raw_content:
PRINTED: 09/02/2020

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL011-204 B. WING 08/13/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
CUMMINGS COTTAGE
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000) INITIAL COMMENTS V 000

Acomplaint survey was completed on 8/13/20.

The complaint was unsubstantiated. (Intake #

NC167014). No deficiencies were cited.

This facility is licensed for the following service

category: 10A NCAC 27G .1900 Psychiatric

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

6899 YUCB11 If continuation sheet 1 of 1

STATE FORM


state: NC

facility_name: Eliada Treatment Center

summary: Statement of Deficiency - MHLCS Complaint

raw_content:
Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

CUMMINGS COTTAGE

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
MHL011-204

A. BUILDING:

B. WING

(X2) MULTIPLE CONSTRUCTION

PRINTED: 06/05/2020
FORM APPROVED

05/28/2020

STREET ADDRESS, CITY, STATE, ZIP CODE

882 ELIADA HOME ROAD

ASHEVILLE, NC 28806

(X3) DATE SURVEY
COMPLETED

(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 5/28/20.
No deficiencies were cited. The complaints were
unsubstantiated. (Intake # NC164384,
NC164621).
This facility is licensed for the following service
category: 10A NCAC 27G .1900 Psychiatric
Residential Treatment Facility.
Division of Health Service Regulation
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
STATE FORM sae QPKZ11 If continuation sheet 1 of 1

inspection_type: MHLCS Complaint

document_type: Statement of Deficiency


raw_content:
Division of Health Service Regulation

STATEMENT
AND PLAN Of

NAME OF PROVIDER OR SUPPLIER

CUMMINGS COTTAGE

OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
F CORRECTION IDENTIFICATION NUMBER:

MHL011-204

STREET ADDRESS, CITY, STATE, ZIP CODE

882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

PRINTED: 04/24/2020

FORM APPROVED
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
A. BUILDING: COMPLETED
c
B.WING 04/23/2020

(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 4/23/20.
No deficiencies were cited. The complaint was
unsubstantiated. (Intake # NC149857).
This facility is licensed for the following service
category: 10A NCAC 27G .1900 Psychiatric
Residential Treatment Facility.
Division of Health Service Regulation
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
STATE FORM 6899 PM5V11 If continuation sheet 1 of 1


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

raw_content:
Division of Health Service Regulation

PRINTED: 11/01/2019
FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL011-204 B. WING 10/15/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE
CUMMINGS COTTAGE
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, complaint and follow up survey was
completed on October 15, 2019. The complaints
were unsubstantiated (HNC00154520,
#NC00156311). No deficiencies were cited.
This facility is licensed for the following service
category: 10A NCAC 27G .1900 Psychiatric
Residential Treatment for Children and
Adolescents.
Division of Health Service Regulation
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
STATE FORM 6899 4EZV11 If continuation sheet 1 of 1

inspection_type: MHLCS Annual, Complaint, and Follow-up


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

raw_content:
Division of Health Service Regulation

CUMMINGS COTTAGE

2 COMPTON DRIVE

PRINTED: 03/15/2019
FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
MHL011-204 B. WING 02/27/2019
NAME OF PROVIDER OR SUPPLIER, STREET ADDRESS, CITY, STATE, ZIP CODE

ASHEVILLE, NC 28806

(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)

(x5)
COMPLETE
DATE

V 000

INITIAL COMMENTS

Acomplaint and limited follow up survey was
completed on February 27, 2019. The complaint
was unsubstantiated (#NC00148935). This was
a limited follow up survey, only 10A NCAC 27G
-1901 Scope (314) and 10A NCAC 27G .0205
Assessment and Habilitation, Treatment or
Service Plan (V112) were reviewed for
compliance. The following were brought back
into compliance: 10A NCAC 27G .1901 Scope
(314) and 10A NCAC 27G .0205 Assessment and
Habilitation, Treatment or Service Plan (V112).
No deficiencies were cited.

This facility is licensed for the following service
category: 10A NCAC 27G .1900 Psychiatric
Residential Treatment for Children and
Adolescents.

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

STATE FORM

V 000

6899

TITLE

(X6) DATE

TW5X11 If continuation sheet 1 of 1

inspection_type: MHLCS Complaint and Follow-up


summary: Plan of Correction - MHLCS Complaint

raw_content:
Division of Health Service Regulation
‘STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X4) ID
PREFIX
TAG

Vv ood

mm

NAME OF PROVIDEROR SUPPLIER,

CUMMINGS COTTAGE

| receive services beyond 30 days.

RECEIVED

f DHSR - Mental Health Lic. & Cert. Section at 11:10 am, Feb 04, |

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

MHL011-204

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY ORLSCIDENTIFYING. INFORMATION)

INITIAL COMMENTS

|
A complaint survey was completed on December
21, 2018. One complaint was unsubstantiated
(NC #00145299) and one complaint was
substantiated (NC #00145744). Deficiencies
were cited.

This facility is licensed for the following service
category: 10A NCAC 27G .1900 Psychiatric
Residential Treatment for Children and
Adolescents.

27G .0205 (C-D)
Assessment/Treatment/Habilitation Plan

10A NCAC 27G .0205 ASSESSMENT AND
TREATMENT/HABILITATION OR SERVICE
PLAN

(c) The plan shall be developed based on the |
assessment, and in partnership with the client or
legally responsible person or both, within 30 days |
of admission for clients who are expected to

(d) The plan shall include:

(1) client outcome(s) that are anticipated tobe
achieved by provision of the service and a
projected date of achievement;

(2) strategies;

(3) staff responsible;

(4) a schedule for review of the plan at least
annually in consultation with the client or legally
responsible person or both;

(5) basis for evaluation or assessmentof
outcome achievement; and

(6) written consent or agreement by the client or
responsible party, or a written statement by the
provider stating why such consent could not be
obtained.

B. WING

(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ___

STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE
ASHEVILLE, NC 28806

ID
PREFIX
TAG

Vv 000

v4112

(X3) DATE SURVEY
COMPLETED

c
12/21/2018

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

DEFICIENCY)

10A NCAC 27G 1901 SCOPE

DATE

Clinical case review is completed for each 11/7/2018

client on a monthly basis, at a minimum.
The review is facilitated by the assigned
linician and includes all cottage staff. The |
jocument that guides this process was
revised in October 2018, with
popiementaiion in November 2018. The
‘evised document is designed to be a “living|
document”: information is updated and
added to the original document at each
review to create a clear progression of
treatment, emerging needs and
implementation of intervention strategies.
Additionally, the revised document includes
detailed, comprehensive crisis planning.

This document was revised again in
December 2018 to include:
1. Prompt under each treatment goal
for goal revision

2. Identification of additional treatment,
needs and immediate intervention
strategies to address these needs.

3. Documentation of the next CFT

Meeting, during which the identified
goal revisions and treatment needs
will be discussed and the PCP will
be updated to reflect the
recommendations.

|The clinical case review process is
designed to elicit observations of client
behaviors and efficacy of interventions from
all staff who have engaged with each client

ind use this information to drive the formal
treatment planning that occurs in the
monthly Child and Family Team Meetings
Pra is documented on the Person-Centered
Plan.

ee

NATURE

ecto _»

TITLE (X6) DATE

08GC11

PRINTED: 01/14/2019
FORM APPROVED

12/31/2018

Hf continuation sheet 1 of 35

PRINTED: 61/14/2019
FORM APPROVED

Division of Health Service Regulation
‘STATEMENT OF DEFICIENCIES __| (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING: _

(X3) DATE SURVEY
COMPLETED

Cc
B. WING 12/21/2018

MHL011-204

NAME OF PROVIDEROR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE
IM TTAGE
Cunmiines © ASHEVILLE, NC 28806

(x4) ID | SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION 0%)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTIONSHOULDBE COMPLETE

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

DEFICIENCY)
V 112) Continued From page 1 v112 _ Eliada’s Residential Director will review 12/31/2018

each Clinical Case Review document

weekly to ensure thorough completion and

appropriate use of this documentation tool.
This responsibility will transfer to the

| ‘ Clinical Director for ongoing supervision 2/1/2019

‘effective February 2019.
This Rule is not met as evidenced by:
Based on record review and interviews the facility Person-Centered Plan development: 42/3/2018
failed to develop and implement goals and Eliada’s Clinical Director and PQI Director
strategies to address the behaviors effecting 1 of have revised Eliada’s PCP Development
3 audited clients (#1). The findings are: Guide which includes specific interventions
. for each service delivered through the
Record review on 11/28/18 for Client #1 revealed: agency and guidance for how to
| -Admitted on 10/1/18 with diagnoses of Complex | individualize and document strategies on
Post-Traumatic Stress Disorder, Major the PCP and respond to emerging needs
Depressive Disorder, and Oppositional Defiant and behavioral patterns.
Disorder (ODD). |
-Discharged on 12/11/18. Training will be provided to all Clinicians
-Age 15. - =o nd Cottage Supervisors on PCP
Referral Review Outline dated 7241 8 indicated evelopment and documentation in January/1/22/2019
...while on the inpatient unit, [Client #1] has had 2019. This training will be repeated with the
self-injurious behaviors including cutting which hire of new clinicians and QPs as part of the
required stitches and increased supervision 1:1. jonboarding process. The next training will 2nsig
[Client #1] will require a high level of structure, occur in February.
supervision and clinical support ...Presenting
Problems ...[hospital] (7/2/18-current) due to a Eliada’s Admission and Discharge 1/15/19
history of multiple suicide attempts, depression, Coordinator updates the Comprehensive
ODD and self-injurious behavior ...while in the Crisis Plan with the child and guardian
hospital setting, she has had some cutting during the admission meeting. This revised
behaviors that have required stitches ...engages document is immediately emailed to the
in verbal aggression multiple times perweek am staff f iew.
..she has endorsed SI (suicidal ideation) had has | oe ie
Jamun slg or besa pda oils [ihe program clinician presents the |
" ’ tu ’s tre it ds, hi Ft
and half a bottle of Ibuprofen") ...history of ld ileal aaah een

if inte
severe bullying both physical and verbal Set lp STC Tira l

ond aan meee trategies during the first Treatment Team
...Psychiatric Hospitalizations ...(7/2/48-Current) ‘ ‘ eel Fei
(6/25/18-6/1 1/18) ..." Meeting following admission (within 7 days).

-Intake Summary indicated an additional During this review, the direct care staff

7 Mtoe . shal tions of the student’
psychiatric hospitalization at another hospital from CE ot he nottalia es orival and

monstrated behavioral patterns and
runaway attempts ...She has been the victim of : pated benaviore aa a

STATE FORM 6809 08GC11 If continuation sheet 2 of 35

. . PRINTED: 01/14/2019
FORM APPROVED
Division of Health Service Regulation

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

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

c
12/21/2018

MHLO011-204 B. WING

NAME OF PROVIDEROR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE
ASHEVILLE, NC 28806

CUMMINGS COTTAGE

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES | PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULDBE COMPLETE
Tac | REGULATORY ORLSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
Continued From page 2 works with the staff to develop
; ' individualized strategies for engaging the
8/7/18 until placement at Eliada. student in treatment.
-Clinical Assessment update dated 6/14/18
indicated " ...Clt (client) was admitted to [hospital] ‘ _
on 5/23/18 after an attempt to commit suicide by iam ssrefin pi bined ie “ plan 2/15/19
cutting her thigh and then running away on verop| P a
5/22/18 ...Clt continued to report SI until 6/7/18 review of ;
..funning away, reports of loose of tempter, a visual/sensory strategies menu at
arguing with authority figures, anger and admission and completed with the program
resentful, and actively refusing fo comply with clinician within 24 hours in the program.
requests from authority ..."
-Client #1 also had a history of participating with Anew Safety and Prevention Plan is being | 2/15/19
self-harm cutting groups, sexting, transmitting developed. The form is trauma-focused
Pornographic photos of herself, stealing, lying, and includes sections designated for self-
Riou een tinued Stay" harm risk assessment and run prevention
ee ndum, son n i ini i i
indicated " ...[Client #1] was admitted to Eliada's Ee, Training will be Provided to 2/19/19
. 4 . ge Supervisors, Clinicians and all
all female locked PRTF (psychiatric residential Residential Staff on th d 2/20/19
treatment facility) ...on 8/16/18 ...since admission eee on ie Use an
to [locked cottage-all female] [Client #1] has implementation of the tools.
engaged in some self-harm as demonstrated by .
eating a piece of a wild mushroom, eating The Safety and Prevention Plan is 2PTN9
(amount unknown) pokeberries, scratching her maintained in the student record, and copy
arm with her finger nail, and head banging on two is located in the cottage’s Student
occasions ...continues to struggle with verbal Awareness Binder to be readily accessed
aggression ...has been hit on several occasions and reviewed by staff. This binder is
by a student ...team agreed to move [Client #1] brought to the Treatment Team Meeting
from [locked PRTF] to [unlocked co-ed PRTF] weekly to be referenced and updated by

| ..the move will also reduce bullying behavior
toward this client ..."

the Cottage Supervisor with full team input.

Eliada’s Child and Family Team Meeting

Review on 11/28/18 of the Treatment Plan for

Client #1 revealed: document and transition plan are being ad 19
-Treatment plan was created on 6/28/18 when revised to better guide interactive treatment

| Client #1 was involved in Intensive In Home planning and guardian input on the
Services and then updated on 8/3/18, 8/16/18, development of discharge plans.

9/19/18, 10/18/18 and 11/13/18.
| -"...Clt struggles deeply with earlier trauma ...Cit
reported that she was traumatized and bullied all
the time at school ...Cit shared recurrent and
persistent thoughts and impulses regarding
Division of Health Service Regulation
STATE FORM 6809 08GC11 If continuation sheet 3 of 35

Division of Health ServiceRegulation
‘STATEMENT OF DEFICIENCIES __| (X1) PROVIDER/SUPPLIERICLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

NAME OF PROVIDEROR SUPPLIER

CUMMINGS COTTAGE

(X2) MULTIPLE CONSTRUCTION
A. BUILDING: _

MHLO011-204 B. WING __

PRINTED: 01/14/2019
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

c
12/21/2018

STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE
ASHEVILLE, NC 28806

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

(x4) 1D
PREFIX
TAG

V 112 Continued From page 3

| negative images of self ...Cit self harms as
evidenced by reportings from clt and visual
extensive markings on clis arms. Cit's mom
reports that clt has scares from self harming all
over her legs ..."
-" ...Due to clt's most recent attempt of SI,
coupled with clt's report of low self-esteem and
| not liking herself, goal regarding SI to combat
‘behaviors is significantly important ...”
-Most of the treatment plan included goals
specific to Intensive In Home services that had
| been provided prior to PRTF placement.
-One goal was added to the treatment plan upon
her admission into the PRTF which was "[Client
#1] will demonstrate an improvement in
post-traumatic stress as evidenced by:
| expression of wider range of emotions, increase
in age appropriate behaviors, decrease in
experiences of dissociation, depersonalization,
de-realization, elimination of angry outbursts,
elimination of nightmares, and elimination of
intrusive recollections ..." |
-Strategies for the goal were" ...to teach coping,
pro-social, decision making, problem solving and
anger management skills. To provide behavioral
and crisis management interventions. To monitor
throughout sleeping hours. To facilitate
therapeutic leave. One staff will provide
transportation off campus as safety allows ..."
-Goal was reviewed on 10/18/18 and indicated "
..Clinician shared with team ...much of [Client
#1's] presentation since entry to [unlocked PRTF]
has been behavioral ...possible revision of goals
| in future based on ongoing presentation in the
residential milleu ..."
| -Goal was reviewed on 11/13/18 and indicated "
...[Client #1] has struggled with safety this month
with self harming behaviors. She had to be IVC'd
(involuntarily committed) today due to running into
and standing in a major road and not responding
Division of Health Service Regulation
STATE FORM

ID

PREFIX

TAG

Vv 112

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVEACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
410A NCAC 27G .0604
The Eliada Residential Treatment Care
Coordination Protocols: Crisis
Communication guide has been added to
the New Employee Pre-Service Manual.
During Eliada’s 10-day on-boarding
process, this protocol in introduced during
the Residential Service Standards section
and then reviewed during Eliada’s Incident |
Response and Reporting Training.

(x5)
COMPLETE
DATE

12/21/18

Eliada’s Procedure for Contacting Law
Enforcement and Procedure for Notifying
(Administration of Critical Incidents have |
been revised.

laaane

hese procedures have been distributed to 1/7/19
Residential Leadership, reviewed with all |
residential staff and included in the new hire
pre-service training manual.

The Crisis Communication Protocol was

leveloped and implemented. Eliada’s
Incident Debriefing Protocol has been
reviewed and revised to ensure that every
incident is reviewed with all staff involved,
facilitated by the Cottage Supervisor,
appropriately documented and reported,
and individualized crisis planning occurs
within 24 hours of the incident.

1/3/19

Eliada’s Director of Performance and
Quality Improvement will revise Eliada’s
Incident Reporting Protocols and staff
training to reflect the new roles established |
in the PRTF program and the reporting and
documentation responsibilities for each role
specific to Cottage Supervisors, Clinicians,
Residential Administrative Assistant and PQ).

2/19/19

08GC11 If continuation sheet 4 of 35

. PRINTED: 01/14/2019
* FORM APPROVED
Division of Health Service Regulation

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

(X3) DATE SURVEY
COMPLETED

Cc
12/21/2018

{X2) MULTIPLE CONSTRUCTION
A. BUILDING:

MHL011-204 B. WING

STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE
ASHEVILLE, NC 28806

NAME OF PROVIDEROR SUPPLIER

CUMMINGS COTTAGE

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

DEFICIENCY)

Continued From page 4

to police presence who were attempting to assist
her ...she continues to struggle with emotion
regulation and requires staff daily interventions ..."
-No goals or strategies to address self-harm,
suicidal ideation, elopement behavior, and
aggressive behaviors.

Review on 12/6/18 of the "Individual Crisis
Management Plans" for Client #1 revealed:

-Initial crisis plan dated 8/16/18 (when admitted to
the locked PRTF) indicated " ...Safety
Concerns-Warnings: Suicidal ideation, suicidal
attempts, self-injurious behaviors (including
cutting which required stitches) ...verbal
aggression, physical aggression ...running
behavior ..." Intervention strategies were listed as
follows: Pre-crisis: staff checks in, positive
reinforcement; Triggering: distraction techniques,
music; Escalation: manage environment, remove
trigger, remove the audience, redirection,
directive statements; Outburst: manage |
environment, proximity; and Recovery: offer
check ins, LSI (life space interview) processing.
-Update to the crisis plan was not implemented
until 11/28/18. The update indicated " ...Safety
concerns-Warnings ...attempting to place herself
in traffic, physically fighting staff ...head banging
..cratching herself with multiple items ...verbal
and physical instigative behavior (threats,
posturing), theft ...creating safety hazards (pulling
| fire alarms, exiting out of her window and setting
off alarms), property destruction (pulling drywall
away from wall, breaking a peer's reading
glasses), assaultive behavior (assaulted a peer
by striking them in the head, assaulted a staff
member unprovoked bystriking them in the head,
striking staff in the groin, biting staff) ... hoarding
self harm items ..."__ Intervention strategies were
listed as follows: Pre-crisis: staff checks in,

| positive reinforcement, validation, offer creative
Division of Health Service Regulation

STATE FORM ee00 08GC11 'f continuation sheet 5 of 35

PRINTED: 64/14/2019

FORM APPROVED
Division of Health ServiceRegulation
———
STATEMENT OF DEFICIENCIES | (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 7 COMPLETED
A. BUILDING: _
Cc
MHLO11-204 B. WING 12/21/2018
NAME OF PROVIDEROR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE
UMMINGS COTTAGE
ql 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 CORRECTIVEACTION SHOULD BE COMPLETE
TAG REGULATORY ORLSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

Continued From page 5 Vv 112

outlets and leadership opportunities; Triggering:
distraction techniques, music, proactive check
ins, time and space away from potential target or
situation, utilizing humor, neutral voice tones;
Escalation: manage environment, remove
trigger, remove the audience, redirection,
directive statements, time and space; Outburst:
manage environment, proximity, isolating her
from the remainder of the milieu, attempt
distraction techniques, reminders of her goals;
and Recovery: neutral voice tone, check in,
attempt a life space interview, increased checks,
manage room, and real talk.

Review on 11/28/18 of incident reports for
40/2018-1 2/2018 for Client #1 revealed:
-On 10/28/18 " ...Staff directed [Client #1] to
seclusion as she began to make aggressive |
threats toward her peer and bang on the window
..She began to run towards to the door to get to
her peer..."
-On 11/2/18" ...[Client #1] was in her room during
a transition and on a check she informed staff
that she had cut herself. She told staff that she
did it with her nail ..."
-On 11/5/18 " .,.Staff provided proximity as [Client
#1] socialized with her peers while in the gym and
played a card game. Staff noted [Client #1] was
in a negative space upon returning to the cottage.
Staff began to pull the robe off of [Client #1's]
neck as she attempted to choke herself. Staff
followed [Client #1] into her room once the robe
was removed. Staff provided real talk to[Client
#1] as she began to pick up another article of
clothing and wrap it around her neck ..."
-On 11/12/18" ...she (Client #1) came out of the |
bathroom holding her arm. Staff called nursing to
| check in ...she self harmed due to feeling afraid

of her peer...”
-On 11/13/18 "...Staff transitioned [Client #1] to
Division of Health Service Regulation
STATE FORM e800 08GC11 If continuation sheet 6 of 35

Division of Health Service Regulation

PRINTED: 01/14/2019
FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL011-204 B. WING _

(X2) MULTIPLE CONSTRUCTION

-

NAME OF PROVIDEROR SUPPLIER

CUMMINGS COTTAGE 2 COMPTON DRIVE

ASHEVILLE, NC 28806

(X3) DATE SURVEY
COMPLETED

c
12/21/2018

STREET ADDRESS, CITY, STATE, ZIP CODE

SUMMARY STATEMENT OF DEFICIENCIES. | ID
{EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX
REGULATORY ORLSC IDENTIFYING INFORMATION) TAG

(X4) 1D
PREFIX
TAG

CROSS-REFERENCED TO THE APPROPRIATE

PROVIDER'S PLAN OF CORRECTION (Xs)
(EACH CORRECTIVE ACTION SHOULD BE | COMPLETE
DATE
DEFICIENCY)

V 112) Continued From page 6

English class. [Client #1] refused to sit down
because she did not like her new seat ...began to
yell at staff ...she refused to follow the prompt
...She threw a pencil at her target peer ...[Client
#1] and her peer stood up and began to walk
towards eachother ...[Client #1] stated that she
was going home, and walked out of the academy
...walked off campus and along the highway.
Staff used directive statements when [Client #1]
walked into the middle of a lane and stopped.
Staff observed cars swerve and nearly hit [Client
#1] and another car as she did not move. Staff
stepped into the road and used their bodies as
barriers to attempt to keep [Client #1] from
moving further into the highway. [Client #1]
continued to push staff into on coming traffic as
she attempted to push past staff to jump in front |
of moving vehicles. Police responded and helped
staff by restraining [Client #1]. Staff and police
used their bodies as a barrier together as [Client
#1] continued to push into on coming traffic.
Additional police responded and hand cuffed
[Client #1] for her safety and others. [Client #1]
was detained in the police vehicle while 1VC was
being submitted. Police transported [Client #1] to
the hospital ..."
-On 11/20/18 at 10:40am " ...[Client #1] |
threatened to slap her peer in the face ...[Client
#1] stood up and hit her peer on the neck ..."
-On 11/20/18 at 3:00pm " ...[Client #1] began to
call her peer a b***h. Staff provided a barrier as
[Client #1] and her peer began to slap each other

| in the face. Staff provided a barrier again as she

| attempted to charge at her peer once the peer
had walked away ...”
-On 11/20/18 at 4:00pm " ...Staff noted [Client #1]
began to superficially self harm and then went to
the bathroom. Staff conducted increased checks
...came out of the bathroom after self harming ..."
-On 11/22/18 " ...she had a towel wrapped around

Vv 112

Division of Health Service Regulation
STATE FORM

08GC11

if continuation sheet 7 of 36

PRINTED: 01/14/2019
FORM APPROVED
Division of Health Service Regulation

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

c
MHLO011-204 B. WING ______________ 1212112018
NAME OF PROVIDEROR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE
ASHEVILLE, NC 28806

CUMMINGS COTTAGE

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVEACTIONSHOULDBE COMPLETE
TAG REGULATORY ORLSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
—_|—
V 112, Continued From page 7 Vv 112

her left arm ...she harmed due to not being with |

her grandparents for thanksgiving ...she harmed
herself by using her fingernail ..."

-On 11/26/18 " ...[Client #1] raised her voice and

began to target the teacher ...Staff used their |
bodies to separate [Client #1] from target staff as
[Client #1] entered target staff's space ...Staff
used their bodies to attempt to block [Client #1]
as she reached around them to strike target staff |
with an open hand ...pushed against them to hit |
target staff again ...attempted to initiate a
standing restraint as [Client #1] hit staff a third
time ...Staff redirected [Client #1] when she
picked up the teacher's grade book. Staff
attempted to take the grade book from [Client #1] |
and provided a firm directive when [Client #1] bit
their wrist ...she took a piece of plastic off the
teacher's desk and attempted to self-harm with it |

-On 11/27/18 " ...Staff blocked [Client #1] from
her peer as she stated that "I'm going to go down
there and punch him". Staff followed as [Client
#1] ran past staff to grab her peer that was self
harming. Staff directed [Client #1] to release her
peer ...Staff then attempted to place a head board
between [Client #1] and the wall as she began to
head bang ...[Client #1] began to then hit staff
with an open hand and grab their arms...[Client
#1] sat down and began to self harm by
reopening her wounds and sticking her fingers |

inside ..."

-On 12/3/18 " ...[Client #1] became escalated
during the nightly reflection with her peers.

[Client #1] yelled instigative comments down the |
opposite hall. [Client #1] encouraged her peers

to join. [Client #1] pushed against staff to get to
her targeted peer. [Client #1] hit staff resulting in

a restrictive intervention ..."

-On 12/4/18 " ...Staff redirected [Client #1] for
targeting a peer ...she began to scream and
Division of Health Service Regulation

STATE FORM esee 08GC11 If continuation sheet 8 of 35

———

° PRINTED: 01/14/2019
FORM APPROVED
Division of Health ServiceRequlation

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

(X3) DATE SURVEY

(X2) MULTIPLE CONSTRUCTION
COMPLETED

A. BUILDING:

c
12/21/2018

MHL011-204 B. WING

NAME OF PROVIDEROR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE
CUMMINGS COTTAGE
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 CORRECTIVEACTION SHOULD BE COMPLETE
TAG REGULATORY ORLSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

Vv 112 Continued From page 8 Vv 112

posture at this peer ...got up and exited the |
cottage ...she approached the road ...transitioned
to a standing restraint ...staff released the
restraint when a staff member was hurt. Staff
continued to follow [Client #1] and lost eye sight
of her briefly when she darted across the road in
to [drug store]. Staff re-gained eyesight of [Client
#1] once entering [drug store]. Staff kept distant
proximity when she yelled at staff to keep their
distance. Staff lost eyesight of [Client #1] again
briefly when she ran out of [drug store]. Staff
te-gained eyesight ...Staff followed [Client #1]
until [restaurant] before losing eyesight as she
ran across the highway towards [liquor store].
Staff attempted to search for her within the area
she was last sighted. Staff returned to campus
and filed missing persons report. Staff returned |
[Client #1] to the cottage a few minutes later ...""_|
|

Review on 11/28/18 of the Nursing notes from
10/1/18-12/4/18 for Client #1 revealed: |
-On 10/17/18 " ...[Client #1] was hit in the back of
the head by a peer. She does not have a
hematoma ...Neurological assessment WNL
(within normal limits) ..."

-On 10/20/18 " ...Student self harmed her R
(right) inner arm on the 19th, has light brown
abrasion. This evening 10/20 she self harmed
her L (left) inner wrist by ripping off light outlet
cover and has red opening area. Did not allow
RN (registered nurse) to cleanse the area and
apply antibiotic oint (ointment) ..."

-10/29/18 " ...Student participated in mild head
banging per staff and in the cafeteria ..."

-11/1/18 " ...New superficial self harm to left
forearm. | horizontal scratch in middle of anterior
forearm, approximately 1.5 inches. Done with
fingernail ..."

-11/12/18 " ...Staff reported to this RN that she
had self harmed. Upon assessment, student had |
Division of Health Service Regulation

STATE FORM 6800 08GC11 If continuation sheet 9 of 35

PRINTED: 01/14/2019
FORM APPROVED

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

(X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
A. BUILDING: COMPLETED

Cc
MHLO11-204 8. WING 12/21/2018
NAME OF PROVIDEROR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE
MMI ITTAGE

CUMMINGS COTTAG! ASHEVILLE, NC 28806

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION ) &s)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULDBE COMPLETE

TAG REGULATORY ORLSCIDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
| DEFICIENCY)
V 112) Continued From page 9 | v112
acut ~1 "long. She had used a piece of plastic
"

-11/20/18 " ...[Client #1] was escalated and went
to the bathroom ...she had several cuts to
bilateral thighs, had pulled the scab off of a
wound to her right forearm and several cuts to
her left forearm ...[Client #1] stated she used a
piece of plastic that she acquired while in school
..during med pass student reported that she had
cut her left forearm 2 more times ...student also
confessed that she stole a part from a
gameboard and broke it then used the part to cut
herself ..."
-11/22/18 " ...Staff reported that [Client #1] had
cut her left FA (forearm) again (on the lateral wrist
area) ...1 " wound (which was new) wasopen
... This had been done on the same FA that she
had cut on on 11/20/18 ..."
-11/27/18 " ...student head banging ...picking at
her old self harm scabs ...she is reopening scabs
...the wounds are not actively bleeding ..wounds
approx. % in width and 1/2cm in depth.” |
-12/4/18" ...She banged the back of her head
against a wall approximately 10-12 times ..."
-12/4/18 "Student asked to have nursing check in
with her when | arrived at the cottage to see
another ...| checked in with [Client #1] at approx.
2:45pm. During this conversation, she stated that | |
she ran from campus earlier today and went to |
[local pharmacy]. She stated that while in [local
pharmacy] a man approached her and asked her
if she was okay and asked her to step outside.
[Client #1] stated that Eliada staff came at that
time and she left [local pharmacy] with Eliada
| staff. [Client #1] then stated that once she left the
{local pharmacy] she ran from staff and into a
forest. She states that the man from the store
followed her and raped her in the forest. Bruising
and scratches were noted on the backs of [Client
#1's] upper arms bilaterally. [Client #1] was
Division of Health Service Regulation
STATE FORM 6809 08GC11 If continuation sheet 10 of 35

PRINTED: 01/14/2019

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING: =
Cc
F MHL011-204 BeWING 12/21/2018
NAME OF PROVIDEROR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE
CUMMINGS COTTAGE
ASHEVILLE, NC 28806
(xa) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIK (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY ORLSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 112, Continued From page 10 Vv 112

informed that since she was reporting that she
had been raped that she would likely be sent to |
the ER (emergency room) and that | needed to
check with administration. She was also
instructed to not take a shower, to which [Client
#1] repolied, "But | feel icky”. | explained to her
the reason for not taking a shower due to

| collecting evidence since she stated that she was
raped ...| left the cottage and reported this
conversation to my supervisor, and then returned

| to [cottage] at approximately 3:30pm to find
[Client #1] in the shower. While in the cottage |
received a message that [Client #1] would be
going to the ER, so staff and | collected her |
clothing and put the items in a bag. [Client #1]
then refused to go to the ER and asked to speak
with her mother. When [Client #1] was off the |
phone with her mother, | was asked to speak with
[Client #1's] mother ...her mother asked me why |
had not called the police. | explained all of the
above as it started at 2:45pm and [Client #1] was
going to the ER but now refusing. | explained to
her that | would be glad to call the police, but had
not yet had time ...I reported this entire incident to
[Residential Director] and [Lead RN]."

Review on 12/4/18 of the daily service notes for
Client #1 revealed:
-On 10/11/18" ...a peer began to make instigative |
remarks ....threw her shoe at the peer...became
escalated again when her peer began to instigate
her again ...ran after the peer ...attempt to push |
past the teacher ...[Client #1] was attempting to
get through the door to her peer while
communicating verbal threats to "punch him in
the face" and "beat his a*s" ...staff observed
[Client #1] run behind staff to reach the target |
peer ...[Client #1] strike her peer in the head with
a closed fist approximately 4 times ..."
_On 10/15/18 " ...[Client #1] became verbally |
Division of Health Service Regulation
STATE FORM Lad 08GC11 'f continuation sheet 11 of 35.

PRINTED: 01/14/2019
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES: (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHLO11-204 B.WING 12/21/2018
NAME OF PROVIDEROR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE
CUMMINGS COTTAGE
s ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x8)
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 112) Continued From page 11 | v112 |

aggressive and brought up previous crisis in
which she hit the target peer. [Client #1]
referenced the incident to threaten the target peer
and made several instigative statements. [Client
#1] struggled to disengage despite her peer
disengaging ..."

-On 10/17/18 " ...Staff transitioned [Client #1] to
the cafeteria for lunch and heard her instigate
peers from another cottage and was not receptive
to redirection. Staff noted [Client #1] stood up

and walked towards the other cottage's table and
begin to yell ...Staff stood in between [Client #1] |
and her peers as she threw punches over staff at
her peers ...her hair was pulled and she was
punched in the head by a peer..."

-On 10/20/18 " ...she stated that she broke a
faceplate off in her restroom ...she stated that
herself harm did not do what she wanted, she
expanded on this and said "she wanted to bleed |
out” ...she spat at staff. Staff redirected her
negative relations with her peers and staff..."
-On 10/21/18 " ...Staff noted [Client #1] had
ripped the drywall off of the wall and had pulled a
screw out ...began to engage in property
destruction in the interest of finding self harm
items ..."

-On 10/23/18 " ...Staff observed [Client #1] disrupt
the milieu numerous times .,.Staff observed
[Client #1] tear apart a plastic cup ...proceeded to
barricade in the rest room with a sharp piece of
the plastic cup. Staff used their body to block the
door from being shut completely and maintained
eyesight ...neutral staff redirected [Client #1] for |

secretive behavior and listened as she cursed at |
staff and eluded becoming physically aggressive
by referencing a past incident in which a student |

hit a staff..."

-On 10/28/18 " ...she began to make aggressive |

threats towards her peer and bang on the window)

..pushed past staff to open the door ...” |
Division of Health Service Regulation
STATE FORM e890 08GC11 If continuation sheet 12 of 35

° PRINTED: 01/14/2019
FORM APPROVED

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

(X3) DATE SURVEY
COMPLETED

c
12/21/2018

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

MHLO011-204 B. WING

NAME OF PROVIDEROR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE
ASHEVILLE, NC 28806

CUMMINGS COTTAGE

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (5)
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 112) Continued From page 12

-On 11/1/18 " ...when a peer then began to

engage her about her behaviors, [Client #1] once |
again became escalated. She began to make
very aggressive statements and insult both staff

and her peers ..." |
-On 11/7/18 " ...[Client #1] struggled with
boundaries while throwing books at her peer
.-Struggled with unfamiliar staff when they
pronounced her name wrong multiple times,
beginning to snap and threaten them if they called
her name wrong one more time ...struggled
throughout the shift with inappropriate, vulgar,
sidebar conversations with her peers ..."

-On 11/10/18 " ...She became upset with a peer
after being called a b***h ...she quickly
transitioned to her room brought glasses out and
bent them in half and threw them on the floor
...Staff quickly stood between her and a peer as
she became escalated by throwing markers at
the peer ..."

-On 11/12/18" ...Staff redirected her for poor |
physical boundaries and being passive
aggressive toward a peer ...she demonstrated

verbal aggression toward a peer receiving help
from the teacher as she struggled to wait ..."

-On 11/14/18 " ...[Client #1] struggled with
boundaries with her peers ...struggled when her
peer was in crisis at the end of the night, yelling
and screaming on the hallway ...”

-On 11/19/18 " ...Staff heard [Client #1] make
instigative statements to her peer ...with
statements such as "if you have something to say
to me, say it to my face" ...showed poor impulse
control by once again indulging in her peers
negativity ..."

-On 11/20/18 " ...Staff used directive statements
when [Client #1] invaded a peers boundaries and
hit them ...[Client #1] argued and called staff a
"p**h" ...Staff redirected [Client #1] as she began
to call her peer a "b***h". Staff provided a barrier
Division of Health Service Regulation

STATE FORM e809 08G6C11 If continuation sheet 13 of 35

PRINTED: 04/14/2019
FORM APPROVED
Division of Health ServiceRegulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA. (X2) MULTIPLE CONSTRUCTION
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

(X3) DATE SURVEY
COMPLETED

Cc
MHLO011-204 B. WING ___ 12/21/2018

NAME OF PROVIDEROR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE
CUMMINGS COTTAGE ASHEVILLE, NC 28806

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

TAG | REGULATORY ORLSC IDENTIFYING INFORMATION) TAG | CROSS-REFERENCED TO THE APPROPRIATE

DEFICIENCY)

V 112) Continued From page 13 Vv 112

as [Client #1] and her peer began to slap each |
other in the face. Staff provided a barrier again

as she attempted to charge at her peer once the
peer had walked away ...[Client #1] began to
superficially self harm ...came out of the
bathroom after self harming ...expressed suicidal
ideation ..."

-On 11/21/18 " ...[Client #1] made negative
comments about a certain peer which amounted
to bullying behaviors. She was not very receptive |
to redirection ...when redirected [Client #1] began
to talk back to staff and even threaten to slap
them in the face ..."

-On 11/26/18 " ...Staff redirected (Client #1] for
bullying behaviors towards a specific peer ...staff
redirected [Client #1] for calling staff a "b***h"
..Staff used directive statements when [Client #1]
continued to engage in bullying behaviors
..began to make threats ...[Client #1 began to
target a specific staff ... make aggressive threats
toward this staff ...continued to call this peer
names like "squirrely b***h" ...engaged in
practicing restraints with her peers ..."

Interview on 11/28/18 with Client #1 revealed:
-She saw the nursing staff twice daily. She had
seen the Physician's Assistant as needed.
-Most nights the nurses checked her skin for
cuts.

-She got along pretty well with her peers.

-She had hit a peer.

-She stated that Client #2 made sexual remarks
to her and she slapped him. She added that
Client #2 had hit her first.

-She stated that she had advocated for the |

boundary plan that was put in place for her and
| Client #2. |
-She had to restrain another client because staff | |

would not help him.

-She stated that on the day she ran into the road
Division of Health Service Regulation
STATE FORM 5800 08GC11 If continuation sheet 14 of 35

. PRINTED: 01/14/2019
FORM APPROVED

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

(X3) DATE SURVEY
COMPLETED

Cc
12/21/2018

(X2) MULTIPLE CONSTRUCTION
A, BUILDING:

MHL011-204 B. WING

NAME OF PROVIDEROR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE
ASHEVILLE, NC 28806

CUMMINGS COTTAGE

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACHCORRECTIVE ACTION SHOULDBE COMPLETE

TAG REGULATORY ORLSCIDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

Continued From page 14

she did so because Client #2 was threatening to
kill her and she had to leave. She would not
discuss details of that incident.

| Interview on 11/29/18 with Client #2 revealed:
-He had been a resident of the cottage for one
and half months.

-He stated it "was not the best" and that there
“was a lot of bullying".

-He stated that there was a crisis every day.
-He had engaged in one fight with Client #1.
Client #1 called him a name, he called her a
name, she slapped him and he hit her. She hit
him again. Staff were actively trying to break it
up.

-He stated that he did not feel safe around her |

-Staff had implemented a boundary plan for he
and Client #1 which restricted their contact and
kept them separate.

-He stated that Client #1 hit one other client and
almost fought another.

Interview on 11/29/18 with Client #3 revealed:
-She had been a resident of the cottage for 4
months.

-She had been targeted and bullied. She
indicated that staff do what they can.

-She did not feel safe around some peers.
-Client #1 had hit her in the head. Client #1 made
threats and followed through on her threats.

Interview on 12/4/18 with Residential Counselor
#1 revealed:
-She worked second shift.

| -Client #1 had poor boundaries with everyone.

| -A boundary plan was implemented for her and |
Client #2 due to concerns regarding their

| interactions. The plan limited contact, proximity
and activities. Client #1 was consistently

Division of Health Service Regulation

STATE FORM bead 08G6C11 If continuation sheet 15 of 35

PRINTED: 01/14/2019
FORM APPROVED
Division of Health ServiceRegulation

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

Cc
12/21/2018

B.WING

MHLO011-204

NAME OF PROVIDEROR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE

CUMMINGS COTTAGE ASHEVILLE, NC 28806

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACHCORRECTIVEACTION SHOULD BE
TAG REGULATORY ORLSCIDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE

DEFICIENCY)

V 112) Continued From page 15

non-compliant with the boundary plan.

-Client #1 "had created a culture where no one
likes him (Client #2)."

-There were times that Client #1 and Client #2

threatened each other. There was a lot of verbal

aggression. |

-Having Client #1 in the milieu was extremely
negative and had caused a "great deal of anxiety"

for other clients. She stated that the other clients
did not know how to separate themselves from |

her. She further added that she thought that
some of the clients were afraid of being targeted
by her.
-In the cottage, Client #1 would pick her target |
and instigate arguments with them. She had
managed to pull other peers into a negative |
space even when they have tried to stay on task. |
-Increased supervision was implemented for

Client #1 at times when she self-harmed.
| -Strategies used in the milieu were isolation from |
peers, boundary plans, taken choice time, and |
real talk approach.
-She was present during the incident that
occurred on 11/5/18. Client #1 was upset about
Client #2. She thought "he looked sad." She was
present and intervened when Client #1 used |
clothing items to try and choke herself. She
redirected Client #1 who immediately stopped.
She was not injured and immediately wanted to
rejoin her peers. |
-She was present for the incidents that occurred
on 11/20/18. Client #1 tried to provoke Client #2. |
She initiated verbal aggression and then it turned |
physical. Staff were acting as a barrier. Client #2
| disengaged. Later on the same date Client #1

engaged in self-harm. She had stolen and hid a |

piece of a game and used it to cut herself.
Nursing staff were involved and her room was
searched.

Division of Health Service Regulation
STATE FORM ‘e500 08GC11 if continuation sheet 16 of 35

PREFIX
TAG

Vv 112

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDEROR SUPPLIER

CUMMINGS COTTAGE

| -"She made it hard for a lot of people to focus on

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

MHL011-204

B. WING

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

2 COMPTON DRIVE

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORYORLSCIDENTIFYING INFORMATION)

ASHEVILLE, NC 28806

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

STREET ADDRESS, CITY, STATE, ZIP CODE

Continued From page 16

Interview on 11/29/18 with Residential Counselor
#2 revealed:

-She worked second shift.

-On shift there were 4 staff uniess a code was
called which would reduce their staffing to 3
temporarily.

-Client #1 changed the milieu. She had poor
boundaries and acts out when she doesn't get her
way.

-She was non-compliant with the boundary plan
put in place with Client #2. The boundary plan
was established when inappropriate notes of a
sexual nature were found.

-Since in the cottage she had punched Client #3
four times in the head, almost fought Client #2
and had threatened to hit staff.

-Client #1 participated in bullying, did a lot of
whispering and was "influential in the milieu."
She stated that Client #1 would make a big deal
out of anything.

-The behaviors of Client #1 changed the milieu
and “added drama."

-Other clients were afraid to go against her.

their treatment."

-Staff would isolate Client #1 and engage in "real
talk" or take her choice time for bullying
behaviors.

-The clients were checked every 10 minutes and
checks were increased when self-harm occurred.
Staff also sat in hallways with eyes on if needed.
-Nurses checked in with Client #1 for her
self-harm.

-Rooms were searched randomly once per week.

Interviews on 11/28/18 and 12/4/18 with the
Cottage Supervisor revealed:

-Life Space Interviews were attempted with Client
#1 in response to her self-harm but many times
she refused. Staff would present alternative

Division of Health Service Regulation
STATE FORM

08GC11

PRINTED: 01/14/2019
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
12/21/2018

lf continuation sheet 17 of 35

PRINTED: 01/14/2019
FORM APPROVED.
Division of Health Service Regulation

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

c
MHL011-204 B. WING _______ 12/21/2018

NAME OF PROVIDEROR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE
ASHEVILLE, NC 28806

‘SUMMARY STATEMENT OF DEFICIENCIES iD | PROVIDER'S PLAN OF CORRECTION

(EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVEACTIONSHOULDBE

REGULATORY ORLSCIDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

CUMMINGS COTTAGE

V 112) Continued From page 17

options to self-harming but she did not want other |
options. Staff would attempt to process with her

when she was in a negative space but she would

resort to self-harm. |
-A boundary plan was implemented for Client #1

and Client #2 after they had passed notes of a

sexual nature. |

Client #1 and Client #2 had assaulted each
other. Staff have had to block Client #1 from
engaging physically with Client #2. |
-Client #1 tried to draw other clients in her
negative space and would instigate negative
behavior in the cottage. |
-Client #1 was moved from another campus
| cottage due to safety. She had been targeted by
a peer in that cottage.
-Client #1 would try to add “gas on the flame of
anything.” Most of the time Client #1 was the
aggressor in the cottage. He indicated that for |
the first week in the cottage she flourished but |
after that she "asserted herself as the alpha" and
tried to instigate multiple peers. He indicated that |
Client #1 had a completely negative effect in the
cottage. She encouraged peers not to talk to
staff and hurt the staff's ability to build rapport
with other clients. |
-He indicated that the milieu had "become nearly
unmanageable." The majority of the clients were
experiencing depression and anxiety. He added |
that Client #1 encouraged a culture of being
non-compliant with staff. He stated that he wasn't |
sure where to go with her.
| -He indicated that usually when clients entered |

| the cottage a support plan/safety plan was
created and signed by the client.
-The system in the cottage was strength based
and motivators/rewards were put in place. Staff |
tried to nurture positive coping skills and teach |
new skills.
-Client #1 would hoard items to use for self-harm. |
Division of Health Service Regulation
STATE FORM ‘Om. 08GC11 If continuation sheet 18 of 35

: PRINTED: 01/14/2019
. FORM APPROVED
Division of Health Service Regulation

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

(X3) DATE SURVEY
COMPLETED

Cc
12/21/2018

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

MHL011-204 B. WING

NAME OF PROVIDEROR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
coTT, 2 COMPTON DRIVE
CUMMINGS ee ASHEVILLE, NC 28806

x4) ID | SUMMARY STATEMENT OF DEFICIENCIES ] ID PROVIDER'S PLAN OF CORRECTION (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)

Continued From page 18

-In the cottage, clients were monitored every 10
minutes or more frequently if self-harm had
occurred,

-Random search and seizures were conducted
weekly and staff monitored and tried to process
with Client #1. She was kept in eyesight if she
had any object to use for self-harm and staff
would try to remove the item.

Interviews on 11/29/18, 12/5/18, and 12/6/18 with
the Clinical Director revealed:
-When admitted to the current cottage Client #1
had a therapist assigned. He was injured and
was no longer employed at the agency. Client #1
had a temporary therapist assigned to her while
the agency hired another therapist.
-When a student engaged in self-harm the
Clinician was notified. The Clinician would
assess the need for increased supervision and
review strategies with staff.
-Support/Safety plans identified what was needed)
to support each client and what the client would |
also do. These plans were kept in the cottage.
She did not know how this was implemented for
Client #1.
-Every week the team addressed the behaviors
exhibited by each client to include triggers and
strategies to address the behaviors.
-If a client was non-compliant with a boundary
plan that was in place then the Leadership team
can meet with that client to review. Next steps
would be considered to ensure safety. She did
not know if this was done for Client #1.
-Intensive in home (IIH) services were in place for
Client #1 prior to her admission to the PRTF

| (psychiatric residential treatment facility). The
agency that provided the IIH service revised the
treatment plan and added the goal to be

| addressed when she was admitted to the PRTF.
The initial therapist that worked with Client #1

Division of Health Service Regulation

STATE FORM 6880 08GC11 If continuation sheet 19 of 35

PRINTED: 04/14/2019
FORM APPROVED

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: AL BUTIDING:

(X3) DATE SURVEY
COMPLETED

c
12/21/2018

MHLO011-204 B. WING

NAME OF PROVIDEROR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE
UMMINGS COTTAGE
¢ ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX {EACH CORRECTIVE ACTION SHOULDBE COMPLETE
TAG REGULATORY ORLSCIDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE. DATE

DEFICIENCY)

V 112, Continued From page 19

completed the first update to the treatment plan
and then she completed the most recent update.
-Neither time the treatment plan was updated
were goals or strategies added to address the
self-harm, aggression or elopement behaviors of
Client #1.
| -Her understanding was that goals in the
treatment plan were related to diagnosis only.
-She indicated that she had been instructed that
the treatment plan could not be individualized
because of how it was set up in their computer
system.
-The treatment plan was treated as an
authorization form only.
-She stated that neither the staff nor the therapist
saw the treatment plans.
-The Licensee was currently in the process of
changing the entire person centered plan process
to ensure interventions were more individualized.
She indicated that their entire system was being
revised.

Interview on 12/5/18 with the Lead RN revealed:
-For any clients who self-harmed random or daily
| body checks were conducted.

-Body checks were documented on the MAR
(medication administration record) and conducted
by nursing staff. If there was a history of
self-injurious behavior body checks were
implemented upon admission. Frequency of

body checks were conducted on an individualized
basis. |

-Daily body checks were determined to be
necessary for Client #1 due to significant
self-harm. The body checks were conducted and
documented for Client #1. | |

Interview on 12/5/18 with RN #1 revealed:

-On 12/4/18 she was contacted at approximately
2:45PM by cottage staff and informed that Client
Division of Health Service Regulation

STATE FORM aa 08GC11 ff continuation sheet 20 of 35

. PRINTED: 01/14/2019

° FORM APPROVED
Division of Health Service Regulation
‘STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA {X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

COMPLETED

c
12/21/2018

AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

A. BUILDING:

MHL011-204 8, WING

NAME OF PROVIDEROR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE
ASHEVILLE, NC 28806

CUMMINGS COTTAGE

(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (%5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULDBE COMPLETE
TAG REGULATORY ORLSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

Continued From page 20

#1 wanted to check in with her.

-Client #1 informed her that she had run away

and gone into a local pharmacy. She indicated

that after walking out of the pharmacy with staff
that she ran off and a man who had spoken to
her in the pharmacy followed her into the forest
and raped her in the forest.

-She indicated that she told Client #1 that she

needed to look at the policy but that she would

need to go to the emergency room and have a

tape kit conducted. She advised Client #1 not to

shower and had Client #1 agree not to shower.

-She consulted the Lead RN who stated that she

would notify the Administration. She was

instructed to take Client #1 to the emergency
room.

-She returned to the cottage at 3:30pm and Client

#1 was in the shower. She collected her clothing

to the take to the emergency room. Client #1 was

refusing at this time to go to the emergency room
and wanted to call her mother. Client #1 then
called her mother.

| -At approximately 4:00PM when Client #1 was on
the phone her mother requested to speak to the
RN and questioned why the local police had not
been contacted. The nurse indicated that she
informed Client #1's mom about the entire
scenario and that they planned to take Client #1
to the emergency room. She indicated that she
also informed Client #1's mother that Client #1
had destroyed any possible evidence by
showering. She indicated that she talked to the
Residential Director following her phone call with
Client #1's mother.

-After the phone call Client #1 agreed to go to the
emergency room. She called ahead to the
emergency room to inform them of the situation.

| -She indicated that the emergency room collected
evidence and informed the police at that time.
-She did not make a police report.

Division of Health Service Regulation

STATE FORM ‘6890 08GC11 If continuation sheet 21 of 35

PRINTED: 01/14/2019
FORM APPROVED
Division of Health ServiceRegulation

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

(X2)} MULTIPLE CONSTRUCTION
A, BUILDING: _

(X3) DATE SURVEY
COMPLETED

Cc
12/21/2018

MHL011-204 B.WING

NAME OF PROVIDEROR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE

CUMMINGS COTTAGE ASHEVILLE, NC 28806

(x4) ID | SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTIONSHOULDBE
TAG REGULATORY ORLSCIDENTIFYINGINFORMATION) TAG (CROSS-REFERENCED TO THE APPROPRIATE

DEFICIENCY)

V 112) Continued From page 21

-At approximately 5:00PM Client #1 went to the
emergency room.
-She stated that when Client #1 eloped she was
barefoot and in her pajamas. Upon her return
she did not observe Client #1 to have any leaves
or debris on her clothing to indicate she had been
on the ground in the forest. She observed

| scratches on her upper arms but indicated Client |
#1 self-harmed.
-She stated that she had 20 years' experience in
the emergency room and had worked with rape |

victims.

Interview on 12/19/18 with the Local Law
Enforcement Detective revealed: |
-On 12/4/18 at 4:25PM the guardian of Client #1 |

| reported to law enforcement that Client #1 had
run away from the facility and had been raped.
-He indicated that no one from the facility had |
contacted law enforcement. He stated that the
allegation should have been reported to local law
enforcement.
-He stated the allegation was very vague and in |
order to move forward with the investigation a
forensic interview with the victim (Client #1) would
have to be conducted. He indicated that the

| guardian of the victim was afraid to have that |
interview conducted due to her prior self-injurious
behavior.

Interviews on 11/29/18 and 12/5/18 with the

Residential Director revealed:

-He received the call from RN #1 about the

allegations of rape made by Client #1 on 12/4/18.

At that time RN #1 was getting things in place for

her to be taken to the hospital. This RN had a lot

| of emergency room experience and experience
working with rape victims. She had directed
Client #1 not to remove clothing or shower before
going to the emergency room. The nurse also

Division of Health Service Regulation

STATE FORM e809 08GC11 if continuation sheet 22 of 35

. PRINTED: 01/14/2019
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

c
12/21/2018

B. WING

MHL011-204

NAME OF PROVIDEROR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE
ASHEVILLE, NC 28806

CUMMINGS COTTAGE

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

V 112 Continued From page 22

advised the staff of those procedures, however,
Client #1 was non-compliant and took a shower.
-The RN advised that the police would be called
upon her admission to the emergency room.

-It was his understanding that Client #1's mother
contacted the police around 5:30-6:00PM and
told the police that Eliada was refusing to report a
rape.

-Local law enforcement came to the campus after
receiving the call from Client #1's mother. The
officer questioned why Eliada had not called to
make a police report and he advised the officer
that they were following nursing protocols.

-The Officer stated that law enforcementshould
have been immediately notified because a child
was involved.

-He indicated that he felt it was a medical issue
and followed the nursing recommendation. They
wanted to get Client #1 in one place so that all

needed professionals could evaluate the |
situation.

This deficiency is cross referenced into 10A
NCAC 27G .1901 Scope (V314) for a Type A1
tule violation and must be corrected within 23
days. |

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

Division of Health Service Regulation
STATE FORM e800 08GC11 If continuation sheet 23 of 35

PRINTED: 01/14/2019
FORM APPROVED
Division of Health Service Regulation

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ____

(X3) DATE SURVEY
COMPLETED

c
12/21/2018

MHL011-204 B.WING

NAME OF PROVIDEROR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE
CUMMINGS COTTAGE 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 (EACHCORRECTIVEACTION SHOULD BE COMPLETE
TAG REGULATORY ORLSCIDENTIFYING INFORMATION) TAG (CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

V 132) Continued From page 23

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 propertyof a |

healthcare facility. |
| d. Diversion of drugs belonging to a health care |

facility or to a patient or client. | |

e. Fraud against a health care facility or against |

a patient or client for whom the employee is |

providing services).

Facilities must have evidence that all alleged

acts are investigated and must make every effort |

to protect residents from harm while the

investigation is in progress. The results of all

investigations must be reported to the |
| Department within five working days of the initial |

notification to the Department. |

| This Rule is not met as evidenced by: |
Based on record review and interviews the facility
failed to report the results of their internal
investigation of abuse by a staff member to the |
Health Care Personnel registry within five working
days of the initial notification to the Department.
Division of Health Service Regulation
STATE FORM S090 0sGc11 I continuation sheet 24 of 35

; PRINTED: 01/14/2019
* FORM APPROVED
Division of Health ServiceRegulation

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

(X3) DATE SURVEY
COMPLETED

Cc
12/21/2018

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

MHLO11-204 B. WING

NAME OF PROVIDEROR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE
ASHEVILLE, NC 28806

CUMMINGS COTTAGE

(X4) 1D 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 ORLSCIDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

Continued From page 24

The findings are:

Review on 11/28/18 of the incident reports for
Client #1 revealed:

-On 10/31/18 " ...The consumer attended Eliada's
Halloween event. During the event she engaged
in off-task and disruptive behavior with her peers.
Staff reviewed the behavioral expectations for the
activity and provided verbal redirection to the
consumer to engage appropriately. The
consumer reacted with defiance and yelled,
"Well, you are a pedophile so | don't have to listen
to you" in front of staff and peers ...Residential
Director was notified of her statement and met
with the consumer. She reported to the
Residential Director at this time that the targeted
staff allegedly "rubbed his penis on her butt" on
several occasions ..."

-Level III Incident report was submitted through
the IRIS (Incident Response Improvement
System) system. This report included notification
to the Health Care Personnel Registry.

Review on 11/28/18 of the Internal Investigation
report revealed:

-Residential Counselor #4 was sent home from
his shift immediately following the allegation.
-Administration met with Residential Counselor
#4 the next morning, obtained his statement and
he was removed as a direct care staff and
assigned administrative duties.

-DSS report made 11/1/48.

-Internal investigation completed.

Interview on 12/13/18 with the Director of
Performance/Quality improvement revealed:
-She indicated this notification was her
responsibility and she had failed to submit their
| findings. |
-She knew that the 5 day report should have been
Division of Health Service Regulation
STATE FORM 6880 08GC11 If continuation sheet 25 of 35

PRINTED: 01/14/2019
FORM APPROVED

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES —_| (X1) PROVIDER/SUPPLIERICLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A, BUILDING: ———

(X3) DATE SURVEY
COMPLETED

Cc
12/21/2018

MHL041-204 B.WING

NAME OF PROVIDEROR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE
CUMMINGS COTTAGE 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 CORRECTIVEACTION SHOULDBE COMPLETE
TAG REGULATORY ORLSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

V 132) Continued From page 25
| submitted but it was simply an oversight.

V314 27G .1901 Psych Res. Tx. Facility - Scope V314 |

140A NCAG 27G .1901 | SCOPE
(a) The rules in this Section apply to psychiatric
residential treatment facilities (PRTF)s. |
(b) APRTF is one that provides care for children |
| or adolescents who have mental illness or |
substance abuse/dependency in a non-acute
| inpatient setting. |
(c) The PRTF shall provide a structured living
environment for children or adolescents who do
| not meet criteria for acute inpatient care, but do |
require supervision and specialized interventions
on a 24-hour basis. |
(d) Therapeutic interventions shall address
functional deficits associated with the child or |
adolescent's diagnosis and include psychiatric |
treatment and specialized substance abuse and
mental health therapeutic care. These | |

therapeutic interventions and services shall be
designed to address the treatment needs
| necessary to facilitate a move to a less intensive |
community setting.
(e) The PRTF shall serve children or adolescents
for whom removal from home or a |
community-based residential setting is essential
to facilitate treatment.
(f) The PRTF shall coordinate with other
| individuals and agencies within the child or
adolescent's catchment area. |
(g) The PRTF shall be accredited through one of |

the following; Joint Commission on Accreditation
of Healthcare Organizations; the Commission on
Accreditation of Rehabilitation Facilities; the
Council on. Accreditation or other national
accrediting bodies as set forth in the Division of
Medical Assistance Clinical Policy Number 8D-1,

Division of Health Service Regulation
STATE FORM Lal 08GC11 if continuation sheet 26 of 35

. PRINTED: 01/14/2019
FORM APPROVED

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES —_| (X1) PROVIDER/SUPPLIERICLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X3) DATE SURVEY
COMPLETED

c
12/21/2018

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

MHL011-204 B. WING _

NAME OF PROVIDEROR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE
CUMMINGS COTTAGE
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTIONSHOULD BE COMPLETE
TAG REGULATORY ORLSCIDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

Continued From page 26

Psychiatric Residential Treatment Facility,
including subsequent amendments and editions.

A copy of Clinical Policy Number 8D-1 is available
at no cost from the Division of Medical Assistance
website at http://www.dhhs.state.nc.us/dma/.

This Rule is not met as evidenced by:
Based on record review and interviews the facility
failed to ensure services were designed to
provide therapeutic interventions to address the
functional deficits associated with the child or
adolescents diagnosis and failed to coordinate
with other agencies within the child or
adolescents catchment area, effecting 1 of 3
audited clients (#1). The findings are:

Cross Reference: 10A NCAC 27G .0205
Assessment and Treatment/Habilitation or
Service Plan (V112) Based on record review and
interviews the facility failed to develop and
implement goals and strategies to address the
behaviors effecting 1 of 3 audited clients (#1).

Review on 12/7/18 and 12/21/18 of the Plan of
Protection signed and dated by the Director of
Performance/Quality Improvement on 12/7/18
revealed:

What will you immediately do to correct the above
tule violations in order to protect clients from
further risk?

"-The identified student has been admitted to an
inpatient psychiatric hospital. If the student |
returns to Eliada, the Residential Director and
Clinical Director will complete a new safety
Division of Health Service Regulation

STATE FORM 6800 08GC11 If continuation sheet 27 of 35

PRINTED: 01/14/2019
FORM APPROVED
Division of Health ServiceRequlation

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

c
MHLO011-204 B, WING ________H4_ 12/21/2018

NAME OF PROVIDEROR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE
ASHEVILLE, NC 28806

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

(EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX {EACH CORRECTIVEACTION SHOULD BE

REGULATORY ORLSCIDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

CUMMINGS COTTAGE

V314 Continued From page 27

| contract and boundary plan with the student prior |
to her re-entry to Cummings Cottage. The |

Residential Director and Chief Operating Officer |

will evaluate and determine necessary staffing

patterns to provide increased supervision and |

monitoring to prevent behaviors that might be |

injurious to the student or others. This student's

needs, treatment and transition planning will be a

priority throughout the action steps detailed

below.

-A strategic intervention and crisis planning

| training will provided to the Cottage Supervisors |

and Clinicians during the Residential Leadership |
Meeting on Tuesday, 12/11/18. This will include

| clear directives on how to engage the cottage |

treatment team in identifying individualized | |

intervention strategies and therapeutic support for

each student during the weekly team supervision |

meetings; thorough and descriptive
documentation of these strategies on both the
Treatment Team Minutes and individual student |
Clinical Case Reviews. |
-The students identified in this survey (3) have
been reviewed through the process of a Clinical |
Case Review. This has been documented on
Eliada's revised Clinical Case Review document,
| which now has an embedded Individual Crisis
Management Plan/Strategies for the
| Comprehensive Crisis Plan. The Clinical Director
will lead a review of these plans with all |
Cummings Cottage staff during the Treatment
Team Meeting on Wednesday, 12/12/18, using
the revised the Clinical Case Review process and, |
documentation, which now has an embedded
| Individual Crisis Management Plan/Strategies for
the Comprehensive Crisis Plan. This plan | |
includes student-specific details for:
a. Pre-Crisis: What is the student's baseline?
What does it look like when the student is doing
well? |
Division of Health Service Regulation
STATE FORM e890 08GC11 If continuation sheet 28 of 35

F . PRINTED: 01/14/2019
FORM APPROVED

Division of Health Service Requlation
STATEMENT OF DEFICIENCIES _| (X1) PROVIDER/SUPPLIERICLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X3) DATE SURVEY
COMPLETED

Cc
12/21/2018

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

MHLO011-204 B. WING

NAME OF PROVIDEROR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE
ASHEVILLE, NC 28806

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (%5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACHCORRECTIVE ACTION SHOULDBE COMPLETE

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

CUMMINGS COTTAGE

Continued From page 28

b. Triggering: (events and early signs that
student is not doing well)

c. Prevention and Early Intervention Strategies:
(Engagement and calming strategies: what works
well, doesn't work well)

d. Escalation and Outburst: (strategies forcrisis
response and stabilization)

e. Recovery: (specific needs or supports after
crisis)

-The developed intervention strategies for each
student will be communicated by the residential
staff through the Cottage Update emails that are
completed daily at the end of each shift.

-The Clinician will review the individualized
strategies developed by the treatment team with
the Child and Family Team. Each student's
progress, needs and intervention strategies will
be included in the monthly Person-Centered Plan
updates and the corresponding Comprehensive
Crisis Plan.

-Cummings Residential Counselors will facilitate
one psycho-educational group with the students
daily, beginning on Tuesday, 12/11/18. Staff have
been provided with manualized group therapy
workbooks and will address topics related to
self-esteem, positive decision-making, managing
emotions, resisting peer influences and coping
strategies. The daily group topic and therapeutic
activities will be detailed in each students
progress note. Group topics completed will be
selected during each weekly

Treatment Team Meeting, then reviewedand
documented on the minutes for the following
week.

-Eliada's PQ! (Performance/Quality Improvement)
Director will revise the critical incidents reporting
procedures and send out an email
communication with the procedures by 12/24/18.
This will include clear guidance on when to file
police reports and the designated Eliada
Division of Health Service Regulation

STATE FORM 6808 08GC11 If continuation sheet 29 of 35

PRINTED: 01/14/2019
FORM APPROVED

Division of Health ServiceRegulation
STATEMENT OF DEFICIENCIES | (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED

Cc
MHL011-204 B. WING 12/21/2018
NAME OF PROVIDEROR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE
ASHEVILLE, NC 28806

CUMMINGS COTTAGE

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

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

V 314) Continued From page 29 | v314
personnel responsible.” |

Describe your plans to make sure the above
| happens:
"The intervention training, conducted on
12/11/18, will be documented in the Residential
| Leadership Meeting Minutes.
-”The Clinical Director will facilitate the Clinical
Case Reviews with the Cummings Treatment
Team on 12/12/18. The Clinical Director will
document all updates to the Clinical Case
Reviews and will share with the team. The
Cottage Supervisor will provide coaching to direct
care staff for implementation and will review each
shift update email to ensure that the
individualized intervention strategies are included |
for each student.
-A therapeutic group weekly schedule will be
maintained for the cottage. The schedule will be
developed by the Cottage Supervisor during the
weekly Residential Leadership Meeting. The
group facilitation will be monitored at least one
time per week by the Residential Director."

Client #1 had a history of sexual trauma, and
suspected physical and verbal abuse. Just prior
to her placement in the PRTF she was
hospitalized twice for depression, self-harm, and
| suicidal behavior. The facility failed to have a
system in place to meet the complex treatment
needs and manage the behaviors of Client #1.
| She was admitted initially to the locked PRTF with |
the knowledge of her extensive cutting behaviors,
suicidal attempts, and runaway attempts. Her | |

treatment goals and strategies upon admission
failed to address her self-injurious behavior.
When targeted and bullied by another client she
was moved into an unlocked PRTF to ensure her
safety. Following the transition to the new |
cottage, her self-harm and elopement behaviors
Division of Health Service Regulation
STATE FORM nee, 08GC11 If continuation sheet 30 of 35

. ss PRINTED: 01/14/2019
FORM APPROVED
Division of Health Service Regulation

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

Cc
12/21/2018

MHLO011-204 B. WING

NAME OF PROVIDEROR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE
ASHEVILLE, NC 28806

CUMMINGS COTTAGE

(xa) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTIONSHOULDBE COMPLETE
TAG REGULATORY ORLSCIDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

V 314| Continued From page 30

began to escalate. The facility failed to develop
goals or strategies in her treatment plan at the
time of this transition or as the behaviors
continued to increase. Client #1 engaged in
self-harm to include scratching, cutting and head
banging 11 times. There were some days when
the self-harm occurred more than once. There
were 11 incidents of verbal and/or physical
aggression to peers, staff, and one teacher.
Client #1 eloped on 2 dates, one of which
resulted in an involuntary commitment when she
was running into traffic on a busy road. When
she eloped the second time she ran from staff
across traffic and ultimately into an area out of
their sight. This incident ended when Client #1
reported an alleged rape by a stranger in the |
community. Failure to design services to meet

the therapeutic needs of Client #1 constitute a

Type A1 rule violation for serious neglect and |
must be corrected within 23 days. An
administrative penalty of $1500.00 is imposed. if
the violation if 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.

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

Division of Health Service Regulation
STATE FORM e800 08GC11 lf continuation sheet 31 of 35

PRINTED: 01/14/2019
FORM APPROVED

Division of Health Service Regulation
‘STATEMENT OF DEFICIENCIES __| (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

I

NAME OF PROVIDEROR SUPPLIER

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

Cc
12/21/2018

MHLO11-204 B, WING

STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE
ASHEVILLE, NC 28806

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACHCORRECTIVE ACTION SHOULDBE
TAG | REGULATORY ORLSCIDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE

CUMMINGS COTTAGE

(xs)
COMPLETE
DATE
DEFICIENCY)

V 367 Continued From page 31 | V 367 |

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 contactand
identification information;
(2) client identification information;
(3) type of incident;
(4) description of incident;
(5) status of the effort to determine the
| cause of the incident; and |
(6) other individuals or authorities notified

| or responding. |

(b) Category A and B providers shall explain any |
missing or incomplete information. The provider
shall submit an updated report to all required

| report recipients by the end of the next business |
day whenever:
(1) the provider has reason to believe that |

information provided in the report may be |

erroneous, misleading or otherwise unreliable; or

(2) the provider obtains information |

required on the incident form that was previously

unavailable.

(c) Category A and B providers shall submit,

upon request by the LME, other information |

obtained regarding the incident, including:

(1) hospital records includingconfidential

| information; | |
(2) reports by other authorities; and
(3) the provider's response to theincident. |

| (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 |

Division of Health Service Regulation
STATE FORM on 08G6C11 If continuation sheet 32 of 35

° PRINTED: 01/14/2019
FORM APPROVED

Division of Health ServiceRequlation
STATEMENT OF DEFICIENCIES —_| (X1) PROVIDER/SUPPLIERICLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X3) DATE SURVEY
COMPLETED

Cc
12/21/2018

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

MHL011-204 B. WING

NAME OF PROVIDEROR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE
ASHEVILLE, NC 28806

CUMMINGS COTTAGE

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION 5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY ORLSCIDENTIFYINGINFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

Continued From page 32

providers shall send a copy of all level Ill
incidents involving a client death to the Division of
Heaith 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 NCAC26C
-0300 and 10A NCAC 27E .0104(e)(18).

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

(1) medication errors that do not meetthe

definition of a level II or level Ill incident;

(2) restrictive interventions that do not meet

the definition of a level II or level IIlincident;

(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 Il 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 review and interview the facility
failed to ensure Level Ill incidents were reported
to the Local Management Entity (LME) within 72
hours of becoming aware of the incident effecting
1 of 3 audited clients (#1). The findings are:

Division of Health Service Regulation
STATE FORM 6880 08GC11 If continuation sheet 33 of 35

PRINTED: 01/14/2019
FORM APPROVED

Division of Health Service Regulation
‘STATEMENT OF DEFICIENCIES __| (X1) PROVIDER/SUPPLIERICLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

Cc
MHLO011-204 B. WING 12/21/2018

NAME OF PROVIDEROR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE
CUMMINGS COTTAGE
ASHEVILLE, NC 28806
(4) ID | SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION 5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
t TAG | REGULATORY ORLSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

V 367 Continued From page 33

Review on 11/28/18 of incident reports for
10/2018-12/2018 for Client #1 revealed:
-Level II incident report completed on 12/4/18
indicated " ...Staff redirected [Client #1] for
targeting a peer ...she began to scream and
posture at this peer ...got up and exited the
cottage ...she approached the road ...transitioned |
to a standing restraint ...staff released the

restraint when a staff member was hurt. Staff
continued to follow [Client #1] and lost eye sight |

of her briefly when she darted across the road in
to [drug store]. Staff re-gained eyesight of [Client
#1] once entering [drug store]. Staff kept distant |

proximity when she yelled at staff to keep their
distance. Staff lost eyesight of [Client #1] again
briefly when she ran out of [drug store]. Staff
re-gained eyesight ...Staff followed [Client #1] |
until [restaurant] before losing eyesight as she |
ran across the highway towards [liquor store].
Staff attempted to search for her within the area
she was last sighted. Staff returned to campus
and filed missing persons report. Staff returned
[Client #1] to the cottage a few minutes later ..."
-No level Il incident report completed when Client
#1 reported that she was allegedly raped by a
stranger in the community.

Review on 11/28/18 of the Nursing notes from
10/1/18-12/4/18 for Client #1 revealed:

-12/4/18 "Student asked to have nursing check in
with her when | arrived at the cottage to see
another ...| checked in with [Client #1] at approx.
2:45pm. During this conversation, she stated that
she ran from campus earlier today and went to
CVS. She stated that while in CVS a man
approached her and asked her if she was okay
and asked her to step outside. [Client #1] stated
that Eliada staff came at that time and she left
CVS with Eliada staff. [Client #1] then stated that
once she left the CVS she ran from staff and into
Division of Health Service Regulation

STATE FORM id 08GC11 If continuation sheet 34 of 35

* PRINTED: 01/14/2019
FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
‘AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X3) DATE SURVEY
COMPLETED

Cc

(X2) MULTIPLE CONSTRUCTION
A, BUILDING:

MHL011-204 B. WING __ —— 12/21/2018
NAME OF PROVIDEROR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE
UMMINGS COTTAGE
q N 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 CORRECTIVEACTION SHOULD BE COMPLETE
TAG REGULATORY ORLSC IDENTIFYING INFORMATION) Tac. CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

V 367 Continued From page 34 | V 367

a forest. She states that the man from the store
followed her and raped her in the forest ..." |
Interview on 12/13/18 with the Director of
Performance/Quality Improvement revealed:

-No IRIS (Incident Response improvement
System) report submitted for the allegation of |
tape only the events leading up to that which |

included an elopement and restrictive

intervention.
-Client #1 kept changing details of what allegedly

occurred. |
-She indicated that the Program Supervisor
should have submitted the report but most likely
was not directed to do so.

= of Health Service Regulation
STATE FORM 6800 08GC11 If continuation sheet 35 of 35

document_type: Plan of Correction