state: NC

facility_name: Green Cottage

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

raw_content:
PRINTED: 10/12/2018
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: . COMPLETED
A. BUILDING: __
R
MHLO11-371 B. WING, 10/05/2018

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

2 COMPTON DRIVE

GREEN LEVEL III
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 OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
| DEFICIENCY)
iF vong INITIAL COMMENTS v000

| An annual, complaint and follow-up survey was
completed on 10/5/18. The complaint was
substantiated (Intake #NC00141963). | RECEIVED

Deficiencies were cited.
By DHSR- Mental Health Lic. & Cert. Section at 1:13 pm, Nov 14, 2018

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

V 112 27G .0205 (C-D) V112 |
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

receive services beyond 30 days.

(d) The plan shall include: |

(1) client outcome(s) that are anticipated to be |
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 assessment of

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.

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (1) PROVIDER/SUPPLIERICLIA.
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

MHL011-371

NAME OF PROVIDER OR SUPPLIER

GREEN LEVEL Ill

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

(X4) ID
PREFIX
TAG

STREET ADDI
2 COMPTO!
ASHEVILLE, NC 28806

(X2) MULTIPLE CONSTRUCTION
A.BUILDING:

B. WING

RESS, CITY, STATE, ZIP CODE
IN DRIVE

ID
PREFIX
TAG

PRINTED: 10/12/2018
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
10/05/2018

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

COMPLETE
DATE

112, Continued From page 1

This Rule is not met as evidenced by:

Based on record reviews and interviews, the
facility failed to implement strategies and services
in the treatment/behavior support plan affecting 2
of 3 current clients (Clients #1 and #2 ). The
findings are:

Review on 9/26/18 of Client #1’s record revealed:
-Admission date: 8/13/18

-Diagnoses: BiPolar Disorder, Hypomanic, in
partial remission, severe, Oppositional Defiant
Disorder.

-An Application for Services dated 6/5/18 noted
Client #1 was currently in a Level IV cottage on
campus and ready to transition to a Level Ill when
a bed became available.

-Current behaviors included a history of running.
-An Intake Summary dated 9/13/18 noted the
client was a run risk and had a history of eloping
from her parents home eight times last year with
a one week average duration of being gone.

Review on 9/26/18 of an Incident Report dated
9/1/18 at 11:30 a.m. revealed:

-Client #1 was observed walking out of the front
door of the cottage.

-Close proximity was maintained as Client #1
continued to walk off campus.

-Client #1 stated she wanted a cigarette.

-After her return, Client #1 stated 'she struggled
with thoughts of running throughout the day.’

Review on 9/26/18 of an Incident Report dated

9/16/18 at 9:30 p.m. revealed:

-Client #1 was in a positive space and trying on

outfits she should wear to school the next day.
jivision of Health Service Regulation

‘STATE FORM

410A NCAC 27G .0205
ASSESSMENT AND
TREATMENT/HABILITATION OR
SERVICE PLAN

Eliada currently maintains an Individual Crisis
Management Plan in addition to the
Comprehensive Crisis Plan that is included in

e Person-Centered Plan. This document is
ised to provide specific guidance to Residential
reatment Staff. To improve consistency in

client-specific service planning and frequency of |
reviews, we have made the following document
jand process revisions:

1. The Individual Crisis Management Plan ae

{ICMP) has been incorporated into the
Monthly Client Clinical Case Review.

2. ICMP components include:

Safety Concerns/Warnings

Current Issues/Potential Triggers

High Risk Behaviors

Intervention Strategies by phase

i. Pre-Crisis

ii. Triggering

iii. Escalation

iv. Outburst

v. Recovery

3. The assigned Clinical Supervisor will
lead the review of this plan with the
entire Green Cottage staff and update |
the ICMP to reflect current behaviors,
incidents, responses to strategies and
revised interventions.

4, The Clinical Case Review document
will now be a “living” document with
each monthly review documented as an
update to the original plan, creating a
timeline of the client's treatment,

progress and needs. This document is 4478

maintained in the Client's Medical

If continuation sheet 2 of 12

aoop

10/30/18

TyeT11

Division of Health Service Regulation

PRINTED: 10/12/2018
FORM APPROVED

Division of Health Service Regulation
STATE FORM

Record.
Every client is reviewed weekly during 11/7/18
the Treatment Team Meeting. The
milieu review portion of this meeting is
documented on the Treatment Team
Meeting Minutes. All incidents are
reviewed as part of this process and
immediate strategies and staff guidance,
for intervention and safety are detailed. |
Person-Centered Plans for students in
Eliada’s Level III Residential Treatment
Program are reviewed with the Child
and Family Team at least monthly.
Each student's progress and needs are
identified and documented. Goals,
services and interventions are updated
to support the student's treatment. |

° PCP standards and 10/25/18
completion timeframes have
been reviewed with the Level
Ill Clinical Supervisor to
ensure compliance with this
expectation.

« PCP goals and interventions 11/27/18
guidelines are being revised
by Eliada’s Clinical Director
and PQI Director. Training on
student-specific intervention
planning will be provided to all
Clinicians and Cottage
Supervisors.

If continuation sheet 3 of 12

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

MHLO11-371 B. WING

NAME OF PROVIDER OR SUPPLIER
2 COMPTON DRIVE
ASHEVILLE, NC 28806

GREEN LEVEL Ill

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 10/12/2018
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
10/05/2018

STREET ADDRESS, CITY, STATE, ZIP CODE

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

ID
PREFIX
TAG

(x4) ID
PREFIX
TAG

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

(x)
COMPLETE
DATE

V 112) Continued From page 2 V112

-Client #1 then "suddenly...bolted out of the front
door of the cottage.”

-There was no known trigger to her running.
-Staff ran after the client asking her to come
back.

-Eye sight of the client was lost and the local
police department was called,

-Client #1 remained off campus for the remainder
of the shift.

Review on 9/26/18 of Client #1's Person
Centered Profile revealed:

-The most recent update or revision date was
7/30/18.

-Goals included to demonstrate an improvement
in BiPolar symptoms, in Oppositional-Defiant or
disruptive behaviors.

-There were no goals or support/intervention
strategies to address Client #1's history of
running and/or her running behavior since being
admitted to the level IlI/staff secure facility.

Interview on 9/28/18 with the Residential Director
revealed:

-Client #1 first ran on 9/1/18 due to wanting a
cigarette.

-Extra measures for client's who left the cottage
without permission were done on a case-by-case
basis.

-In Client #1's case they talked with her about
what could have happened to her while she was
gone and discussed alternative solutions.

-Client #1 ran again on 9/16/18 and they later
found out she had been making plans with a boy
at school to do this.

-Client #1 had not returned to the facility since.

Review on 9/29/18 of Client #2's record revealed:
-Admission date 8/13/18.
~Diagnoses of Disruptive Mood Dysregulation

Division of Health Service Regulation
STATE FORM

TY8T11

If continuation sheet 4 of 12

PRINTED: 10/12/2018

FORM APPROVED
Division of Health Service Regulation
‘STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A.BUILDING: COMPLETED
R
MHL011-374 B. WING _ — 10/05/2018

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

GREEN LEVEL III
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 ACTION SHOULD BE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE.
| DEFICIENCY)
|
Vv 112 Continued From page 3 | vi112

| Disorder, Stimulant Use Disorder, severe, and
| Alcohol Use Disorder, moderate.
-Comprehensive Clinical Assessment dated
7/6/18 included a history of verbal aggression, |
depression, substance use and self-injurious
behaviors.
-There was no history of run risk noted.

Review on 9/29/18 of the updated/revised
Person-Centered Plan dated 8/1/18 revealed:
-"Long Range Outcome: To complete recovery
and treatment; finish school, obtain job, obtain
license. Return home to family.”

-"Where am | now in the process of achieving this
outcome?” |
~"9/17/18: Per [Client #2's] CFT [Child and Family
Team]...[Client #2] continues to show signs of
depression and anxiety as he has contemplated
running..."

Review on 9/29/18 of an Incident Report dated
9/1/18 at 11:30 a.m. revealed:

-Client #2 was observed to follow his peer out the
front door of the cottage.

-Eye sight on the client was lost as he walked
around the back of the cottage.

-Client came back into the cottage in a negative
space.

-"Debriefing Summary: ...[Client #2] was
struggling throughout the day with thoughts of
running..."

| Review on 9/29/18 of an Incident Report dated
9/24/18 at 5:00 p.m. revealed:

~Staff provided random checks on Client #2 while |

he was in his room.

~"Staff noted [Client #2] was not in his room and

his window was open..." |
-Nearby neighborhoods and roads were searched

and the client could not be found.

Division of Health Service Regulation
STATE FORM 8800 TyveT11 If continuation sheet 5 of 12

V112

v114

NAME OF PROVIDER OR SUPPLIER

GREEN LEVEL Il
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES

PREFIX
TAG

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

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHLO011-371

B. WING

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ___

PRINTED: 10/12/2018
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
10/05/2018

(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)

Continued From page 4

-The local police and guardian were called.
-Approximately 10:00 p.m. Client #2 was found
and brought back to campus.

-Staff and nursing noted Client #2 appeared
intoxicated, he began vomiting, and an
ambulance was called due to possible overdose.

Review on 9/29/18 of Client #2's
Person-Centered Pian revealed:

-The date the goals were last reviewed was
9/17/18.

-Goals included to demonstrate improvement in
Depressive Disorder, Anxiety Disorder, Cannabis
Use Disorder, symptoms of Sedative, Hypnotic,
or Anxiolytic Use Disorder, Stimulant Use
Disorder, and Alcohol! Use Disorder.

-There were no goals or support/intervention
strategies to address Client #2's running behavior
since being admitted to the level Ill/staff secure
facility.

Interview on 9/29/18 with Client #1 and #2's
Therapist revealed:

-When a child had a history or had actually ran
from the cottage, strategies and motivators
should be developed in efforts to help the child
stay.

27G .0207 Emergency Plans and Supplies

410A NCAC 27G .0207 EMERGENCY PLANS
AND SUPPLIES

| (a) A written fire plan for each facilityand

area-wide disaster plan shall be developed and
shall be approved by the appropriate local
authority.

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

Vv 112

Vv 114

40A NCAC 27G .0207 EMERGENCY PLANS
‘AND SUPPLIES

Eliada’s Residential Treatment Fire and Disaster 9/17/18
Drill Procedures and Drill Log have been
fevieod. (attached for review) |

Revised procedures were reviewed with Cottage S78
Supervisors on 9/17/18 and Direct Care staff

were trained on the new procedures and

compliance standards during the Team

‘Supervision Meeting on 9/18/18. 9/18/18

Division of Health Service Regulation

STATE FORM

TY8T11 If continuation sheet 6 of 12

PRINTED: 10/12/2018
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:

R

MHLO11-371 B. WING 10/05/2018

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

NAME OF PROVIDER OR SUPPLIER.

GREEN LEVEL I!

(x4) ID
PREFIX
TAG

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

STATE FORM

Continued From page 5

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

This Rule is not met as evidenced by:

Based on record review and interview the facility
failed to conduct fire and disaster drills quarterly
on each shift. The findings are:

Review on 9/29/18 of the fire and disaster drills
for October 2017 through June 2018 revealed:
January 2018 - March 2018

-No documentation of disaster drills for the 3rd
shift.

April 2018 - June 2018

-No documentation of fire drills for the 3rd shift.
-No documentation of disaster drills for the 1st
and 3rd shifts.

Interview on 9/29/18 with the Director of
Performance and Quality Improvement revealed:
-she was aware the facility was behind on
conducting some of the drills.

27G .0404 (A-E) Operations During Licensed
Period

10A NCAC 27G .0404 OPERATIONS.
DURING LICENSED PERIOD

(a) An initial license shall be valid for a period not
to exceed 15 months from the date on which the
license is issued. Each license shali be renewed
annually thereafter and shall expire at the end of

Division of Health Service Regulation

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

10A NCAC 27G .0207 EMERGENCY PLANS
‘AND SUPPLIES

Eliada’s Maintenance Supervisor will develop an 10/1/18
annual schedule for Disaster Drills to ensure that

all types are scheduled with appropriate shift

Variation. The cottage drill log will be compared

to this annual schedule by the Residential

‘Administrative Assistant to ensure compliance

and accuracy.

rill Procedure, the Residential Administrative
sistant will monitor drill completion and
documentation monthly:

br reflected on the Revised Fire and Disaster | 9/18/18

I. Drills must be completed by the 15th of
ach month. Cottage supervisors are required
io scan each cottage’s drill log and email to the
Residential Administrative Assistant by the 25th
each month.

th. The Residential Administrative
Assistant will notify the respective Cottage
Supervisor, Residential Director and PQI team of
any incomplete drills on the 26th each month, or
the first business day following the 25th.

It. The Residential Administrative
Assistant will send an email confirmation that all
monthly drills have been completed by the 1st of
the month (for the month prior) to the Residential
Director and PQI |

Eliada’s PQI Director has verified the completion | 11/8/18
‘and documentation of fire and disaster drills for
he month of October.

TY8T11 If continuation sheet 7 of 12

Division of Health Service Regulation
fr STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
MHL011-371

NAME OF PROVIDER OR SUPPLIER

B. WING _

STREET ADDRESS, CITY, STATE, ZIP CODE

2 COMPTON DRIVE
ASHEVILLE, NC 28806

GREEN LEVEL Ill

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

V 138) Continued From page 6

the calendar year.

(b) For all facilities providing periodic and
day/night services, the license shall be posted in
a prominent location accessible to public view
within the licensed premises.

(c) For 24-hour facilities, the license shallbe
available for review upon request.

(d) For residential facilities, the DHSRcomplaint
hotline number shall be posted in a public place
in each facility.

(e) A facility shall accept no more clients than the
number for which it is licensed.

This Rule is not met as evidenced by:
Based on record review and interviews, the
facility failed to ensure that it would serveno
more clients than the number for which itis
licensed. The findings are:

Review on 9/25/18 of the facility's license issued
by the Division of Health Service Regulation valid
through 12/31/18 revealed:

-Capacity 4.

Interview on 9/26/18 with Client #2 revealed:

-The facility combined all level Ili cottages at
times, and that "...it was really bad this summer."
-There were "like 8 kids and 4 staff - then they got
back to their own cottage like at 10:00 [p.m.]."
-"Drives me nuts. | don't want to be around all
those kids."

Interview on 9/26/18 with Client #3 revealed:
-Cottages were combined sometimes with other
cottages "...because they don't have enough
staff."

PRINTED: 10/12/2018
FORM APPROVED

(X2) MULTIPLE CONSTRUCTION
ABULDING

(X3) DATE SURVEY
COMPLETED

R
10/05/2018

ID
PREFIX
| TAG

V 138

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

(x5)
COMPLETE
DATE

10A NCAC 27G .0404
OPERATIONS DURING
LICENSED PERIOD

Eliada is committed to serving students in their
mitted cottage with the appropriate
staff:student ratio. Eliada has not admitted more
han 4 children to the Green Level III Residential
Treatment program at any given time.

|Eliada currently operates 3 Level III Residential
reacon programs on Eliada’s campus The

10/9/18

Residential leadership team has met to

rategize how to support staffing that meets this
requirement across all programs and support
inter-program activities.

An internal review of the statements included in

the survey findings indicated:

| 4. Client #2 statement describes
appropriate staff:student ratio of 2:4,
Students from multiple cottages,
providing the same level of care joined
together for activities. Adequate staff
was in place.

Division of Health Service Regulation
STATE FORM

If continuation sheet 8 of 12

TY8T11

PRINTED: 10/12/2018
FORM APPROVED

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

(X3) DATE SURVEY
COMPLETED

R
10/05/2018

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

MHL011-374 B. WING

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

GREEN LEVEL III
ASHEVILLE, NC 28806

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

DEFICIENCY)

V 138 Continued From page 7

-There were 7 total students at their cottage for a
whole 1:30 p.m. to 10:30 p.m. shift.

Interview on 9/28/18 with Staff #4 revealed:

-Level Ill cottages were combined at times due to

a shortage of staff. |
-They were combined for an entire shift making a

total of 7 students in the facility.

Interview on 9/28/18 with the Residential Director

revealed:

-He was aware the staff had been combining

student cottages. |
-This had been going on for approximately 6-8

weeks due to a shortage of staff on second shift .

-None of the cottage were combined during sleep

hours. |

Interview on 10/5/18 with the Chief Operations
Officer revealed:

-She was aware of the cottages being combined
and approved this each time it occurred.

-They were only combining in “open areas" until
about a month ago, they were told it was
acceptable to combine inside the cottages in
order to maintain ratio.

-This usually did not occur for an entire shift and
was never overnight.

V 300 27G .1708 Residential Tx. Child/Adol - Trans or Vv 300
dischg

140A NCAC27G 1708 TRANSFEROR 10A NCAC 27G .1708 TRANSFER

DISCHARGE OR DISCHARGE

(a) The purpose of this Rule is to address the Eliada’s Residential Treatment Program 9/2/18
transfer or discharge of a child or adolescent csteised a new professional role to support

from the facility. ‘students as they begin their treatment at Eliada

| (b) Achild or adolescent shail not be discharged and to coordinate discharge planning and step-
r transferred from a facility, except in case of down services. A tenured case manager
assumed the Admission and Discha

ge

Division of Health Service Regulation
STATE FORM Ld TY8T11 If continuation sheet 9 of 12

PRINTED: 10/12/2018
FORM APPROVED
Division of Health Service Regulation

Coordinator role on September 2, 2018. Key
responsibilities of this position are to:
| 1. attend the last two child and family
team meetings,

2. review the clinical service
recommendations,

3. communicate with the legal guardian to
determine service selection and
preferred providers

4. obtain consents to release confidential
information and complete referrals for
service with the selected provider

5. ensure that the start date of the new
services coincides with Eliada’s
discharge and transition date.

The assigned clinician will communicate with | 9/2/18
the guardian on a weekly basis to discuss
rogress in treatment, service recommendations,
ind family support needs. This expectation for
mmunication was clarified with the addition of |
the Admission and Discharge Coordinator
sition.

Please note that per Eliada’s CEO, outpatient
rvices were offered to FC #4’s guardian, prior
the date of discharge, to provide support and

intervention until the services with the new

| rovider were initiated.

Division of Health Service Regulation
STATE FORM bod TY8T11 If continuation sheet 10 of 12

Division of Health Service Regulation

PRINTED: 10/12/2018
FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY.
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
ABUILDING:
R
| MHLO11-374 B. WING —____ 10/05/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

(x4) ID
PREFIX
TAG

GREEN LEVEL III

2 COMPTON DRIVE
ASHEVILLE, NC 28806

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

DEFICIENCY)

V 300

Continued From page 8

emergency, without the advance written
notification of the treatment team, including the
legally responsible person. For purposes of this
Rule, treatment team means the same as the
existing child and family team or other involved
persons as set forth in Paragraph (c) of this Rule.
(c) The facility shall meet with existing child and
family teams or other involved persons including
the parent(s) or legal guardian, area authority or
county program representative(s) and other
representatives involved in the care and
treatment of the child or adolescent, including
local Department of Social Services, Local
Education Agency and criminal justice agency, to
make service planning decisions prior to the
transfer or discharge of the child or adolescent
from the facility.

(d) In case of an emergency, the facility shall
notify the treatment team including the legally
responsible person of the transfer or discharge of
the child or adolescent as soon as the emergency
situation is stabilized.

(e) In case of an emergency, notification may be
by telephone. A service planning meeting as set
forth in Paragraph (c) of this Rule shall be held
within five business days of an emergency
transfer or discharge.

This Rule is not met as evidenced by:
Based on record review and interview the facility
failed to ensure involved persons, including the
legal guardian and other representatives involved
in the care and treatment of Former Client (FC)
#4 were prepared to implement the service
planning decisions upon discharge of the
adolescent from the facility. The findings are:

Division of Health Service Regulation

STATE FORM

#898 TyeT11 If continuation sheet 11 of 12

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 10/12/2018

FORM APPROVED
Division of Health Service Regulation
‘STATEMENT OF DEFICIENCIES (41) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (Xa) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED
R
MHLO11-374 B. WING _ — 10/05/2018

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

2 COMPTON DRIVE
GREEN LEVEL III
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) | tac
V300 Continued From page 9 Vv 300

Review on 9/25/18 and 10/1/18 of FC#4's record
revealed:

-14 year old female admitted 1/30/18 and
discharged 7/16/18.

-Diagnoses included Oppositional Defiant
Disorder, Post-Traumatic Stress Disorder, and
Major Depressive Disorder, recurrent, severe with
Psychosis.

Review on 9/25/18 of FC #4's Multidisciplinary
Staffing dated 6/14/18 revealed:

-"Transition Plan: [FC #4's guardian] did not
attend the last CFT [Child Family Team] so there
is not an updated transition plan as of 5/10/18.
Case Manager and Therapist are recommending
[FC #4] transition home with in home services.”
-"Discharge: July 27, 2018."

Review on 9/25/18 of FC #4's Comprehensive
Clinical Assessment Addendum dated 7/5/18
revealed:

="... The home environment still presents
significant challenges for her recovery...[guardian]
is hesitant to accept her into the home...”
-"...therapist is recommending an in-home service
to help [FC #4] establish and maintain stability in
the home environment...”

Review on 9/25/18 of FC #4's final
Muitidisciplinary Staffing dated 7/12/18 revealed:
-"...[guardian] has since communicated with
therapist via email and in-session that she wants
to seek a foster care placement for the child and
does not believe she can support [FC #4]."
-"This is in contradiction to previous...services
discussed...[guardian] has not been consistently
communicating with members of the treatment
team..."

-"Transition Plan: [FC #4's guardian] did not
Division of Health Service Regulation

STATE FORM

on TyeTt1

i continuation sheet 12 of 12

PRINTED: 10/12/2018
FORM APPROVED
Division of Health Service Ri

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A.BUILDING:

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

R
10/05/2018

MHLO11-371 B. WING

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

(4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x6)
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)

NAME OF PROVIDER OR SUPPLIER,

GREEN LEVEL Ill

¥ 300 Continued From page 10

attend the last CFT [Child Family Team] so there
is not an updated transition plan as of 5/10/18.
Case Manager and Therapist are recommending
| [FC #4] transition home with in home services.” |
-"Discharge: July 16 or 17, 2018.”

Review on 9/25/18 of FC #4's Discharge

Summary (undated) and written by the

Residential Case Manager revealed:

-"_.Aftercare plans and responsibilities: [FC #4's

guardian] will make an appointment for an

assessment by [local family services agency] for |
7/25/18."

Interview on 9/25/18 and 10/1/18 with the
Qualified Professional/Residential Case Manager

revealed: |
-FC #4's guardian refused to talk to them or come

to CFT meetings the entire month of June.

-The guardian finally came in July and FC #4 was
discharged 7/16/18, a week early, due to shutting

down the cottage for renovations.

-She confirmed intensive in-home services were

scheduled and found out they were expected to

see FC #4 a week after her discharge, 7/25/18.

-She asked for an appointment as soon as |
possible; she assumed they could not get to the

home any sooner.

Interview on 10/1/08 with FC #4's therapist

revealed:

-It was not his recommendation to have FC #4 be
discharged prior to having something in place
within a couple of days of discharge.

-This was a risky case for that given FC#4's
guardian and her inconsistencies and
questionable support at home. |
-FC #4 was ready to go home, it was more of
trying to get the guardian ready and the delay of
in-home services; she needed more time for that.
Division of Health Service Regulation

STATE FORM 8800 Tv8T11 continuation sheet 13 of 12

PRINTED: 10/12/2018
FORM APPROVED

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

R
MHLO11-374 B. WING __ 10/05/2018

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

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

GREEN LEVEL ill

Division of Health Service Regulation
STATE FORM e800 TY8T14 If continuation sheet 14 of 12

inspection_type: MHLCS Annual, Complaint, and Follow-up

document_type: Plan of Correction


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

raw_content:
Division of Health Service Regulation

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

MHLO011-371

NAME OF PROVIDER OR SUPPLIER

A. BUILDING:

2 COMPTON DRIVE
ASHEVILLE, NC 28806

GREEN LEVEL Ill

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/12/2018

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R
10/05/2018

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

ID
PREFIX
TAG

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

(xs)
COMPLETE
DATE

V 000} INITIAL COMMENTS

An annual, complaint and follow-up survey was
completed on 10/5/18. The complaint was
substantiated (Intake #NC00141963).
Deficiencies were cited.

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

V 112] 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
receive services beyond 30 days.

(d) The plan shall include:

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

(2) strategies;

(3) staff responsible;

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

(5) basis for evaluation or assessment of
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.

V 000

Vv 112

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

STATE FORM

6899

TITLE

(X6) DATE

If continuation sheet 1 of 12

TY8T11

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/12/2018
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHLO011-371 10/05/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE
GREEN LEVEL Ill
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 112] Continued From page 1 Vv 112

This Rule is not met as evidenced by:

Based on record reviews and interviews, the
facility failed to implement strategies and services
in the treatment/behavior support plan affecting 2
of 3 current clients (Clients #1 and #2 ). The
findings are:

Review on 9/26/18 of Client #1's record revealed:
-Admission date: 8/13/18

-Diagnoses: BiPolar Disorder, Hypomanic, in
partial remission, severe, Oppositional Defiant
Disorder.

-An Application for Services dated 6/5/18 noted
Client #1 was currently in a Level IV cottage on
campus and ready to transition to a Level IIl when
a bed became available.

-Current behaviors included a history of running.
-An Intake Summary dated 9/13/18 noted the
client was a run risk and had a history of eloping
from her parents home eight times last year with
a one week average duration of being gone.

Review on 9/26/18 of an Incident Report dated
9/1/18 at 11:30 a.m. revealed:

-Client #1 was observed walking out of the front
door of the cottage.

-Close proximity was maintained as Client #1
continued to walk off campus.

-Client #1 stated she wanted a cigarette.

-After her return, Client #1 stated 'she struggled
with thoughts of running throughout the day."

Review on 9/26/18 of an Incident Report dated
9/16/18 at 9:30 p.m. revealed:

-Client #1 was in a positive space and trying on
outfits she should wear to school the next day.

Division of Health Service Regulation
STATE FORM

6809

TY8T11

If continuation sheet 2 of 12

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/12/2018
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHLO011-371 10/05/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE
GREEN LEVEL Ill
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 112] Continued From page 2 Vv 112

-Client #1 then "suddenly...bolted out of the front
door of the cottage."

-There was no known trigger to her running.
-Staff ran after the client asking her to come
back.

-Eye sight of the client was lost and the local
police department was called.

-Client #1 remained off campus for the remainder
of the shift.

Review on 9/26/18 of Client #1's Person
Centered Profile revealed:

-The most recent update or revision date was
7/30/18.

-Goals included to demonstrate an improvement
in BiPolar symptoms, in Oppositional-Defiant or
disruptive behaviors

-There were no goals or support/intervention
strategies to address Client #1's history of
running and/or her running behavior since being
admitted to the level III/staff secure facility.

Interview on 9/28/18 with the Residential Director
revealed:

-Client #1 first ran on 9/1/18 due to wanting a
cigarette.

-Extra measures for client's who left the cottage
without permission were done on a case-by-case
basis.

-In Client #1's case they talked with her about
what could have happened to her while she was
gone and discussed alternative solutions.

-Client #1 ran again on 9/16/18 and they later
found out she had been making plans with a boy
at school to do this.

-Client #1 had not returned to the facility since.

Review on 9/29/18 of Client #2's record revealed:
-Admission date 8/13/18.
-Diagnoses of Disruptive Mood Dysregulation

Division of Health Service Regulation
STATE FORM

6809

TY8T11

If continuation sheet 3 of 12

Division of Health Service Regulation

GREEN LEVEL Ill

NAME OF PROVIDER OR SUPPLIER

A. BUILDING:

MHLO011-371

2 COMPTON DRIVE
ASHEVILLE, NC 28806

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

PRINTED: 10/12/2018

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

R
10/05/2018

Disorder, Stimulant Use Disorder, severe, and
Alcohol Use Disorder, moderate.
-Comprehensive Clinical Assessment dated
7/6/18 included a history of verbal aggression,
depression, substance use and self-injurious
behaviors.

-There was no history of run risk noted.

Review on 9/29/18 of the updated/revised
Person-Centered Plan dated 8/1/18 revealed:
-"Long Range Outcome: To complete recovery
and treatment; finish school, obtain job, obtain
license. Return home to family."

-"Where am | now in the process of achieving this
outcome?"

-"9/17/18: Per [Client #2's] CFT [Child and Family
Team]...
depression and anxiety as he has contemplated
running..."

Review on 9/29/18 of an Incident Report dated
9/1/18 at 11:30 a.m. revealed:

-Client #2 was observed to follow his peer out the
front door of the cottage.

-Eye sight on the client was lost as he walked
around the back of the cottage.

-Client came back into the cottage in a negative
space.

-"Debriefing Summary: ...[Client #2] was
struggling throughout the day with thoughts of
running..."

Review on 9/29/18 of an Incident Report dated
9/24/18 at 5:00 p.m. revealed:

-Staff provided random checks on Client #2 while
he was in his room.

-"Staff noted [Client #2] was not in his room and
his window was open..."

-Nearby neighborhoods and roads were searched
and the client could not be found.

(Client #2] continues to show signs of

Division of Health Service Regulation
STATE FORM

6809

TY8T11

(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 112] Continued From page 3 Vv 112

If continuation sheet 4 of 12

Division of Health Service Regulation

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

MHLO011-371

NAME OF PROVIDER OR SUPPLIER

A. BUILDING:

2 COMPTON DRIVE
ASHEVILLE, NC 28806

GREEN LEVEL Ill

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/12/2018
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
10/05/2018

STREET ADDRESS, CITY, STATE, ZIP CODE

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

ID
PREFIX
TAG

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

CROSS-REFERENCED TO THE APPROPRIATE, DATE
DEFICIENCY)

V 112] Continued From page 4

-The local police and guardian were called.
-Approximately 10:00 p.m. Client #2 was found
and brought back to campus.

-Staff and nursing noted Client #2 appeared
intoxicated, he began vomiting, and an
ambulance was called due to possible overdose.

Review on 9/29/18 of Client #2's
Person-Centered Plan revealed:

-The date the goals were last reviewed was
9/17/18.

-Goals included to demonstrate improvement in
Depressive Disorder, Anxiety Disorder, Cannabis
Use Disorder, symptoms of Sedative, Hypnotic,
or Anxiolytic Use Disorder, Stimulant Use
Disorder, and Alcohol Use Disorder.

-There were no goals or support/intervention
strategies to address Client #2's running behavior
since being admitted to the level III/staff secure
facility.

Interview on 9/29/18 with Client #1 and #2's
Therapist revealed:

-When a child had a history or had actually ran
from the cottage, strategies and motivators
should be developed in efforts to help the child
stay.

V 114) 27G .0207 Emergency Plans and Supplies

10A NCAC 27G .0207 EMERGENCY PLANS
AND SUPPLIES

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

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

Division of Health Service Regulation
STATE FORM

Vv 112

Vv 114

6809

TY8T11

If continuation sheet 5 of 12

Division of Health Service Regulation

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

MHLO011-371

NAME OF PROVIDER OR SUPPLIER

A. BUILDING:

2 COMPTON DRIVE
ASHEVILLE, NC 28806

GREEN LEVEL Ill

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/12/2018
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
10/05/2018

STREET ADDRESS, CITY, STATE, ZIP CODE

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

ID
PREFIX
TAG

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

CROSS-REFERENCED TO THE APPROPRIATE, DATE
DEFICIENCY)

V 114] Continued From page 5

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

This Rule is not met as evidenced by:

Based on record review and interview the facility
failed to conduct fire and disaster drills quarterly
on each shift. The findings are:

Review on 9/29/18 of the fire and disaster drills
for October 2017 through June 2018 revealed:
January 2018 - March 2018

-No documentation of disaster drills for the 3rd
shift.

April 2018 - June 2018

-No documentation of fire drills for the 3rd shift.
-No documentation of disaster drills for the 1st
and 3rd shifts.

Interview on 9/29/18 with the Director of
Performance and Quality Improvement revealed:
-she was aware the facility was behind on
conducting some of the drills.

V 138] 27G .0404 (A-E) Operations During Licensed
Period

10A NCAC 27G .0404 OPERATIONS
DURING LICENSED PERIOD

(a) An initial license shall be valid for a period not
to exceed 15 months from the date on which the
license is issued. Each license shall be renewed
annually thereafter and shall expire at the end of

Division of Health Service Regulation
STATE FORM

Vv 114

V 138

6809

TY8T11

If continuation sheet 6 of 12

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHLO011-371

A. BUILDING:

2 COMPTON DRIVE

GREEN LEVEL Ill
ASHEVILLE, NC 28806

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/12/2018

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

R
10/05/2018

the calendar year.

(b) For all facilities providing periodic and
day/night services, the license shall be posted in
a prominent location accessible to public view
within the licensed premises.

(c) For 24-hour facilities, the license shall be
available for review upon request.

(d) For residential facilities, the DHSR complaint
hotline number shall be posted in a public place
in each facility.

(e) A facility shall accept no more clients than the
number for which it is licensed.

This Rule is not met as evidenced by:
Based on record review and interviews, the
facility failed to ensure that it would serve no
more clients than the number for which it is
licensed. The findings are:

Review on 9/25/18 of the facility's license issued
by the Division of Health Service Regulation valid
through 12/31/18 revealed:

-Capacity 4.

Interview on 9/26/18 with Client #2 revealed:

-The facility combined all level Ill cottages at
times, and that "...it was really bad this summer."
-There were "like 8 kids and 4 staff - then they got
back to their own cottage like at 10:00 [p.m.]."
-"Drives me nuts. | don't want to be around all
those kids."

Interview on 9/26/18 with Client #3 revealed:
-Cottages were combined sometimes with other
cottages "...because they don't have enough
staff."

Division of Health Service Regulation
STATE FORM

6809

TY8T11

(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 138] Continued From page 6 V 138

If continuation sheet 7 of 12

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/12/2018
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED
R
MHLO011-371 10/05/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE
GREEN LEVEL Ill
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 138] Continued From page 7 V 138
-There were 7 total students at their cottage for a
whole 1:30 p.m. to 10:30 p.m. shift.
Interview on 9/28/18 with Staff #4 revealed:
-Level Ill cottages were combined at times due to
a shortage of staff.
-They were combined for an entire shift making a
total of 7 students in the facility.
Interview on 9/28/18 with the Residential Director
revealed:
-He was aware the staff had been combining
student cottages.
-This had been going on for approximately 6-8
weeks due to a shortage of staff on second shift.
-None of the cottage were combined during sleep
hours.
Interview on 10/5/18 with the Chief Operations
Officer revealed:
-She was aware of the cottages being combined
and approved this each time it occurred.
-They were only combining in "open areas" until
about a month ago, they were told it was
acceptable to combine inside the cottages in
order to maintain ratio.
-This usually did not occur for an entire shift and
was never overnight.
V 300] 27G .1708 Residential Tx. Child/Adol - Trans or V 300

dischg

10A NCAC 27G .1708
DISCHARGE

(a) The purpose of this Rule is to address the
transfer or discharge of a child or adolescent
from the facility.

(b) Achild or adolescent shall not be discharged
or transferred from a facility, except in case of

TRANSFER OR

Division of Health Service Regulation
STATE FORM

6809

TY8T11

If continuation sheet 8 of 12

PRINTED: 10/12/2018

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL011-371 — 10/05/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE
GREEN LEVEL Ill
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

V 300] Continued From page 8 V 300

emergency, without the advance written
notification of the treatment team, including the
legally responsible person. For purposes of this
Rule, treatment team means the same as the
existing child and family team or other involved
persons as set forth in Paragraph (c) of this Rule.
(c) The facility shall meet with existing child and
family teams or other involved persons including
the parent(s) or legal guardian, area authority or
county program representative(s) and other
representatives involved in the care and
treatment of the child or adolescent, including
local Department of Social Services, Local
Education Agency and criminal justice agency, to
make service planning decisions prior to the
transfer or discharge of the child or adolescent
from the facility.

(d) In case of an emergency, the facility shall
notify the treatment team including the legally
responsible person of the transfer or discharge of
the child or adolescent as soon as the emergency
situation is stabilized.

(e) In case of an emergency, notification may be
by telephone. A service planning meeting as set
forth in Paragraph (c) of this Rule shall be held
within five business days of an emergency
transfer or discharge.

This Rule is not met as evidenced by:

Based on record review and interview the facility
failed to ensure involved persons, including the
legal guardian and other representatives involved
in the care and treatment of Former Client (FC)
#4 were prepared to implement the service
planning decisions upon discharge of the
adolescent from the facility. The findings are:
Division of Health Service Regulation

STATE FORM 809 TY8T11 If continuation sheet 9 of 12

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/12/2018
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHLO011-371 10/05/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE
GREEN LEVEL Ill
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 300] Continued From page 9 V 300

Review on 9/25/18 and 10/1/18 of FC#4's record
revealed:

-14 year old female admitted 1/30/18 and
discharged 7/16/18.

-Diagnoses included Oppositional Defiant
Disorder, Post-Traumatic Stress Disorder, and
Major Depressive Disorder, recurrent, severe with
Psychosis.

Review on 9/25/18 of FC #4's Multidisciplinary
Staffing dated 6/14/18 revealed:

-"Transition Plan: [FC #4's guardian] did not
attend the last CFT [Child Family Team] so there
is not an updated transition plan as of 5/10/18.
Case Manager and Therapist are recommending
[FC #4] transition home with in home services."
-"Discharge: July 27, 2018."

Review on 9/25/18 of FC #4's Comprehensive
Clinical Assessment Addendum dated 7/5/18
revealed:

-"... The home environment still presents
significant challenges for her recovery...[guardian]
is hesitant to accept her into the home..."
-"...therapist is recommending an in-home service
to help [FC #4] establish and maintain stability in
the home environment..."

Review on 9/25/18 of FC #4's final
Multidisciplinary Staffing dated 7/12/18 revealed:
-"...[guardian] has since communicated with
therapist via email and in-session that she wants
to seek a foster care placement for the child and
does not believe she can support [FC #4]."
-"This is in contradiction to previous...services
discussed...[guardian] has not been consistently
communicating with members of the treatment
team..."

-"Transition Plan: [FC #4's guardian] did not

Division of Health Service Regulation
STATE FORM

6809

TY8T11

If continuation sheet 10 of 12

Division of Health Service Regulation

PRINTED: 10/12/2018
FORM APPROVED

attend the last CFT [Child Family Team] so there
is not an updated transition plan as of 5/10/18.
Case Manager and Therapist are recommending
[FC #4] transition home with in home services."
-"Discharge: July 16 or 17, 2018."

Review on 9/25/18 of FC #4's Discharge
Summary (undated) and written by the
Residential Case Manager revealed:
-"..Aftercare plans and responsibilities: [FC #4's
guardian] will make an appointment for an
assessment by [local family services agency] for
7/25/18."

Interview on 9/25/18 and 10/1/18 with the
Qualified Professional/Residential Case Manager
revealed:

-FC #4's guardian refused to talk to them or come
to CFT meetings the entire month of June.

-The guardian finally came in July and FC #4 was
discharged 7/16/18, a week early, due to shutting
down the cottage for renovations.

-She confirmed intensive in-home services were
scheduled and found out they were expected to
see FC #4 a week after her discharge, 7/25/18.
-She asked for an appointment as soon as
possible; she assumed they could not get to the
home any sooner.

Interview on 10/1/08 with FC #4's therapist
revealed:

-It was not his recommendation to have FC #4 be
discharged prior to having something in place
within a couple of days of discharge.

-This was a risky case for that given FC#4's
guardian and her inconsistencies and
questionable support at home.

-FC #4 was ready to go home, it was more of
trying to get the guardian ready and the delay of
in-home services; she needed more time for that.

Division of Health Service Regulation
STATE FORM

6809

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHLO011-371 10/05/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE
GREEN LEVEL Ill
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 300] Continued From page 10 V 300

TY8T11

If continuation sheet 11 of 12

PRINTED: 10/12/2018

FORM APPROVED
Division of Health Service Re
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHLO011-371 10/05/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE
GREEN LEVEL Ill
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

Division of Health Service Regulation

STATE FORM

6809

TY8T11

If continuation sheet 12 of 12

document_type: Statement of Deficiency


summary: Plan of Correction - MHLCS Complaint

raw_content:
PRINTED: 08/20/2018

FORM APPROVED

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

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

MHLO011-371 B. WING __ 08/03/2018

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

2 COMPTON DRIVE
GREEN LEVEL Ill
ASHEVILLE, NC 28806

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

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

Vv 000 INITIAL COMMENTS Vv 000

Acomplaint survey was completed on 8/3/18.
The complaint was substantiated (Intake
#NC001 40645). Deficiencies were cited.

RECEIVED

By DHSR - Mental Health Lic. & Cert. Section at 11:41 am, Sep 10, 2018

This facility is licensed for the following service

category: 10A NCAC 27G .1700 Residential |
Treatment Staff Secure for Children or

Adolescents.

V 512 27D .0304 Client Rights - Harm, Abuse, Neglect Vv512 |

10A NCAC 27D .0304. =9PROTECTIONFROM
HARM, ABUSE, NEGLECT OREXPLOITATION
(a) Employees shall protect clients fromharm,
abuse, neglect and exploitation in accordance
with G.S. 122C-66.
(b) Employees shall not subject a client to any
sort of abuse or neglect, as defined in 10ANCAC
27C .0102 of this Chapter.
(c) Goods or services shall not be sold toor |
purchased from a client except through
established governing body policy.
(d) Employees shall use only that degree offorce
necessary to repel or secure a violent and
aggressive client and which is permitted by
governing body policy. The degree of force that
is necessary depends upon the individual
characteristics of the client (such as age, size
| and physical and mental health) and the degree
of aggressiveness displayed by the client. Use of
intervention procedures shall be compliance with |
Subchapter 10A NCAC 27E of this Chapter.
(e) Any violation by an employee of Paragraphs
| (a) through (d) of this Rule shall be grounds for
dismissal of the employee. |

This Rule is not met as evidenced by:
Based on interviews and record reviews one of

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

STATE FORM aoe 4w3011 If continuation sheet 7 of 12

0 W106) 1&—
vk Porfarnon O10 Otay DhynverinT—

PRINTED: 08/20/2018
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

Cc
08/03/2018

MHL011-371 B. WING

NAME OF PROVIDER OR SUPPLIER

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

GREEN LEVEL Ill

(x4) 1D ‘SUMMARY STATEMENT OF DEFICIENCIES iD PROVIDER'S PLAN OF CORRECTION (5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG BE DATE
| CROSS-REFERENCED TO THE
APPROPRIATE DEFICIENCY)
512 Continued From page 4 V512 27D .0304 Client Rights - Harm, Abuse,
‘Neglect
one former staff (Former Staff #1) exploited and
two of two Associate Professionals (Program Eliada’s Staff-Student Boundary Standards in | 8/6/18
Manager #1 and the Lead Night Residential Residential Treatment document has been
Counselor) failed to protect one of one client revised to include:
(Client #1) from exploitation and neglect. The 1. No tolerance statement
findings are: 2. Immediate reporting process that
includes both verbal and written
Review on 7/19/18 of Former Client (FC) #1's notification by concerned staff to the
record revealed: direct supervisor. Verbal
| -Admission 4/10/18 notification to occur immediately
-17 years old upon observation and written
-Diagnoses: Conduct Disorder, Unspecified documentation to be completed
Onset and Unspecified Trauma and Stressor within 24 hours.
Related Disorder . 3. Expectation for Direct Supervisor to
respond immediately to assess the
Review on 7/19/18 of an assessment for FC #1 concern and intervene to ensure
dated 3/1/18 and completed by the Qualified client safety.
Professional revealed: 4, Residential Director will develop
-FC #1 was beat up and left for dead by a gang and implement a plan of action
she belonged to; within 2 business days to address the
-she was physically abused by her father and staff's performance, assignment and
witnessed domestic abuse. employment status.
Review on 7/19/18 of FC #1's Person-Centered Staff-Student Boundary Standards in
Profile revealed: Residential Treatment are taught in Eliada’s
~"CHARACTERISTICS/OBSERVATION/JUSTIFI Residential Pre-Service Training with all
CATION FOR THIS GOAL: Client was assaulted new hires. A signed acknowledgement of
by former friends in gang-related activity, these standards is maintained in the
seriously injured in attack, family dynamics personnel record.
putting stress on the family unit."
-FC #1 "will demonstrate an improvement in post Eliada is implementing an online learning Access begins
traumatic stress symptoms, as evidenced by: ... system that will enhance pre-service training on 10/1/18.
2. Elimination of intrusive recollections and continuing education for all staff. All
3. Increased trust ; residential staff will complete the following Added to Pre-
4. Decrease in experiences of dissociation, course(s) to reduce the risk of exploitation Service
| depersonalization, derealization \ hrough the establishment of healthy training:

5. Increase in age-appropriate behaviors ...

7. Decreased irritability

8. Increased optimism ..."

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

professional boundaries: 10/8/18

1. Ethics, Rules and Boundaries for the Current staff to}
Paraprofessional ‘complete b:

STATE FORM ase 13011 If continuation sheet 2 of 12

PRINTED: 08/20/2018
FORM APPROVED

Division of Health Service Regulation

2. Boundaries and Dual Relationships 11/1/18
for Paraprofessionals (2.25 hours)

Reporting of and response to staff-student
boundary concerns, as well as general staff
performance will be enhanced through:

1. Eliada’s new hire mentorship TA2NB&
program that includes:
a. Shift partner assignment
| b. Review of completed new hire
| checklist
c. Individual supervision
completed with the Cottage |
Supervisor between 30-60 days
of their start date

d. Senior Leader mentor
assignment to support
onboarding with at least 3 |

supportive conferences.

e. Three week post-training follow
up call to review preparedness,
clarify practice standards and
identify support needs. Calls
facilitated by Eliada’s Agency
Trainer and/or Director of
Performance and Quality
Improvement.

2. Ongoing, documented individual 10/1/18
supervision provided by the
Residential Director with the
Assistant Residential Director bi-
weekly.

3. Ongoing , documented individual 10/1/18
supervision provided by the
Assistant Residential Director with
the following residential leaders:

| a. Cottage Supervisors

b. Night Residential Counselor

Managers
c. Crisis Manager
4. Revision of team supervision | 9/17/18

discussion of staff concerns and.

| meeting agendas to include detailed
program development needs with

corresponding action steps and.
| responsible staff assignments.
a. Residential Leadership Meeting
Agenda
b. Weekly Residential Cottage
Team Meeting Agenda
5. Corrective Action completed with 8/10/18

staff involved in this incident to

STATE FORM e200 1W3011 If continuation sheet 3 of 12

PRINTED: 08/20/2018
FORM APPROVED
Division of Health Service Regulation

address reporting and responding to
concerns.
A comprehensive review of residential 10/1/18
treatment program practices is being
completed and has resulted in the develop
and/or revision of the following protocols:
1. Student access to staff offices
2. Facilitation of student phone calls
3. Support walks and de-escalation |
strategies
4. Use of student-specific motivators to
reinforce positive behaviors,

Introduction of a new program structure for 8/15/18
Eliada’s LIII Residential Treatment

programs: A Hero’s Journey

Video surveillance has been installed in the | 8/22/18
Green Cottage staff office. |

Division of Health Service Regulation
STATE FORM 00 1w3011 I continuation sheet 4 of 12

PRINTED: 08/20/2018
FORM APPROVED
Division of Health Service Regulation

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

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

c
BWING _____ HH. 08/03/2018

MHL011-371

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE

ASHEVILLE, NC 28806

GREEN LEVEL Il!

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES 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)

V512 Continued From page 2 Vv512

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

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

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

Review on 7/19/18 of Former Staff #1's (FS #1)

personnel record revealed:

-position - Night Residential Counselor (NRC)

-date of hire 4/2/18 |
-date of termination 6/29/18

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

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

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

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

-FS #1 talked with her about having a family;
-they spent time together in the office of the
cottage with the door shut - the clients were

| allowed to call their family and had to have a staff
present while making these calls;
Division of Health Service Regulation

STATE FORM e800 1W3011 If continuation sheet 5 of 12

PRINTED: 08/20/2018
FORM APPROVED
Division of Health Service Regulation

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

c
MHL011-371 B. WING —________ 08/03/2018

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

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

GREEN LEVEL Ill

Continued From page 3

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

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

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

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

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

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

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

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

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

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

Record review on 7/26/18 of Staff #2's interview
with the local Department of Social Services
(DSS) revealed :
-she felt FS #1 was not appropriate in that he
“catered” to FC #1's needs more than other
clients;
-he would "check-in" with FC #1 for up to two
hours when check-ins were to be a maximum of
20 minutes;
-she confronted FS #1 about two months ago
Division of Health Service Regulation
STATE FORM 6890 1W3011 lf continuation sheet 6 of 12

PRINTED: 08/20/2018
FORM APPROVED

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED
c
MHL011-374 B. WING _ __$§—— 08/03/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2 GOMPTON DRIVE
GREEN LEVEL Il
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES. ID | PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 512 Continued From page 4 Vv 512

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

-she reported these concerns about FS #1 to her |
Program Manager (PM #1)" ...on three

occasions: 2 months ago, 1 month ago, and on

Thursday [6/28/18]";

-on 6/28/18 FC #1 disclosed to her she was ina

relationship with FS #1 and had been for about

three months.

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

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

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

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

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

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

-on 6/23/18 she provided FS #1 instantaneous
verbal feedback by discussing these concerns; |

-she realized there were a couple of "serious

flags",

-she " ...knew he needed corrective action

immediately ...coaching ..." but felt it was not her

place as she was not his direct supervisor;

-she voiced Staff #2's concems in the next PM

meeting, 6/26/18 ;

-the Assistant Residential Director asked her to

have Staff #2 write an email about her

Division of Health Service Regulation

STATE FORM e000 4W3011 If continuation sheet 7 of 12

PRINTED: 08/20/2018
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

c
08/03/2018

MHLO011-371 B.WING

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

ASHEVILLE, NC 28806

GREEN LEVEL Ili

(4) 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)

Continued From page 5

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

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

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

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

-"| have some concerns about staff [FS #1] and

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

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

revealed:

-she was FS #1's direct supervisor;

-the first she heard of "concerns" regarding FS

#1's work was at the PM meeting on 6/26/18; |
nothing specifically was mentioned about those
concerns and she felt like more information was
needed;

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

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

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

Division of Health Service Regulation
STATE FORM sate, 1w3011 if continuation sheet 8 of 12

PRINTED: 08/20/2018
FORM APPROVED

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

(X3) DATE SURVEY

(2) MULTIPLE CONSTRUCTION
COMPLETED

A. BUILDING:

Cc
08/03/2018

MHLO11-374 B. WING

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

NAME OF PROVIDER OR SUPPLIER

GREEN LEVEL It

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

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

Continued From page 6

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

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

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

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

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

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

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

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

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

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

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

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

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

-she immediately reported this to the Director of
Performance and Quality Improvement and the
Division of Health Service Regulation

STATE FORM 8809 1W3011 If continuation sheet 9 of 12

PRINTED: 08/20/2018
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

c
08/03/2018

MHL011-371 B. WING

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

ASHEVILLE, NC 28806

GREEN LEVEL Ill

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES Db | 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)

Continued From page 7

Residential Director.

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

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

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

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

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

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

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

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

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

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

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

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

-the PM was responsible to observe staff

interactions and take feedback from shift

partners;

-there was no procedure of this set in stone,

however generally speaking every staff member |
received "supervisory visits";

-if a PM received a verbal concem regarding a

staff member's performance she would expect

Division of Health Service Regulation

STATE FORM sano 1W3011 If continuation sheet 10 of 12

PRINTED: 08/20/2018
FORM APPROVED
Division of Health Service Regulation

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

(X3) DATE SURVEY
COMPLETED

c
08/03/2018

MHLO011-371 ENG

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

GREEN LEVEL Ill

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES. PROVIDER'S PLAN OF CORRECTION

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

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

V 512) Continued From page 8

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

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

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

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

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

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

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

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

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

-he was not aware the Lead NRC had verbally
coached FS #1 concerning boundary issues; |
-he was not aware of any "red flags" concerning

FS #1 until 6/28/18.

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

Division of Health Service Regulation
STATE FORM e800 4W3011 lf continuation sheet 11 of 12

PRINTED: 08/20/2018
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
08/03/2018

MHLO11-371 B. WING _____

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

ASHEVILLE, NC 28806

GREEN LEVEL It

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

PROVIDER'S PLAN OF CORRECTION

PREFIX {EACH CORRECTIVE ACTION SHOULD BE
TAG CROSS-REFERENCED TO THE APPROPRIATE

DEFICIENCY)

(X4) 1D
PREFIX
TAG

V512| Continued From page 9

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

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

"1. Eliada's Professional Boundaries with
Students and Staff "Red Flags" Protocol is being
revised to include clear reporting guidelines to |
immediate supervisors within 24 hours of the

observed behavior, documentation of the

observation and response by the Program

Director completed and documented within 2 |
business days. |
2. Eliada’s CEO will send an email

correspondence to ALL Eliada staff detailing the

shared responsibility of all employees to maintain

a safe environment for students and families, and

the clear expectation that any concerns be
communicated promptly to Eliada's PQI Director.
Eliada's Child Abuse Reporting Policy will be

included with this correspondence.

3. The Residential Director will develop and

implement a Corrective Action plan for the two
leadership staff involved in this situation [Lead

NRC and PM #1] by Tuesday, 8/7/18.

4, The Residential Director will initiate and

document bi-weekly individual supervision

sessions with the Residential Program Managers |

and the Lead NRC beginning the week of August

6, 2018. |
5. No students will be permitted in the cottage

offices. Student phone calls (in Eliada’s

Residential Programs) will be facilitated in

common areas, with the use of cordless phones.

If privacy is needed, the phone call will be

facilitated in the seclusion room, where there isa

video surveillance window in the doors for staff
observation.

Division of Health Service Regulation
STATE FORM ieee. 1W3011 lf continuation sheet 12 of 12

PRINTED: 08/20/2018
FORM APPROVED
Division of Health Service Regulation

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

(X3) DATE SURVEY
COMPLETED

c
08/03/2018

MHL011-371 B. WING

NAME OF PROVIDER OR SUPPLIER. STREET ADDRESS, CITY, STATE, ZIP CODE
2 COMPTON DRIVE

GREEN LEVEL Ill
ASHEVILLE, NC 28806

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

V512 Continued From page 10 V512

6. The office door in Green Cottage will be

removed to ensure line of sight and shift partner |
accountability until the video surveillance camera
is installed.” |

Describe your plans to make sure the above
happens.

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

3. The Residential Director will send a written
email correspondence to all Residential Staff on
8/3/18 detailing standards for student phone calls.
4. Awalk through of Green Cottage will be
completed prior to admission of studentson
8/8/18 to ensure the physical safety of the |

cottage, including open access/line of sight
| supervision from the cottage office."

FC #1 had a history of being assaulted and left
for dead by her friends associated in a gang with
her; was physically abused by her father and |

witnessed domestic abuse, She had difficulty
trusting others and was experiencing nightmares
from her trauma. FS #1 was hired 4/2/18 and
| by the end of April was in a relationship with FC
#1. FC #1 disclosed she and FS #1 had sex and
FS #1 said he wanted her to have his baby. PM
Division of Health Service Regulation
STATE FORM 8880 1W3011 if continuation sheet 13 of 12

PRINTED: 08/20/2018
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
08/03/2018

MHL011-371 B. WING

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

GREEN LEVEL Ill

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

DEFICIENCY)

Continued From page 11

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

Division of Health Service Regulation
STATE FORM e800 4W3011 lf continuation sheet 14 of 12

inspection_type: MHLCS Complaint