the female clients;

-he spoke to FS #1 reiterating staff/student
boundaries;

-he advised FS #1 that he needed to be careful
and always have a female staff present with him
when he was with female clients;

-he made a note of this interaction with FS #1 in
an email; he could not remember when or to
whom the email was sent.

Interview on 7/20/18 and 7/27/18 with the Human
Resources (HR) Director revealed:

-on 6/28/18 at approximately 5:00 p.m. she
received a telephone call regarding FS #1
"flirting" with FC #1 and telling FC #1 he wanted
her to have his baby;

-most of the call was concerning how FS #1 was
in a gang and the caller was concerned for FC
#1's safety;

-she immediately reported this to the Director of
Performance and Quality Improvement and the

Division of Health Service Regulation

STATE FORM

6809

1W3011

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHLO011-371 08/03/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE
GREEN LEVEL Ill
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 512] Continued From page 6 V 512

If continuation sheet 7 of 12

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/20/2018
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHLO011-371 08/03/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE
GREEN LEVEL Ill
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 512] Continued From page 7 V 512

Residential Director.

Interview on 7/20/18, 7/30/18 and 8/2/18 with the
Director of Performance and Quality
Improvement revealed:

-on 6/28/18 the HR Director informed her of the
call she received concerning FS #1;

-she and the Residential Director and the Crisis
Manager determined FS #1 was scheduled to
work in FC #1's cottage that evening;

-they decided to remove FS #1 from FC #1's
cottage and scheduled him to work at another
cottage;

-prior to this she was not aware of any concerns
regarding FS #1's performance;

-on 6/29/18 FC #1 disclosed to Staff #2 she was
in a relationship with FS #1;

-later that morning after interviewing FS #1 during
the investigation, FS #1 was terminated.

-there had been no written disciplinary action
against FS #1 since his employment;

-she learned during her investigation PM #1
verbally coached FS #1 regarding poor
boundaries with students;

-during orientation/training for new staff handouts
were given and training was provided regarding
"red flags" and staff/student boundaries;

-each new employee signed a staff boundaries
form as part of their personnel file.

Interview on 8/2/18 with the Assistant Residential
Director revealed:

-the PM was responsible to observe staff
interactions and take feedback from shift
partners;

-there was no procedure of this set in stone,
however generally speaking every staff member
received "supervisory visits";

-if a PM received a verbal concern regarding a
staff member's performance she would expect

Division of Health Service Regulation
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1W3011

If continuation sheet 8 of 12

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHLO011-371

A. BUILDING:

2 COMPTON DRIVE
ASHEVILLE, NC 28806

GREEN LEVEL Ill

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/20/2018

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

Cc
08/03/2018

that the PM ask the staff to send an email and
then the PM should call her, the Residential
Director or the Chief Operating Officer and report
the concerns;

-if the PM observed staff concerns first hand she
would expect the PM to call or email her, the
Residential Director or the Chief Operating
Officer;

-if the PM verbally spoke to a staff member
concerning boundary issues and then another
concern about this same staff member was
brought to the PM team, then this would have
been a second issue and would have been
considered more serious, more of a "red flag";
-she was not aware of any "red flags" or boundary
issues concerning FS #1 until 6/28/18.

Interview on 7/30/18 and 8/2/18 with the
Residential Director revealed:

-he did not recall concerns brought to the PM
meeting on 6/26/18 regarding FS #1;

-after reviewing the "Staff Concerns" note from
the PM meeting he stated there should have
been more discussion regarding FS #1's behavior
and corrective action would have been
determined;

-PM #1 should have reported her direct
observations of FS #1 at the PM meeting and this
should have been documented.

-FS #1 was a NRC and the Lead NRC did rounds
for all the cottages and would have observed FS
#1's performance;

-he did not receive any concerns from the Lead
NRC verbally or via email regarding FS #1;

-he was not aware the Lead NRC had verbally
coached FS #1 concerning boundary issues;

-he was not aware of any "red flags" concerning
FS #1 until 6/28/18.

Review on 8/3/18 of the Plan of Protection dated

Division of Health Service Regulation
STATE FORM

6809

1W3011

(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 12

Division of Health Service Regulation

GREEN LEVEL Ill

NAME OF PROVIDER OR SUPPLIER

A. BUILDING:

MHLO011-371

2 COMPTON DRIVE
ASHEVILLE, NC 28806

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

PRINTED: 08/20/2018

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

Cc
08/03/2018

8/3/18 written by the Director of Performance and
Quality Improvement revealed:

What will you immediately do to correct the above
rule violations in order to protect clients from
further risk or additional harm?

"1. Eliada's Professional Boundaries with
Students and Staff "Red Flags" Protocol is being
revised to include clear reporting guidelines to
immediate supervisors within 24 hours of the
observed behavior, documentation of the
observation and response by the Program
Director completed and documented within 2
business days.

2. Eliada's CEO will send an email
correspondence to ALL Eliada staff detailing the
shared responsibility of all employees to maintain
a safe environment for students and families, and
the clear expectation that any concerns be
communicated promptly to Eliada's PQI Director.
Eliada's Child Abuse Reporting Policy will be
included with this correspondence.

3. The Residential Director will develop and
implement a Corrective Action plan for the two
leadership staff involved in this situation [Lead
NRC and PM #1] by Tuesday, 8/7/18.

4. The Residential Director will initiate and
document bi-weekly individual supervision
sessions with the Residential Program Managers
and the Lead NRC beginning the week of August
6, 2018.

5. No students will be permitted in the cottage
offices. Student phone calls (in Eliada's
Residential Programs) will be facilitated in
common areas, with the use of cordless phones.
If privacy is needed, the phone call will be
facilitated in the seclusion room, where there is a
video surveillance window in the doors for staff
observation.

Division of Health Service Regulation
STATE FORM

6809

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(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 V 512

If continuation sheet 10 of 12

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 08/20/2018
FORM APPROVED

(X3) DATE SURVEY

6. The office door in Green Cottage will be
removed to ensure line of sight and shift partner
accountability until the video surveillance camera
is installed."

Describe your plans to make sure the above
happens.

"4. The revised protocol and accompanying form
for documentation will be emailed to all
Residential staff by Monday, 8/6/18. The
Residential Director will review the reporting and
documentation procedures with the Residential
Case Managers on Tuesday, 8/7/18 and each
Program Manager will review with their respective
teams during the Team Meetings on Wednesday,
8/8/18. All staff will sign the revised protocol,
which will be maintained in the personnel record.
2 Eliada's CEO will review the Corrective Action
plan prior to implementation and the HR Director
will confirm receipt of the plan and documentation
file in the personnel records by 8/8/18.

3. The Residential Director will send a written
email correspondence to all Residential Staff on
8/3/18 detailing standards for student phone calls.
4. Awalk through of Green Cottage will be
completed prior to admission of students on
8/8/18 to ensure the physical safety of the
cottage, including open access/line of sight
supervision from the cottage office."

FC #1 had a history of being assaulted and left
for dead by her friends associated in a gang with
her; was physically abused by her father and
witnessed domestic abuse. She had difficulty
trusting others and was experiencing nightmares
from her trauma. FS #1 was hired 4/2/18 and
by the end of April was in a relationship with FC
#1. FC #1 disclosed she and FS #1 had sex and
FS #1 said he wanted her to have his baby. PM

Division of Health Service Regulation

STATE FORM

6809

1W3011

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHLO011-371 08/03/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE
GREEN LEVEL Ill
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 512] Continued From page 10 V 512

If continuation sheet 11 of 12

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHLO011-371

(X2) MULTIPLE CONSTRUCTION

A. BUILDING:

2 COMPTON DRIVE
ASHEVILLE, NC 28806

GREEN LEVEL Ill

PRINTED: 08/20/2018

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

Cc
08/03/2018

#1 and the Lead NRC received reports from
paraprofessional staff as early as May that FS #1
had extended check-ins with FC #1, remained
behind closed doors for up to 2 hours in the
cottage office with FC #1, seemed "too friendly"
with FC #1 and catered to FC #1's needs more
than any other client. PM #1 had direct
observations of FS #1 conducting frequent
check-ins with FC #1, and was eager to do
support walks with the clients. PM #1 realized he
needed immediate corrective action and on
6/23/18 verbally coached FS #1 but did not report
this to her supervisor. The Lead NRC verbally
coached FS #1 at the end of April or early May
but did not report concerns to his supervisor. The
failure of the facility to take action for
approximately two months allowed former staff #1
unsupervised access to and a sexual relationship
with client #1. This deficiency constitutes a Type
A1 rule violation for exploitation and neglect and
must be corrected within 23 days. An
administrative penalty of $1,000.00 is imposed. If
the violation is not corrected within 23 days, an
additional administrative penalty of $500.00 per
day will be imposed for each day the facility is out
of compliance beyond the 23rd day.

Division of Health Service Regulation
STATE FORM

6809

(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 11 V 512

If continuation sheet 12 of 12


state: NC

facility_name: Eliada Treatment Center

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

raw_content:
Division of Health Service Requlation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

MHL011-443

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

B. WING

PRINTED: 07/16/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
07/15/2025

NAME OF PROVIDER OR SUPPLIER

ELIADA TREATMENT CENTER

STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

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

(x4) 1D
PREFIX
TAG

V000 INITIAL COMMENTS

An annual, follow up and complaint survey was
completed on July 15, 2025. The complaint were
substantiated (Intake #NC00232481).

| Deficiencies were cited.

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

This facility is licensed for 8 and has a current
census of 8. The survey sample consisted of
audits of 3 current clients.

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

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

ID
PREFIX
TAG

Vv 000

V 132

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

(x5)
COMPLETE
DATE

Correct: The HCPR required reports
shall be submitted by the CCO in regard
to this staff member.

Prevent: The PQI Investigations
Procedure Form will include a check box
for HCPR Required Reports and denote
all allegations against a staff must be
reported. |

Prevent: The COO will retrain
residential staff on the timeline and
process for reporting allegations to PQI
and DSS

Monitor: Upon completion of a PQ!
Investigation, the entire PQI| team shall
review the completed form which shall
denote the completion of the HCPR
required report

| 9/12/25

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

TITLE (x6) DATE

STATE FORM

6898

wertt If continuation sheet 1 of 11

RECEIVED

DHSR-MH Licensure Sect

Division of Health Service Requlation

PRINTED: 07/16/2025
FORM APPROVED

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED
R
MHLO11~-443 EeWING 07/15/2025
NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ELIADA TREATMENT CENTER
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D 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

(X3) DATE SURVEY

DEFICIENCY)

V 132 Continued From page 1 V 132

e. Fraud against a health care facility or against |
| a patient or client for wnom 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 report an allegation of abuse to
the Health Care Personnel Registry (HCPR)
affecting 1 of 3 audited staff (Staff #1). The
findings are:

Review on 7/14/25 of Staff #1's record revealed:
-Title: Youth Mentor.
-Date of Hire: 3/31/25.

Review on 7/14/15 of the facility incident reports
| revealed:
-No documentation of a report to the HCPR for
allegation of abuse reported the local Department
| of Social Services (DSS) 7/8/25.

| Review on 7/14/25 of the Licensee Internal
Investigation completed by the Performance and
Quality Improvement (PQ|) team dated 6/23/25
revealed:
-Date of incident: 6/16/25-6/17/25.
-There were no listed allegations of abuse.

Interview on 7/15/25 with the local DSS worker
revealed:

-Confirmed allegation of abuse against Staff #1
involving Client #1 and Client #2 reported 7/8/25,

Division of Health Service Regulation
STATE FORM 099 wert

If continuation sheet 2 of 11

PRINTED: 07/16/2025
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
MHLO11-443 B. WING —______________ 07/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ELIADA TREATMENT CENTER
ASHEVILLE, NC 28806
(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

| DEFICIENCY)

V 132) Continued From page 2 Vv 132

Interview on 7/15/25 with the Quality Assurance

Manager revealed:

-Was a member of the PO! team

-PQI team was responsible for reporting to the

HCPR for allegations of abuse against

employees.

-Was not aware of an allegation of abuse prior to

7/8125.

-HCPR was not completed for allegation of abuse

against Staff #1 reported to the local DSS on

7/8/25.

-HCPR was not completed due to "a series of

miscommunications, (PQI) did not communicate

effectively as a team."

| -Aware of the requirement for HCPR reporting,
"...we dropped the ball honestly (not reporting to
the HCPR for allegation of abuse against Staff #1
reported 7/8/25)."

Interview on 7/15/25 with the Chief Compliance

Officer revealed:

-Was a member of the PQI team.

-PQI team was responsible for reporting to the

HCPR for allegations of abuse against

employees,

-Was not aware of an allegation of abuse prior to

7/8/25.

-HCPR was not compieted for allegation of abuse

against Staff #1 reported to the local DSS on

7/8/25,

-"...was rushing (completing internal investigation)

since the incident had already been delayed."

-Will make sure to use her checklist for

processing incidents moving forward to ensure

required departments are notified of any

allegation of abuse upon being made aware.

-Will update the incident investigation form to |

include to refer back to incident processing |
| checklist to ensure all steps are taken.

Division of Health Service Regulation
STATE FORM 099 wertt If continuation sheet 3 of 11

Division of Health Service Requlation

PRINTED: 07/16/2025
FORM APPROVED

(x2) MULTIPLE CONSTRUCTION
A. BUILDING:

‘STATEMENT OF DEFICIENCIES (<1) PROVIDER/SUPPLIERICLIA,
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

B. WING

MHLO011-443

(X3) DATE SURVEY
COMPLETED

R
07/15/2025

STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

NAME OF PROVIDER OR SUPPLIER

ELIADA TREATMENT CENTER

SUMMARY STATEMENT OF DEFICIENCIES 1D
(EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX
REGULATORY OR LSC IDENTIFYING INFORMATION) TAG

(x4) 1D
PREFIX |
TAG

Vv 132) Continued From page 3 V 132

Interview on 7/15/25 with the Chief Operating
Officer revealed:

-PQI team responsible for notifying the HCPR for
allegations of abuse against employees.

-Will ensure clear systematic overview of who is
following up and the step by step process
reviewing the incidents and processes involved.
V 293

V 293 27G .1701 Residential Tx. Child/Adol - Scope

10ANCAC 27G 1701 SCOPE Correction

(a) Aresidential treatment staff secure facility for
children or adolescents is one that is a
free-standing residential facility that provides
intensive, active therapeutic treatment and
interventions within a system of care approach. It
shall not be the primary residence of an individual
who is not a client of the facility.
(b) Staff secure means staff are required to be
awake during client sleep hours and supervision
shall be continuous as set forth in Rule .1704 of
this Section.
(c) The population served shall be children or
adolescents who have a primary diagnosis of
| mental illness, emotional disturbance or
substance-related disorders; and may also have
co-occurring disorders including developmental
| disabilities. These children or adolescents shall
not meet criteria for inpatient psychiatric services.
(d) The children or adolescents served shall
require the following:
(1) removal from home to a
community-based residential setting in order to
facilitate treatment; and
(2) treatment in a staff secure setting.
(e) Services shall be designed to:
(1) include individualized supervision and
structure of daily living;
| (2) minimize the occurrence of behaviors

| the CCO.

Pr

completed

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

notified in regard to the allegation by

Prevention:
dure Form shall be updated to

include a step to inform all guardians of
all students involved in an investigation |

Monitor: The PQ! Investigation
Procedure Form shall be shared with
the entire PQ| team upon its
completion and shall denote that
guardian notification has been

os)

COMPLETE
DATE

DEFICIENCY) |

The guardian shall be
1e guardian sha 7/9/25

The PQI Investigation .
9/12/25

| 9/12/25

Division of Health Service Regulation

STATE FORM wWwé8T11

If continuation sheet 4 of 11

PRINTED: 07/16/2025
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: UBOIDING! COMPLETED
R
MHL011-443 BrWING 07/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ELIADA TREATMENT CENTER
ASHEVILLE, NC 28806
aio | SUMMARY STATEMENT OF DEFICIENCIES ID | PROVIDER'S PLAN OF CORRECTION | axs)
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)
| T
V 293 Continued From page 4 V 293

| related to functional deficits;

| (3) ensure safety and deescalate out of
control behaviors including frequent crisis
management with or without physical restraint;
(4) assist the child or adolescent in the
acquisition of adaptive functioning in self-control,
communication, social and recreational skills; and
(5) support the child or adolescent in
gaining the skills needed to step-down to a less
intensive treatment setting.

| (f) The residential treatment staff secure facility

| shall coordinate with other individuals and
agencies within the child or adolescent's system
of care.

| This Rule is not met as evidenced by:
Based on record reviews and interviews, the
facility failed to coordinate with individuals within
the client's system of care for 1 of 3 current
clients (Client #1). The findings are:

Review on 7/14/25 of Client #1's record revealed:

-Age: 12. |

-Date of admission: 6/5/25.

-Diagnoses: Personality Disorder, Major

Depressive Disorder, and Anxiety Disorder.

-No documentation of facility notification to

guardian for incident on 6/16/25 and 6/17/25.

-Child Family Team meeting dated 7/7/25:
-Guardian was not notified of incident dated

Division of Health Service Regulation

STATE FORM 099 weéeTt1 If continuation sheet 5 of 11

PRINTED: 07/16/2025
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: ‘R. COMPLETED
BUILDING:
R
MHLO11-443 BLWING 07/15/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD

ELIADA TREATMENT CENTER
ASHEVILLE, NC 28806

oayio | 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)
——) T
V 293

V 293 Continued From page 5
6/16/25 and 6/17/25.

| Review on 7/14/25 of the Licensee Internal
Investigation completed by the Performance and
Quality Improvement (PQI) team dated 6/23/25
revealed:
-Date of incident: 6/16/25-6/17/25.
-There were no listed allegations of abuse.

Interview on 7/15/25 with the local DSS Worker
revealed:

-Confirmed allegation of abuse against Staff #1
involving Client #1 reported 7/8/25.

Interview on 7/15/25 with Client #1's guardian
revealed:

-Was first informed by Client #1 while on a home
| visit on 7/7/25 of the allegation of abuse.

Interview on 7/15/25 with Therapist #1 revealed:
-Did not notify Client #1's guardian of incident
dated 6/16/25 and 6/17/25.

Interview on 7/15/25 with the Quality Assurance
| Manager revealed:
-Was not sure why Client #1's guardian was not
made aware of the allegation of abuse.
-"| thought she (Client #1) had been made aware
(of allegation of abuse), assumption that she was
made aware."

Interview on 7/15/25 with the Chief Compliance
Officer revealed:
-"| should of notified [Client #1's] guardian, didn't
use my checklist of processing incidents."
-"...was rushing (completing internal investigation)
since the incident had already been delayed."
-Will make sure to use her checklist for
processing incidents moving forward to ensure

| required departments are notified of any

Division of Health Service Regulation

STATE FORM e099 Wetit If continuation sheet 6 of 11

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA

(X2) MULTIPLE CONSTRUCTION

PRINTED: 07/16/2025
FORM APPROVED

(x3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: R BOLEING: COMPLETED
R
MHL011-443 B. WING 07/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ELIADA TREATMENT CENTER
ASHEVILLE, NC 28806
aio | 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 293 Continued From page 6 V 293
| allegation of abuse upon being made aware.
-Will update the incident investigation form to
include to refer back to incident processing
checklist to ensure all steps are taken.
Interview on 7/15/25 with the Chief Operating
Officer revealed:
-The staff an allegation of abuse was reported to
would notify the Client's therapist and the PQI
team.
-No one told Client #1's therapist or their guardian
| about the allegation of abuse.
-Will ensure clear systematic overview of who is
following up and the step by step process
reviewing the incidents and processes involved.
|
V 367 27G .0604 Incident Reporting Requirements V 367

410A NCAC 27G .0604 INCIDENT
| REPORTING REQUIREMENTS FOR
CATEGORY AAND B PROVIDERS
(a) Category A and B providers shall report all
| level Il incidents, except deaths, that occur during
| the provision of billable services or while the
consumer is on the providers premises or level III
incidents and level II deaths involving the clients
to whom the provider rendered anv service within
| 90 days prior to the incident to the LME
responsible for the catchment area where
services are provided within 72 hours of
becoming aware of the incident. The report shall
be submitted on a form provided by the
Secretary. The report may be submitted via mail,
in person, facsimile or encrypted electronic
means. The report shall include the following
information:
(1) reporting provider contact and
identification information;
(2) client identification information;

Division of Health Service Regulation
STATE FORM

|
715/25

Correct: IRIS reports for all students
involved in this investigation shall be
completed and submitted by the QAM.

Prevent: The PQI Investigation | 9/12/25
Procedure Form shall be updated to EES
include a step for completing all required

| IRIS reports

Prevent: The COO will retrain
residential staff on the timeline and
process for reporting allegations to PQI
and DSS

7/30/25

Monitor: Upon completion of an
nvestigation, the completed form shall
be shared with the entire PQ| team and
denote that the IRIS reports have been
completed

9/12/25

watt If continuation sheet 7 of 11

Division of Health Service Regulation

PRINTED: 07/16/2025
FORM APPROVED

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

MHL011-443

NAME OF PROVIDER OR SUPPLIER

ELIADA TREATMENT CENTER

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

STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION

A. BUILDING:

R
07/15/2025

iD PROVIDER'S PLAN OF CORRECTION 5)
| PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

| DEFICIENCY)

Vv 367 | Continued From page 7

(3) type of incident;

| (4) description of incident;

| (8) status of the effort to determine the
cause of the incident; and
(6) other individuals or authorities notified
or responding.
(b) Category A and B providers shall explain any
missing or incomplete information. The provider
shall submit an updated report to all required
report recipients by the end of the next business
day whenever:
(1) the provider has reason to believe that
information provided in the report may be
erroneous, misleading or otherwise unreliable; or
(2) the provider obtains information
required on the incident form that was previously
unavailable.
(c) Category A and B providers shall submit,
upon request by the LME, other information

| obtained regarding the incident, including:
(1) hospital records including confidential
information;

(2) reports by other authorities; and
(3) the provider's response to the incident.
(d) Category A and B providers shall send a copy

| of all level Ill incident reports to the Division of

| Mental Health, Developmental Disabilities and
Substance Abuse Services within 72 hours of
becoming aware of the incident. Category A
providers shall send a copy of all level Ill
incidents involving a client death to the Division of
Health Service Regulation within 72 hours of

| becoming aware of the incident. In cases of

| client death within seven days of use of seclusion

| or restraint, the provider shall report the death
immediately, as required by 10A NCAC 26C

| 0300 and 10A NCAC 27E .0104(e)(18).

| (e) Category A and B providers shall send a
report quarterly to the LME responsible for the

V 367

Division of Health Service Regulation
STATE FORM

aad wettt {fcontinuation sheet 8 of 11

PRINTED: 07/16/2025

FORM APPROVED

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIER/CLIA

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED
R
MHLO11-443 B. WING ____ 07/15/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD

Tl N
ELIADA TREATMENT CENTER ASHEVILLE, NC 28806

—
(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES | 10 PROVIDER'S PLAN OF CORRECTION 5)
PREFIX (EACH DEFICIENCY MUST 8E PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TaG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
| DEFICIENCY)

———j—___ |
| ]
V 367 Continued From page 8 V 367

catchment area where services are provided.
The report shall be submitted on a form provided
by the Secretary via electronic means and shall
include summary information as follows:

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

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

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

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

(6) a statement indicating that there have

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

This Rule is not met as evidenced by: |
Based on record reviews and interviews, the
facility failed to report level II incidents in the
Incident Response Improvement System (IRIS)
within 72 hours of becoming aware of the
incident. The findings are:

Review on 7/14/25 of Client #1's record revealed:
-Age: 12.
-Date of admission: 6/5/25.
-Diagnoses: Personality Disorder, Major
| Depressive Disorder, and Anxiety Disorder.

Division of Health Service Regulation
STATE FORM 6390 watt If continuation sheet 9 of 11

Division of Health Service Requlation

PRINTED: 07/16/2025
FORM APPROVED

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

MHL011-443

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

B. WING

(X3) DATE SURVEY
COMPLETED

R
07/15/2025

NAME OF PROVIDER OR SUPPLIER

ELIADA TREATMENT CENTER

STREET ADDRESS, CITY, STATE, ZIP CODE

882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

Continued From page 9

| Review on 7/14/25 of Client #2's record revealed:
-Age: 16.

-Date of admission: 2/25/25.

-Diagnoses: Disruptive Mood Dysregulation
Disorder, and Attention Deficit Hyperactivity
Disorder, combined type.

Review on 7/14/25 of IRIS revealed:

-No documentation of level II IRIS report for
allegation of abuse reported to the local
Department of Social Services (DSS) on 7/8/25
involving Client #1 and #2.

Review on 7/14/25 of the Licensee Internal
Investigation completed by the Performance and
Quality Improvement (PQI) team dated 6/23/25

| revealed:

| -Date of incident: 6/16/25-6/17/25.

| -There were no listed allegations of abuse.
Interview on 7/15/25 with the local DSS Worker
revealed:
-Confirmed allegation of abuse against Staff #1

| involving Client #1 and Client #2 reported 7/8/25.

| Interview on 7/15/25 with the Quality Assurance
| Manager revealed:

-Was a member of the PQI team.

-PQ| team was responsible for reporting level II
incidents in IRIS.

-Was not aware of an allegation of abuse prior to
7/8/25.

-Level I incident was not completed in IRIS for
the allegation of abuse against Staff #1 reported
to the local DSS on 7/8/25.

-Level I incident was not completed in IRIS for
the allegation of abuse against Staff #1 involving
Client #1 and Client #2 due to "a series of
miscommunications, (PQ!) did not communicate
effectively as a team.”

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
—$$__—_—
|
V 367 |

Division of Health Service Regulation
STATE FORM

6009

V8T11 If continuation sheet 10 of 11

Division of Health Service Regulation

‘STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION
A. BUILDING:

AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

PRINTED: 07/16/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R

| -Aware of the requirement for incident reporting in
IRIS, "...we dropped the ball honestly (Level I!

| incident was not completed in IRIS for the
allegation of abuse against Staff #1 involving
Client #1 and Client #2)."

Interview on 7/15/25 with the Chief Compliance
Officer revealed:

-Was a member of the PQI team.

-PQI team was responsible for reporting level II
incidents in IRIS.

-Was not aware of an allegation of abuse prior to
7/8/25.

-Level Il incident was not completed in IRIS for
the allegation of abuse against Staff #1 involving
Client #1 and Client #2 reported to the local DSS
on 7/8/25.

-"...was rushing (completing internal investigation)
since the incident had already been delayed."

| -Will make sure to use her checklist for
processing incidents moving forward to ensure
required departments are notified of any
allegation of abuse upon being made aware. |
-Will update the incident investigation form to
include to refer back to incident processing
checklist to ensure all steps are taken.

| Interview on 7/15/25 with the Chief Operating
Officer revealed:
-PQI team responsible for reporting level II
incidents in IRIS for allegations of abuse against
employees.
-Level II incident was not completed in IRIS for
the allegation of abuse against Staff #1 involving
Client #1 and Client #2 reported to the local DSS |
on 7/8/25.
-Will ensure clear systematic overview of who is
| following up and the step by step process
reviewing the incidents and processes involved.

MHL011-443 07/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ELIADA TREATMENT CENTER
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES iD | PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL | PREFIX {EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG ‘CROSS-REFERENCED TO THE APPROPRIATE DATE
|
V 367 | Continued From page 10 V 367

Division of Health Service Regulation
STATE FORM 6899 WwérT11

If continuation sheet 11 of 11

inspection_type: MHLCS Annual, Complaint, and Follow-up

document_type: Plan of Correction


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

raw_content:
Division of Health Service Regulation

PRINTED: 07/16/2025
FORM APPROVED

Allegations, & Protection

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

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

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

c. Misappropriation of the property of a
healthcare facility.

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

Division of Health Service Regulation

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

STATE FORM

6808 w8T11

TITLE

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED
R
MHL011-443 07/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ELIADA TREATMENT CENTER
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000} INITIAL COMMENTS V 000
An annual, follow up and complaint survey was
completed on July 15, 2025. The complaint were
substantiated (Intake #NC00232481).
Deficiencies were cited.
This facility is licensed for the following service
category: 10A NCAC 27G .1700 Residential
Treatment Staff Secure for Children or
Adolescents.
This facility is licensed for 8 and has a current
census of 8. The survey sample consisted of
audits of 3 current clients.
V 132} G.S. 131E-256(G) HCPR-Notification, V 132

(X6) DATE

If continuation sheet 1 of 11

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 07/16/2025
FORM APPROVED

(X3) DATE SURVEY

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 report an allegation of abuse to
the Health Care Personnel Registry (HCPR)
affecting 1 of 3 audited staff (Staff #1). The
findings are:

Review on 7/14/25 of Staff #1's record revealed:
-Title: Youth Mentor.
-Date of Hire: 3/31/25.

Review on 7/14/15 of the facility incident reports
revealed:

-No documentation of a report to the HCPR for
allegation of abuse reported the local Department
of Social Services (DSS) 7/8/25.

Review on 7/14/25 of the Licensee Internal
Investigation completed by the Performance and
Quality Improvement (PQI) team dated 6/23/25
revealed:

-Date of incident: 6/16/25-6/17/25.

-There were no listed allegations of abuse.

Interview on 7/15/25 with the local DSS worker
revealed:

-Confirmed allegation of abuse against Staff #1
involving Client #1 and Client #2 reported 7/8/25.

Division of Health Service Regulation
STATE FORM

6809

w8T11

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL011-443 07/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ELIADA TREATMENT CENTER
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 132] Continued From page 1 V 132

If continuation sheet 2 of 11

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 07/16/2025
FORM APPROVED

(X3) DATE SURVEY

Interview on 7/15/25 with the Quality Assurance
Manager revealed:

-Was a member of the PQI team.

-PQI team was responsible for reporting to the
HCPR for allegations of abuse against
employees.

-Was not aware of an allegation of abuse prior to
7/8/25.

-HCPR was not completed for allegation of abuse
against Staff #1 reported to the local DSS on
7/8/25.

-HCPR was not completed due to "a series of
miscommunications, (PQI) did not communicate
effectively as a team."

-Aware of the requirement for HCPR reporting,
"...we dropped the ball honestly (not reporting to
the HCPR for allegation of abuse against Staff #1
reported 7/8/25)."

Interview on 7/15/25 with the Chief Compliance
Officer revealed:

-Was a member of the PQI team.

-PQI team was responsible for reporting to the
HCPR for allegations of abuse against
employees.

-Was not aware of an allegation of abuse prior to
7/8/25.

-HCPR was not completed for allegation of abuse
against Staff #1 reported to the local DSS on
7/8/25.

-"...was rushing (completing internal investigation)
since the incident had already been delayed."
-Will make sure to use her checklist for
processing incidents moving forward to ensure
required departments are notified of any
allegation of abuse upon being made aware.
-Will update the incident investigation form to
include to refer back to incident processing
checklist to ensure all steps are taken.

Division of Health Service Regulation
STATE FORM

6809

w8T11

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL011-443 07/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ELIADA TREATMENT CENTER
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 132] Continued From page 2 V 132

If continuation sheet 3 of 11

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 07/16/2025
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL011-443 07/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ELIADA TREATMENT CENTER
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 132] Continued From page 3 V 132
Interview on 7/15/25 with the Chief Operating
Officer revealed:
-PQI team responsible for notifying the HCPR for
allegations of abuse against employees.
-Will ensure clear systematic overview of who is
following up and the step by step process
reviewing the incidents and processes involved.
V 293] 27G .1701 Residential Tx. Child/Adol - Scope V 293

10A NCAC 27G .1701 SCOPE

(a) Aresidential treatment staff secure facility for
children or adolescents is one that is a
free-standing residential facility that provides
intensive, active therapeutic treatment and
interventions within a system of care approach. It
shall not be the primary residence of an individual
who is not a client of the facility.

(b) Staff secure means staff are required to be
awake during client sleep hours and supervision
shall be continuous as set forth in Rule .1704 of
this Section.

(c) The population served shall be children or
adolescents who have a primary diagnosis of
mental illness, emotional disturbance or
substance-related disorders; and may also have
co-occurring disorders including developmental
disabilities. These children or adolescents shall
not meet criteria for inpatient psychiatric services.
(d) The children or adolescents served shall
require the following:

(1) removal from home to a
community-based residential setting in order to
facilitate treatment; and

(2) treatment in a staff secure setting.

(e) Services shall be designed to:

(1) include individualized supervision and
structure of daily living;

(2) minimize the occurrence of behaviors

Division of Health Service Regulation
STATE FORM

6809

w8T11

If continuation sheet 4 of 11

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL011-443

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 07/16/2025

STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

R
07/15/2025

related to functional deficits;

(3) ensure safety and deescalate out of
control behaviors including frequent crisis
management with or without physical restraint;
(4) assist the child or adolescent in the
acquisition of adaptive functioning in self-control,
communication, social and recreational skills; and
(5) support the child or adolescent in
gaining the skills needed to step-down to a less
intensive treatment setting.

(f) The residential treatment staff secure facility
shall coordinate with other individuals and
agencies within the child or adolescent's system
of care.

This Rule is not met as evidenced by:

Based on record reviews and interviews, the
facility failed to coordinate with individuals within
the client's system of care for 1 of 3 current
clients (Client #1). The findings are:

Review on 7/14/25 of Client #1's record revealed:

-Age: 12.

-Date of admission: 6/5/25.

-Diagnoses: Personality Disorder, Major

Depressive Disorder, and Anxiety Disorder.

-No documentation of facility notification to

guardian for incident on 6/16/25 and 6/17/25.

-Child Family Team meeting dated 7/7/25:
-Guardian was not notified of incident dated

Division of Health Service Regulation
STATE FORM

6809

ELIADA TREATMENT CENTER
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 293] Continued From page 4 V 293

If continuation sheet 5 of 11

Division of Health Service Regulation

PRINTED: 07/16/2025
FORM APPROVED

6/16/25 and 6/17/25.

Review on 7/14/25 of the Licensee Internal
Investigation completed by the Performance and
Quality Improvement (PQI) team dated 6/23/25
revealed:

-Date of incident: 6/16/25-6/17/25.

-There were no listed allegations of abuse.

Interview on 7/15/25 with the local DSS Worker
revealed:

-Confirmed allegation of abuse against Staff #1
involving Client #1 reported 7/8/25.

Interview on 7/15/25 with Client #1's guardian
revealed:

-Was first informed by Client #1 while on a home
visit on 7/7/25 of the allegation of abuse.

Interview on 7/15/25 with Therapist #1 revealed:
-Did not notify Client #1's guardian of incident
dated 6/16/25 and 6/17/25.

Interview on 7/15/25 with the Quality Assurance
Manager revealed:

-Was not sure why Client #1's guardian was not
made aware of the allegation of abuse.

-"| thought she (Client #1) had been made aware
(of allegation of abuse), assumption that she was
made aware."

Interview on 7/15/25 with the Chief Compliance
Officer revealed:

-"| should of notified [Client #1's] guardian, didn't
use my checklist of processing incidents."
-"...was rushing (completing internal investigation)
since the incident had already been delayed."
-Will make sure to use her checklist for
processing incidents moving forward to ensure
required departments are notified of any

Division of Health Service Regulation

STATE FORM

6808 w8T11

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL011-443 07/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ELIADA TREATMENT CENTER
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 293] Continued From page 5 V 293

If continuation sheet 6 of 11

Division of Health Service Regulation

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

MHL011-443

NAME OF PROVIDER OR SUPPLIER

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

882 ELIADA HOME ROAD

ELIADA TREATMENT CENTER

ASHEVILLE, NC 28806

PRINTED: 07/16/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
07/15/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

(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 (xs)
(EACH CORRECTIVE ACTION SHOULD BE. COMPLETE

CROSS-REFERENCED TO THE APPROPRIATE, DATE
DEFICIENCY)

V 293] Continued From page 6

allegation of abuse upon being made aware.
-Will update the incident investigation form to
include to refer back to incident processing
checklist to ensure all steps are taken.

Interview on 7/15/25 with the Chief Operating
Officer revealed:

-The staff an allegation of abuse was reported to
would notify the Client's therapist and the PQI
team.

-No one told Client #1's therapist or their guardian
about the allegation of abuse.

-Will ensure clear systematic overview of who is
following up and the step by step process
reviewing the incidents and processes involved.

V 367] 27G .0604 Incident Reporting Requirements

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

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

(1) reporting provider contact and
identification information;

(2) client identification information;

Division of Health Service Regulation
STATE FORM

V 293

V 367

6809

w8T11

If continuation sheet 7 of 11

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 07/16/2025
FORM APPROVED

(X3) DATE SURVEY

(3) type of incident;

(4) description of incident;

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

(6) other individuals or authorities notified

or responding.

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

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

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

(1) hospital records including confidential
information;

(2) reports by other authorities; and

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

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

(e) Category A and B providers shall send a
report quarterly to the LME responsible for the

Division of Health Service Regulation
STATE FORM

6809

w8T11

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL011-443 07/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ELIADA TREATMENT CENTER
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 367] Continued From page 7 V 367

If continuation sheet 8 of 11

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 07/16/2025
FORM APPROVED

(X3) DATE SURVEY

catchment area where services are provided.
The report shall be submitted on a form provided
by the Secretary via electronic means and shall
include summary information as follows:

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

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

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

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

(6) a statement indicating that there have

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

This Rule is not met as evidenced by:

Based on record reviews and interviews, the
facility failed to report level II incidents in the
Incident Response Improvement System (IRIS)
within 72 hours of becoming aware of the
incident. The findings are:

Review on 7/14/25 of Client #1's record revealed:
-Age: 12.

-Date of admission: 6/5/25.

-Diagnoses: Personality Disorder, Major
Depressive Disorder, and Anxiety Disorder.

Division of Health Service Regulation
STATE FORM

6809

w8T11

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL011-443 07/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ELIADA TREATMENT CENTER
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 367 | Continued From page 8 V 367

If continuation sheet 9 of 11

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 07/16/2025
FORM APPROVED

(X3) DATE SURVEY

Review on 7/14/25 of Client #2's record revealed:

-Age: 16.

-Date of admission: 2/25/25.

-Diagnoses: Disruptive Mood Dysregulation
Disorder, and Attention Deficit Hyperactivity
Disorder, combined type.

Review on 7/14/25 of IRIS revealed:

-No documentation of level II IRIS report for
allegation of abuse reported to the local
Department of Social Services (DSS) on 7/8/25
involving Client #1 and #2.

Review on 7/14/25 of the Licensee Internal
Investigation completed by the Performance and
Quality Improvement (PQI) team dated 6/23/25
revealed:

-Date of incident: 6/16/25-6/17/25.

-There were no listed allegations of abuse.

Interview on 7/15/25 with the local DSS Worker
revealed:

-Confirmed allegation of abuse against Staff #1
involving Client #1 and Client #2 reported 7/8/25.

Interview on 7/15/25 with the Quality Assurance
Manager revealed:

-Was a member of the PQI team.

-PQI team was responsible for reporting level II
incidents in IRIS.

-Was not aware of an allegation of abuse prior to
7/8/25.

-Level II incident was not completed in IRIS for
the allegation of abuse against Staff #1 reported
to the local DSS on 7/8/25.

-Level II incident was not completed in IRIS for
the allegation of abuse against Staff #1 involving
Client #1 and Client #2 due to "a series of
miscommunications, (PQI) did not communicate
effectively as a team."

Division of Health Service Regulation

STATE FORM

6809

w8T11

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL011-443 07/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ELIADA TREATMENT CENTER
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 367] Continued From page 9 V 367

If continuation sheet 10 of 11

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 07/16/2025
FORM APPROVED

(X3) DATE SURVEY

-Aware of the requirement for incident reporting in
IRIS, "...we dropped the ball honestly (Level II
incident was not completed in IRIS for the
allegation of abuse against Staff #1 involving
Client #1 and Client #2)."

Interview on 7/15/25 with the Chief Compliance
Officer revealed:

-Was a member of the PQI team.

-PQI team was responsible for reporting level II
incidents in IRIS.

-Was not aware of an allegation of abuse prior to
7/8/25.

-Level II incident was not completed in IRIS for
the allegation of abuse against Staff #1 involving
Client #1 and Client #2 reported to the local DSS
on 7/8/25.

-"...was rushing (completing internal investigation)
since the incident had already been delayed."
-Will make sure to use her checklist for
processing incidents moving forward to ensure
required departments are notified of any
allegation of abuse upon being made aware.
-Will update the incident investigation form to
include to refer back to incident processing
checklist to ensure all steps are taken.

Interview on 7/15/25 with the Chief Operating
Officer revealed:

-PQI team responsible for reporting level II
incidents in IRIS for allegations of abuse against
employees.

-Level II incident was not completed in IRIS for
the allegation of abuse against Staff #1 involving
Client #1 and Client #2 reported to the local DSS
on 7/8/25.

-Will ensure clear systematic overview of who is
following up and the step by step process
reviewing the incidents and processes involved.

Division of Health Service Regulation
STATE FORM

6809

w8T11

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL011-443 07/15/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ELIADA TREATMENT CENTER
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 367 | Continued From page 10 V 367

If continuation sheet 11 of 11

document_type: Statement of Deficiency