state: NC

facility_name: Luca's Hope III

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

raw_content:
Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHLO002-028

A. BUILDING:

243 LILEDOUN ROAD
TAYLORSVILLE, NC 28681

LUCA'S HOPE III

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 10/27/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R-C
10/10/2025

(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 (xs)
(EACH CORRECTIVE ACTION SHOULD BE. COMPLETE
CROSS-REFERENCED TO THE APPROPRIATE, DATE

DEFICIENCY)

V 000!

V 105]

INITIAL COMMENTS

A complaint and follow up survey was completed
on October 10, 2025. The complaint was
unsubstantiated (intake #NC00233424).
Deficiencies were cited.

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

This facility is licensed for 6 and has a current
census of 1. The survey sample consisted of
audits of 1 current client and 1 former client.

Asister facility is identified in this report. The
sister facility will be identified as sister facility A.

All staff at the facility are related. The Chief
Executive Officer/Director/Licensee (CEO/D/L) is
the Vice President/Licensee/Qualified
Professional (VP/L/QP)'s and Staff #1's Mother.
The VP/L/QP and Staff #1 are Sister and
Brother.The CEO/D/L is Staff #2's Aunt. Staff #2
and the VP/L/QP and Staff #1 are cousins and
Staff #3 is Staff #2's Aunt.

27G .0201 (A) (1-7) Governing Body Policies

10A NCAC 27G .0201 GOVERNING BODY
POLICIES

(a) The governing body responsible for each
facility or service shall develop and implement
written policies for the following:

(1) delegation of management authority for the
operation of the facility and services;

(2) criteria for admission;

(3) criteria for discharge;

(4) admission assessments, including:

(A) who will perform the assessment; and
(B) time frames for completing assessment.

Division of Health Service Regulation

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

STATE FORM

V 000

V 105

6899

7MO411

TITLE

(X6) DATE

If continuation sheet 1 of 64

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/27/2025
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL002-028 10/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
\ 243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 105] Continued From page 1 Vv 105

(5) client record management, including:

(A) persons authorized to document;

(B) transporting records;

(C) safeguard of records against loss, tampering,
defacement or use by unauthorized persons;

(D) assurance of record accessibility to
authorized users at all times; and

(E) assurance of confidentiality of records.

(6) screenings, which shall include:

(A) an assessment of the individual's presenting
problem or need;

(B) an assessment of whether or not the facility
can provide services to address the individual's
needs; and

(C) the disposition, including referrals and
recommendations;

(7) quality assurance and quality improvement
activities, including:

(A) composition and activities of a quality
assurance and quality improvement committee;
(B) written quality assurance and quality
improvement plan;

(C) methods for monitoring and evaluating the
quality and appropriateness of client care,
including delineation of client outcomes and
utilization of services;

(D) professional or clinical supervision, including
a requirement that staff who are not qualified
professionals and provide direct client services
shall be supervised by a qualified professional in
that area of service;

(E) strategies for improving client care;

(F) review of staff qualifications and a
determination made to grant
treatment/habilitation privileges:

(G) review of all fatalities of active clients who
were being served in area-operated or contracted
residential programs at the time of death;

(H) adoption of standards that assure operational

Division of Health Service Regulation
STATE FORM

6809

7MO411

If continuation sheet 2 of 64

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/27/2025
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL002-028 10/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
\ 243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 105] Continued From page 2 Vv 105

and programmatic performance meeting
applicable standards of practice. For this
purpose, "applicable standards of practice"
means a level of competence established with
reference to the prevailing and accepted
methods, and the degree of knowledge, skill and
care exercised by other practitioners in the field;

This Rule is not met as evidenced by:

Based on record review and interview, the facilty
failed to ensure admission screenings for
potential clients were conducted to include the
clients presenting problems and whether or not
the facility can provide the services the clients
need. The findings are:

Review on 9/26/25 of Former Client (FC) #5's
record revealed:

-A total of 9 pages.

-2 pages of July 2025 Medication Administration
Record (MARs), 2 pages of August 2025 MARs, 2
pages of September 2025 MARs, 2 pages
regarding placement of school and 1 page of the
Department of Social Services (DSS) legal
custody letter.

-MARs for July, August and September 2025 had
age 11 years old and diagnoses of Disruptive
Mood Disorder and Attention Deficit Hyperactivity
Disorder.

-No admission screening to include an
assessment of the client's presenting problems or

Division of Health Service Regulation
STATE FORM

6809

7MO411

If continuation sheet 3 of 64

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHLO002-028

A. BUILDING:

243 LILEDOUN ROAD

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/27/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R-C
10/10/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

needs.

Interview on 10/7/25 with FC #5's local DSS legal
guardian and DSS Supervisor revealed:

-FC #5 was admitted to the facility on 7/15/25 and
he was discharged on 9/5/25.

Interview on 10/8/25 with Staff #1 revealed:
-Was notified verbally by the Chief Executive
Officer/Director/Licensee (CEO/D/L) a “few hours
before" FC #5 was admitted to the facility.

Interview on 10/8/25 with Staff #2 revealed:

-Was "told" by the CEO/D/L "[FC #5] was going to
be a respite...he wasn't going to be there (facility)
that long..."

Interview on 10/6/25 with the Vice
President/Licensee/Qualified Professional
(VP/L/QP) revealed:

-"...work with [CEO/D/L] in tandem to see if the
kids (clients) are a good fit...A lot of information
comes from [CEO/D/L] first since she's been
doing it longer...We have video conferences with
the prospective client and the guardian and the
social worker...It's a group effort of DSS,
[CEO/D/L], but in the wheel house
(responsibilities) that will be me...That's dropping
the ball on my end and there are things we need
to start looking out for..."

-"We do have conversations (about clients). The
staff doesn't go in green (uninformed). We make
staff familiar with each of the kid's and each of
their diagnosis. It can be from the CCA
(Comprehensive Clinical Assessment) or the PCP
(Person Centered Plan/Treatment Plan) and staff
are aware of what is going on with these kids and
there are conversations going on at our meetings
of what has been happening and going on at the
house (facility). Staff are made very aware of

Division of Health Service Regulation

STATE FORM

6809

7MO411

LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 105] Continued From page 3 Vv 105

If continuation sheet 4 of 64

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHLO002-028

A. BUILDING:

243 LILEDOUN ROAD

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/27/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R-C
10/10/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

each kid's diagnosis and how to approach
them..."

-Documentation of client information was not
maintained.

Interviews on 9/26/25 and 10/6/25 with the
CEO/DIL revealed:

-The 9 documents she provided were the only
records she had for FC #5.

-"| take emergency placements for the county and
it might be for 1 night...He (FC #5) was admitted
as a DSS emergency situation...DSS said for a
day or night...when | take them (clients) this is all
| have (papers presented)...this is late at
night...he (FC #5) ended up staying longer
because the placement they had for him didn't
work out...we don't just take them without
information about them...with [FC #5] they (DSS)
just called and said ‘Just for one night...just one
night’..."

-"...Biggest thing (need) for him (FC #5) was his
bed wetting, incontinence."

-Policy prior to admissions was to "ask them
(referral agency) to send us something...an
updated CCA (Comprehensive Clinical
Assessment)...a PCP...some type of
evaluation...if we think it's (client) something we
can handle...depends on the group of kids
currently have too...If we want to move forward,
will contact them (for admission)..."

-"We (CEO/D/L and VP/L/QP) would tell them
(staff) about the clients. Things are told but we
are not documenting it."

-"Usually" the VP/L/QP was responsible to
conduct the admission screenings.

-"We (CEO/D/L and VP/L/QP) usually do a meet
and greet and get an idea if he (prospective
client) would fit with the group (clients)...think |
should be involved too and talk to them
(clients)..."

Division of Health Service Regulation

STATE FORM

6809

7MO411

LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 105] Continued From page 4 Vv 105

If continuation sheet 5 of 64

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/27/2025
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL002-028 10/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 105] Continued From page 5 Vv 105
-"Didn't do it (admission screening) because
thought (DHSR and DSS) were under the same
umbrella..."
This deficiency is cross referenced into 10A
NCAC 27G.1301 Scope (V179) for a Type A1 rule
violation and must be corrected within 23 days.
V 108] 27G .0202 (F-I) Personnel Requirements V 108

10A NCAC 27G .0202 PERSONNEL
REQUIREMENTS

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

(1) general organizational orientation;

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

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

(4) training in infectious diseases and
bloodborne pathogens.

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

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

Division of Health Service Regulation
STATE FORM

6809

7MO411

If continuation sheet 6 of 64

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHLO002-028

A. BUILDING:

243 LILEDOUN ROAD

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/27/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

R-C
10/10/2025

and communicable diseases of personnel and
clients.

This Rule is not met as evidenced by:

Based on record review and interview, the facility
failed to provide training to meet the mh/dd/sa
needs of the clients affecting 2 of 3 audited
paraprofessional staff (Staff #1 and #2). The
findings are:

Review on 9/26/25 of Staff #1's record revealed:
-Date of hire 9/6/23.

-Job title of Residential Counselor.

-No documentation of client specific mh/dd/sa
needs training.

Review on 9/26/25 of Staff #2's record revealed:
-Date of hire 12/13/23.

-Job title of Residential Counselor.

-No documentation of client specific mh/dd/sa
needs training.

Review on 9/26/25 of Former Client (FC) #5's
record revealed:

-A total of 9 pages.

-2 pages of July 2025 Medication Administration
Record (MARs), 2 pages of August 2025 MARs, 2
pages of September 2025 MARs, 2 pages
regarding placement of school and 1 page of the
Department of Social Services (DSS) legal
custody letter.

-MARs for July, August and September 2025 had
age 11 years old and diagnoses of Disruptive
Mood Disorder and Attention Deficit Hyperactivity
Disorder.

Division of Health Service Regulation
STATE FORM

6809

7MO411

LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 108] Continued From page 6 V 108

If

continuation sheet 7 of 64

PRINTED: 10/27/2025

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL002-028 10/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
\ 243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 108] Continued From page 7 V 108

-No documentation which identified the specific
mh/dd/sa needs.

Interview on 10/8/25 with Staff #1 revealed:
-Was notified verbally by the Chief Executive
Officer/Director/Licensee (CEO/D/L) a “few hours
before" FC #5 arrived to the facility.

-Was aware FC #5 had "Autism...talked about
he's very quiet...reserved...wets the bed
sometimes..."

-"...Been assigned so much, don't remember
(client specifics)..."

Interview on 10/8/25 with Staff #2 revealed:
-Was "told" by the CEO/D/L "[FC #5] was going to
be a respite...he wasn't going to be there (facility)
that long...he has some disabilities...know he had
some form of Autism...! did learn that he was a
bed wetter, that he had to wear pull ups..."

-She would normally read the clients
Comprehensive Clinical Assessment (CCA) to
learn about the client needs.

-She would also ask the Vice
President/Licensee/Qualified Professional
(VP/L/QP) and the CEO/D/L "as many questions
as | can, like his behavior, his dislikes and likes..."
Interview on 10/6/25 with the VP/L/QP revealed:
-"We do have conversations (client needs). The
staff doesn't go in green (uninformed). We make
staff familiar with each of the kids and each of
their diagnosis. It can be from the CCA or the
PCP (Person Centered Plan) and staff are aware
of what is going on with these kids (clients) and
there are conversations going on at our meetings
of what has been happening and going on at the
house (facility). Staff are made very aware of
each kids diagnosis and how to approach them. |
make them very aware of what's going on and
what has been brought up to me like during 1:1s

Division of Health Service Regulation

STATE FORM

6809

7MO411

If continuation sheet 8 of 64

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHLO002-028

A. BUILDING:

243 LILEDOUN ROAD
TAYLORSVILLE, NC 28681

LUCA'S HOPE III

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/27/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R-C
10/10/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

(x4) ID
PREFIX
TAG

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

ID
PREFIX
TAG

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

(xs)
COMPLETE
DATE

V 108

V 109]

Continued From page 8

(one-on-ones)...It's just something we have
shared (verbally)... think we are covered
because new staff never start alone..."

Interview on 10/6/25 with the CEO/D/L revealed:
-The VP/L/QP was responsible to ensure staff
were trained.

-"We do talk about the clients when we do our
staffing like what is going on with this client and
that client...We do talk about the kiddos
(clients)...We would tell them (new staff) about
the clients. Things are told but we are not
documenting it..."

This deficiency is cross referenced into 10A
NCAC 27G.1301 Scope (V179) for a Type A1 rule
violation and must be corrected within 23 days.

27G .0203 Privileging/Training Professionals

10A NCAC 27G .0203 COMPETENCIES OF
QUALIFIED PROFESSIONALS AND
ASSOCIATE PROFESSIONALS.

(a) There shall be no privileging requirements for
qualified professionals or associate professionals.
(b) Qualified professionals and associate
professionals shall demonstrate knowledge, skills
and abilities required by the population served.
(c) At such time as a competency-based
employment system is established by rulemaking,
then qualified professionals and associate
professionals shall demonstrate competence.

(d) Competence shall be demonstrated by
exhibiting core skills including:

(1) technical knowledge;

(2) cultural awareness;

(3) analytical skills;

(4) decision-making;

(5) interpersonal skills;

Division of Health Service Regulation
STATE FORM

V 108

V 109

6809

7MO411

If continuation sheet 9 of 64

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/27/2025
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL002-028 10/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
\ 243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 109] Continued From page 9 Vv 109

(6) communication skills; and

(7) clinical skills.

(e) Qualified professionals as specified in 10A
NCAC 27G .0104 (18)(a) are deemed to have
met the requirements of the competency-based
employment system in the State Plan for
MH/DD/SAS.

(f) The governing body for each facility shall
develop and implement policies and procedures
for the initiation of an individualized supervision
plan upon hiring each associate professional.
(g) The associate professional shall be
supervised by a qualified professional with the
population served for the period of time as
specified in Rule .0104 of this Subchapter.

This Rule is not met as evidenced by:

Based on record review and interview, 1 of 1
Qualified Professional (Vice
President/Licensee/Qualified Professional
(VP/L/QP)) failed to demonstrate the knowledge,
skills and abilities required by the population
served. The findings are:

Review on 9/26/25 of the VP/L/QP record
revealed:

-Date of hire: 8/7/23.

-Job title: QP.

-Job description signed and dated 8/7/23: "1.
Overall responsibility for the interdisciplinary
Team process with each individual served...Work
in conjunction with these individuals, other
professionals, consultants and staff in developing,
implementing, documenting, monitoring and

Division of Health Service Regulation
STATE FORM

6809

7MO411

If continuation sheet 10 of 64

PRINTED: 10/27/2025

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL002-028 TT 10/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
\ 243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 109] Continued From page 10 Vv 109

adjusting the plan of care and related
programs...2. Ensure admission and discharge
procedures are followed according to policy.
Coordinates admissions and discharges with the
appropriate staff. 3. Ensure, through regular
audits, that accurate and timely documentation is
occurring and that client records are maintained
according to policy. Prepare and submit required
or requested reports, documents, assessments,
evaluations and paperwork. Review and sign off
on clinical documentation as
required...Continuously use person-centered
approaches and positive approach strategies
when interacting with consumers. Integrate
strategies into program plans. 5. Provide direction
and supervision to staff...Monitor performance
and implementation of the responsibilities by
being present when day-to-day activities; routines
and rhythms are taking place, on all shifts and by
unannounced visits. 6. Ensure staff are
appropriately trained regarding plans and
demonstrate and understanding of specific plan
components..."

Review on 9/26/25 of Former Client (FC) #5's
record revealed:

-A total of 9 pages.

-2 pages of July 2025 Medication Administration
Record (MARs), 2 pages of August 2025 MARs, 2
pages of September 2025 MARs, 2 pages
regarding placement of school and 1 page of the
Department of Social Services (DSS) legal
custody letter.

-MARs for July, August and September 2025 had
age 11 years old and diagnoses of Disruptive
Mood Disorder and Attention Deficit Hyperactivity
Disorder (ADHD).

-There was no pre-admission screening,
assessment, treatment goals and strategies,
client specifics or physician orders.
Division of Health Service Regulation

STATE FORM 6899 7MO411 If continuation sheet 11 of 64

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/27/2025
FORM APPROVED

(X3) DATE SURVEY

Interview on 10/7/25 with FC #5's local DSS legal
guardian and DSS Supervisor revealed:

-DSS placed FC #5 at the facility on 7/15/25, and
he was discharged on 9/5/25.

-FC #5's needs were that he "bites himself
sometimes when he gets upset...and
incontinence."

Interview on 10/6/25 with the VP/L/QP revealed:
-"| should be responsible (for admission
assessments) but we have gone through them
together (her and the Chief Executive
Officer/Director/Licensee (CEO/D/L)). We have
video conferences with the prospective client and
the guardian and the social worker..."

-"| will be the one who does the PCP (Person
Centered Plan/Treatment Plan). It's a group effort
of DSS, and [CEO/D/L] but in the wheel house
(responsibilities) that will be me...That's dropping
the ball on my end (no treatment strategies) and
there are things we need to start looking out for.
We make sure of the focus that the kids (clients)
are meeting their goals."

-"We do have conversations (with staff about the
clients). The staff doesn't go in green
(uninformed). We make staff familiar with each of
the kids and each of their diagnosis... Staff are
made very aware of each kids diagnosis and how
to approach them. | make them very aware of
what's going and what has been brought up to me
like during 1:1s (one-on-ones) so there's never an
eyes closed situation with staff...It's just
something we have shared...| think we are
covered because new staff never start alone..."

This deficiency is cross referenced into 10A
NCAC 27G.1301 Scope (V179) for a Type A1 rule
violation and must be corrected within 23 days.

Division of Health Service Regulation
STATE FORM

6809

7MO411

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL002-028 10/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
\ 243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 109] Continued From page 11 Vv 109

If continuation sheet 12 of 64

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/27/2025
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL002-028 10/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 110) Continued From page 12 Vv 110
V 110| 27G .0204 Training/Supervision Vv 110

Paraprofessionals

10A NCAC 27G .0204 COMPETENCIES AND
SUPERVISION OF PARAPROFESSIONALS
(a) There shall be no privileging requirements for
paraprofessionals.

(b) Paraprofessionals shall be supervised by an
associate professional or by a qualified
professional as specified in Rule .0104 of this
Subchapter.

(c) Paraprofessionals shall demonstrate
knowledge, skills and abilities required by the
population served.

(d) At such time as a competency-based
employment system is established by rulemaking,
then qualified professionals and associate
professionals shall demonstrate competence.
(e) Competence shall be demonstrated by
exhibiting core skills including:

(1) technical knowledge;

(2) cultural awareness;

(3) analytical skills;

(4) decision-making;

(5) interpersonal skills;

(6) communication skills; and

(7) clinical skills.

(f) The governing body for each facility shall
develop and implement policies and procedures
for the initiation of the individualized supervision
plan upon hiring each paraprofessional.

This Rule is not met as evidenced by:

Division of Health Service Regulation
STATE FORM

6809

7MO411

If continuation sheet 13 of 64

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHLO002-028

A. BUILDING:

243 LILEDOUN ROAD

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/27/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R-C
10/10/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Based on record review and interview, 1 of 3
paraprofessional staff (Chief Executive
Officer/Director/Licensee (CEO/D/L)) failed to
demonstrate the knowledge, skills and abilities
required by the population served. The findings
are:

Review on 10/6/25 of the CEO/D/L record
revealed:

-Date of hire: 6/2/09.

-Job title: Owner/Executive Director.

-Job description unsigned and undated: "The
duties of the Owner/Executive Director vary within
the facility, but are responsible for the success of
the company...This position is responsible for
ensuring that each consumer receives supports
that are individually tailored and flexible..."

-Job description for Residential Counselor
(paraprofessional) signed by the CEO/D/L on
1/15/09: "...primarily responsible for the direct
implementation of individual goals...1. Support
and assist individuals in meeting their emotional,
physical, and medical needs as well as carrying
out day to day activities. Facilitate effective,
positive relationships with participants that are
person-centered utilizing positive approach and
promote independence throughout all daily
activities..."

Review on 10/3/25 of a "Staff and Client
Information" sheet completed by CEO/D/L on
10/3/25 revealed:

-A list of client names, admission dates,
discharge dates and location for the facility and
sister facility A.

-Former Client (FC) #5 was not listed as being a
client at the facility.

Review on 9/26/25 of FC #5's record revealed:
-A total of 9 pages.

Division of Health Service Regulation

STATE FORM

6809

7MO411

LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 110) Continued From page 13 Vv 110

If continuation sheet 14 of 64

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/27/2025
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL002-028 10/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
\ 243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 110) Continued From page 14 Vv 110

-2 pages of July 2025 Medication Administration
Record (MARs), 2 pages of August 2025 MARs, 2
pages of September 2025 MARs, 2 pages
regarding placement of school and 1 page of the
Department of Social Services (DSS) legal
custody letter.

-MARs for July, August and September 2025 had
age 11 years old and diagnoses of Disruptive
Mood Disorder and Attention Deficit Hyperactivity
Disorder.

-There was no pre-admission screening,
assessment, treatment goals and strategies,
client specifics or physician orders.

Interview on 10/7/25 with FC #5's local DSS legal
guardian and DSS Supervisor revealed:

-DSS placed FC #5 at the facility on 7/15/25, and
he was discharged on 9/5/25.

-FC #5 was admitted with both of his medications,
Aripiprazole (antipsychotic) and Clonidine HCL
(hydrochloride) (ADHD).

-FC #5's needs were that he "bites himself
sometimes when he gets upset...and
incontinence."

Interview on 10/6/25 with the CEO/D/L revealed:
-"| let [Vice President/Licensee/Qualified
Professional (VP/L/QP)] type that (Staff and
Client Information) for me, | should have worked
on it myself."

-The 9 documents provided were the only records
she had for FC #5.

-"He (FC #5) was admitted as a DSS emergency
situation...DSS said for a day or night...It's always
just 1 or 2 nights (according to what DSS says)...1
just don't want them (clients) to be on the
couches at DSS..."

-Was responsible to maintain the client records.
-She and the VP/L/QP were responsible to
complete the admission screenings,

Division of Health Service Regulation
STATE FORM

6809

7MO411

If continuation sheet 15 of 64

Division of Health Service Regulation

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

MHLO002-028

NAME OF PROVIDER OR SUPPLIER

A. BUILDING:

243 LILEDOUN ROAD
TAYLORSVILLE, NC 28681

LUCA'S HOPE III

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/27/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R-C
10/10/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

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

(x4) ID
PREFIX
TAG

ID
PREFIX
TAG

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

CROSS-REFERENCED TO THE APPROPRIATE, DATE
DEFICIENCY)

V 110) Continued From page 15

assessments and Person Centered Plans.

-Staff were supervised and trained by the
"[VP/L/QP] and myself. | like to be involved."
-"We (CEO/D/L and VP/L/QP) usually do a meet
and greet and get an idea if he (prospective
client) would fit with the group (clients)...think |
should be involved too and talk to them
(clients)..."

-"We do talk about the clients when we do our
staffing like what is going on with this client and
that client...That's the only time we get
together... Things are told but we are not
documenting it...We have a chat of what we need
to do ourselves...It's like a communication chat."
-"| am responsible for therapy sessions
(appointments). | am aware they need bi-monthly
sessions."

This deficiency is cross referenced into 10A
NCAC 27G.1301 Scope (V179) for a Type A1 rule
violation and must be corrected within 23 days.

V 111] 27G .0205 (A-B)

Assessment/Treatment/Habilitation Plan

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

(a) An assessment shall be completed for a
client, according to governing body policy, prior to
the delivery of services, and shall include, but not
be limited to:

(1) the client's presenting problem;

(2) the client's needs and strengths;

(3) a provisional or admitting diagnosis with an
established diagnosis determined within 30 days
of admission, except that a client admitted to a
detoxification or other 24-hour medical program
shall have an established diagnosis upon

Division of Health Service Regulation
STATE FORM

Vv 110

v 111

6809

7MO411

If continuation sheet 16 of 64

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/27/2025
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL002-028 10/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
\ 243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 111} Continued From page 16 vi111

admission;

(4) a pertinent social, family, and medical history;
and

(5) evaluations or assessments, such as
psychiatric, substance abuse, medical, and
vocational, as appropriate to the client's needs.
(b) When services are provided prior to the
establishment and implementation of the
treatment/habilitation or service plan, hereafter
referred to as the "plan," strategies to address the
client's presenting problem shall be documented.

This Rule is not met as evidenced by:

Based on record review and interview, the facilty
failed to ensure prior to the establishment and
implementation of the treatment/habilitation plan
strategies were identified to address the client's
presenting problem for 1 of 1 former client (FC
#5). The findings are:

Review on 9/26/25 of FC #5's record revealed:
-Age 11 years old and diagnoses of Disruptive
Mood Disorder and Attention Deficit Hyperactivity
Disorder per the Medication Administration
Records for July, August and September 2025.
-No documentation of an admission assessment
to address strategies for the client's presenting
problem.

Division of Health Service Regulation
STATE FORM

6809

7MO411

If continuation sheet 17 of 64

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHLO002-028

A. BUILDING:

243 LILEDOUN ROAD

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/27/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

R-C
10/10/2025

Interview on 10/7/25 with FC #5's local
Department of Social Services (DSS) legal
guardian and DSS Supervisor revealed:

-DSS placed FC #5 at the facility on 7/15/25 and
he was discharged on 9/5/25.

-FC #5's Comprehensive Clinical Assessment
(CCA) was reviewed with the CEO/D/L prior to
the client being admitted to the facility and a copy
of the CCA was provided to the CEO/D/L upon
admission.

Attempted review on 9/26/25 of FC #5's CCA was
unsuccessful. No CCA for FC #5 was provided
prior to the exit of the survey.

Interview on 10/8/25 with Staff #1 revealed:
-Was notified verbally by the CEO/D/L a "few
hours before" FC #5 was admitted to the
facility..."a few hours before he came, [CEO/D/L]
called and she gave me a quick update of him,
like he does have autism that | know of, and
that's been said by a doctor, and | know it was
talked about that he's very quiet, reserved and
like he wets the bed sometimes. It was a quick
update like that..."

Interview on 10/8/25 with Staff #2 revealed:

-Was "told" by the CEO/D/L "[FC #5] was going to
be a respite...he wasn't going to be there (facility)
that long...he has some disabilities...know he had
some form of Autism...! did learn that he was a
bed wetter, that he had to wear pull ups..."

-lf a new client was getting admitted to the facility,
"| would get a call from [CEO/D/L] or [VP/L/QP]...I
was told [FC #5] was going to be a respite, and
he wasn't going to be there (at the facility) that
long and he had some disabilities, and | want to
say the DSS worker didn't know all his diagnoses,
but he had some form of autism. [CEO/D/L] let
me know this...| learned he was a bedwetter and |

Division of Health Service Regulation
STATE FORM

6809

7MO411

LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 111} Continued From page 17 vi111

If continuation sheet 18 of 64

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHLO002-028

A. BUILDING:

243 LILEDOUN ROAD
TAYLORSVILLE, NC 28681

LUCA'S HOPE III

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/27/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

R-C
10/10/2025

(x4) ID
PREFIX
TAG

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

ID
PREFIX
TAG

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

(xs)
COMPLETE
DATE

v111

Vv 112

Continued From page 18

was made aware he had to wear pull ups. | knew
that before | worked with him. | think it was more
of an emergency placement."

Interview on 10/6/25 with the Vice
President/Licensee/Qualified Professional
(VP/L/QP) revealed:

-"...A lot of information comes from [CEO/D/L]
first since she's been doing it longer...| should be
responsible (for admission assessments) but we
have gone through them together, me and
[CEO/D/LJ...It's a group effort of DSS, [CEO/D/L],
but in the wheel house (responsibilities) that will
be me...That's dropping the ball on my end and
there are things we need to start looking out for..."
-"We do have conversations (about the clients).
The staff doesn't go in green (uninformed). We
make staff familiar with each of the kids’ (clients)
and each of their diagnosis...Staff are made very
aware of each kids diagnosis and how to
approach them..."

Interviews on 9/26/25 and 10/6/25 with the
CEO/DIL revealed:

-The 9 documents she provided were the only
records she had for FC #5.

-VP/L/QP was responsible to conduct the
admission assessments, "...but | want to be
involved..."

-"... think | should be involved too and talk to
them (clients)."

This deficiency is cross referenced into 10A
NCAC 27G.1301 Scope (V179) for a Type A1 rule
violation and must be corrected within 23 days.

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

Division of Health Service Regulation
STATE FORM

v 111

Vv 112

6809

7MO411

If continuation sheet 19 of 64

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/27/2025
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL002-028 10/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
\ 243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 112) Continued From page 19 Vv 112

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.

This Rule is not met as evidenced by:

Based on record review and interview, the facilty
failed to develop and implement treatment
strategies based on client needs within 30 days of
admission for 1 of 1 former client (FC #5). The
findings are:

Division of Health Service Regulation
STATE FORM

6809

7MO411

If continuation sheet 20 of 64

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHLO002-028

A. BUILDING:

243 LILEDOUN ROAD

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/27/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

R-C
10/10/2025

Review on 9/26/25 of FC #5's record revealed:
-Age 11 years old and diagnoses of Disruptive
Mood Disorder and Attention Deficit Hyperactivity
Disorder per the Medication Administration
Records from July, August and September 2025.
-No documentation of a treatment plan with
strategies to address client needs such as
incontinence and biting himself.

Interview on 10/7/25 with FC #5's local
Department of Social Services (DSS) legal
guardian and DSS Supervisor revealed:

-DSS placed FC #5 at the facility on 7/15/25 and
he was discharged on 9/5/25 back to his family.
-A copy of FC #5's Comprehensive Clinical
Assessment (CCA) was given to the Chief
Executive Officer/Director/Licensee (CEO/D/L)
upon admission.

-FC #5's needs were that he "bites himself
sometimes when he gets upset...and
incontinence."

-"... sent a long list of things we still needed for
[FC #5] including a PCP (Person Centered
Plan/Treatment Plan) and we (DSS and
CEO/D/L) had a conversation about this...| had to
send it (another list of things needed)...to
[CEO/D/L]...had a hard time keeping up. She
never produced a PCP..."

Interview on 10/8/25 with Staff #1 revealed:
-Was aware FC #5 had "...wets the bed
sometimes..."

-Not aware of any treatment goals and strategies
for FC #5.

Interview on 10/8/25 with Staff #2 revealed:
-Was "told" by the CEO/D/L "...he (FC #5) ..
a bed wetter, that he had to wear pull ups...
-Not aware of any treatment goals and strategies
for FC #5.

.was

Division of Health Service Regulation
STATE FORM

6809

7MO411

LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 112) Continued From page 20 Vv 112

If continuation sheet 21 of 64

Division of Health Service Regulation

PRINTED: 10/27/2025
FORM APPROVED

Interview on 9/23/25 and 10/6/25 with the Vice
President/Licensee/Qualified Professional
(VP/L/QP) revealed:

-"Both myself and [CEO/D/L] are responsible for
treatment plans. | am responsible for scheduling
treatment team meetings. The majority of the
time it is virtual because most of the people
involved prefer virtual..."

-"... will be the one who does the PCP. It's a
group effort of DSS, [CEO/D/L], but in the wheel
house that will be me...That's (keeping PCPs
current) dropping the ball on my end and there
are things we need to start looking out for. We
make sure of the focus that the kids (clients) are
meeting their goals..."

Interviews on 9/18/25, 9/26/25 and 10/6/25 with
the CEO/D/L revealed:

-The only records she possessed for FC #5
consisted of a total of 9 documents.

-She and the VP/L/QP were responsible for
completing PCPs.

-"CFTs (Child and Family Team) are initiated by
[VP/L/QP]...| will write things down if | am part of it
and [VP/L/QP] does, and now | realize we should
be adding more to it (PCP)..."

-"We have had CFT meetings, and | can show
that, but | haven't updated the PCPs...| have been
sick a lot and had to take care of my sister... We
(facility) haven't been required to submit
documentation like we used to. The meetings
(CFTs) have happened. | am now trying to get
caught up. They (clients) have been getting good
care...but | have got slack on the paperwork. |
have signature pages because after our CFT, |
send it to the guardian, and they sign it, but it is
up to me to update the plan. A lot of meetings are
virtual now and it's hard for everyone to physically
meet together. | send the signature pages. I've

Division of Health Service Regulation

STATE FORM

6808 7MO411

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL002-028 10/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
\ 243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 112) Continued From page 21 Vv 112

If continuation sheet 22 of 64

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/27/2025
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL002-028 10/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 112} Continued From page 22 Vv 112
never had to do that before..."
-"He (FC #5) was admitted as a DSS emergency
situation...DSS said for a day or night...It's always
just 1 or 2 nights (according to what DSS says)...1
just don't want them (clients) to be on the
couches at DSS..."
This deficiency is cross referenced into 10A
NCAC 27G.1301 Scope (V179) for a Type A1 rule
violation and must be corrected within 23 days.
V 113| 27G .0206 Client Records V 113

10A NCAC 27G .0206 CLIENT RECORDS

(a) Aclient record shall be maintained for each
individual admitted to the facility, which shall
contain, but need not be limited to:

1) an identification face sheet which includes:
‘A) name (last, first, middle, maiden);

client record number;

date of birth;

race, gender and marital status;

admission date;

) discharge date;

(2) documentation of mental illness,
developmental disabilities or substance abuse
diagnosis coded according to DSM IV;

(3) documentation of the screening and
assessment;

(4) treatment/habilitation or service plan;

(5) emergency information for each client which
shall include the name, address and telephone
number of the person to be contacted in case of
sudden illness or accident and the name, address
and telephone number of the client's preferred
physician;

(6) a signed statement from the client or legally
responsible person granting permission to seek
emergency care from a hospital or physician;

B
Cc
D

(
(
(
(
(
(
(

E
F

Division of Health Service Regulation
STATE FORM

6809

7MO411

If continuation sheet 23 of 64

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/27/2025
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL002-028 10/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
\ 243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 113) Continued From page 23 V 113

(7) documentation of services provided;

(8) documentation of progress toward outcomes;
(9) if applicable:

(A) documentation of physical disorders
diagnosis according to International Classification
of Diseases (ICD-9-CM);

(B) medication orders;

(C) orders and copies of lab tests; and

(D) documentation of medication and
administration errors and adverse drug reactions.
(b) Each facility shall ensure that information
relative to AIDS or related conditions is disclosed
only in accordance with the communicable
disease laws as specified in G.S. 130A-143.

This Rule is not met as evidenced by:

Based on record review and interview, the facilty
failed to maintain complete client records for 1 of
1 former client (FC #5). The findings are:

Review on 9/26/25 of FC #5's record revealed:

-A total of 9 pages.

-2 pages of July 2025 Medication Administration
Record (MARs), 2 pages of August 2025 MARs, 2
pages of September 2025 MARs, 2 pages
regarding placement of school and 1 page of the
Department of Social Services (DSS) legal
custody letter.

-MARs for July, August and September 2025 had
age 11 years old and diagnoses of Disruptive
Mood Disorder and Attention Deficit Hyperactivity
Disorder.

-There was no identification face sheet to include
a client record number, date of birth, race,

Division of Health Service Regulation
STATE FORM

6809

7MO411

If continuation sheet 24 of 64

Division of Health Service Regulation

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

MHLO002-028

NAME OF PROVIDER OR SUPPLIER

243 LILEDOUN ROAD

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 10/27/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

R-C
10/10/2025

LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 113) Continued From page 24 V 113

gender, admission date, or discharge date.
-No documentation of mental illness,
developmental disabilities, or substance abuse
diagnoses coded according to Diagnostic and
Statistical Manual of Mental Disorders (DSM) IV.
-No documentation an admission screening, or
admission assessment.

-No treatment/habilitation or service plan.

-No documentation of services that were
provided.

-No documentation of client progress toward
outcomes.

-No physician orders.

Interview on 10/7/25 with FC #5's local
Department of Social Services (DSS) legal
guardian and DSS Supervisor revealed:

-DSS placed FC #5 at the facility on 7/15/25 and
he was discharged on 9/5/25.

-A copy of FC #5's Comprehensive Clinical
Assessment (CCA) was provided to the Chief
Executive Officer/Director/Licensee (CEO/D/L)
upon admission.

Interview on 10/6/25 with the Vice
President/Licensee/Qualified Professional
revealed:

-"We do have conversations (with staff about
clients). The staff doesn't go in green
(uninformed). We make staff familiar with each of
the kid's (clients) and each of their diagnosis. It
can be from the CCA or the PCP (Person
Centered Plan/Treatment Plan) and staff are
aware of what is going on with these kids and
there are conversations going on at our meetings
of what has been happening and going on at the
house (facility). Staff are made very aware of
each kids diagnosis and how to approach them..."

Interviews on 9/26/25 and 10/6/25 with the

Division of Health Service Regulation
STATE FORM

6809

7MO411

If continuation sheet 25 of 64

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHLO002-028

A. BUILDING:

243 LILEDOUN ROAD
TAYLORSVILLE, NC 28681

LUCA'S HOPE III

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/27/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R-C
10/10/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

(x4) ID
PREFIX
TAG

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

ID
PREFIX
TAG

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

(xs)
COMPLETE
DATE

V 113

V 118)

Continued From page 25

CEO/DIL revealed:

-The 9 documents she provided were the only
records she had for FC #5.

-"...the filing is horrible. | used to do it (maintain
client records) but | got sick... will make sure |
am maintaining the records...I've been
updating...Let others help. | let [Staff #2] put
information like names, dates and stuff like that
and | found out that allowing her to complete
paperwork, she made mistakes. | saw paperwork
completed and not knowing it was incorrect. | am
going to go back to doing it myself. It should be
my responsibility...and | am going to take on
those things back myself."

-"We do talk about the clients when we do our
staffing like what is going on with this

client... Things are told but we are not
documenting it."

This deficiency is cross referenced into 10A
NCAC 27G.1301 Scope (V179) for a Type A1 rule
violation and must be corrected within 23 days.

27G .0209 (C) Medication Requirements

10A NCAC 27G .0209 MEDICATION
REQUIREMENTS

(c) Medication administration:

(1) Prescription or non-prescription drugs shall
only be administered to a client on the written
order of a person authorized by law to prescribe
drugs.

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

(3) Medications, including injections, shall be
administered only by licensed persons, or by
unlicensed persons trained by a registered nurse,
pharmacist or other legally qualified person and

Division of Health Service Regulation
STATE FORM

Vv 113

V 118

6809

7MO411

If continuation sheet 26 of 64

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/27/2025
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL002-028 10/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
\ 243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118) Continued From page 26 Vv 118

privileged to prepare and administer medications.
(4) A Medication Administration Record (MAR) of
all drugs administered to each client must be kept
current. Medications administered shall be
recorded immediately after administration. The
MAR is to include the following:

(A) client's name;

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

(C) instructions for administering the drug;

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

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

This Rule is not met as evidenced by:

Based on record review and interview, the facility
failed to ensure medications were administered
on the written order of a physician, failed to keep
the MAR current affecting 1 of 1 former client (FC
#5), and failed to ensure medications were
administered only by persons trained by a legally
qualified person to prepare and administer
medications for 2 of 3 paraprofessional staff
(Staff #1 and Staff #2). The findings are:

Finding #1:
Review on 9/26/25 of FC #5's record revealed:
-Age 11 years old and diagnoses of Disruptive
Mood Disorder and Attention Deficit Hyperactivity
Disorder per the MARs from July, August and
September 2025.

Division of Health Service Regulation
STATE FORM

6809

7MO411

If continuation sheet 27 of 64

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHLO002-028

A. BUILDING:

243 LILEDOUN ROAD

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/27/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R-C
10/10/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Interview on 10/7/25 with FC #5's local
Department of Social Services (DSS) legal
guardian and DSS Supervisor revealed:

-DSS placed FC #5 at the facility on 7/15/25 and
he was discharged on 9/5/25.

Review on 10/1/25 of FC #5's physician's orders
requested on 9/26/25 and received from the Chief
Executive Officer/Director/Licensee (CEO/D/L) on
10/1/25 revealed:

-Aripiprazole 5 mg 1 tablet daily written 8/8/25.
-Clonidine HCL 0.1 mg 1 tablet twice daily written
8/13/25.

-No physician's order to change the
administration directions of clonidine HCL from
twice daily to 1 tablet every night.

-No documentation of a physician's order to
administer "Allergy relief."

Review on 9/26/25 of FC #5's MARs dated July
2025 through September 2025 revealed:
-Aripiprazole (Autistic Disorder) 5 milligrams (mg)
1 tablet daily was initialed as administered
7/16/25-9/5/25 (24 doses prior to order dated
8/8/25.

-Clonidine HCL (hydrochloride) (ADHD) 0.1 mg
twice daily was initialed as administered
7/16/25-8/31/25 (57 doses prior to order dated
8/13/25).

-Clonidine HCL 0.1 mg had instructions to
administer "1 tablet every night" instead of twice
daily on the September 2025 MAR, but was
initialed as administered at 8am and 8pm
9/1/25-9/4/25 and at 8am on 9/5/25.

-"Allergy relief 5 mg" was documented as
"NON-PRESCRIPTION MEDICATION(S) GIVEN"
and initialed as administered once each day on
9/2/25, 9/3/25 and 9/4/25 with no instructions of
the frequency, route, or reason for administering

Division of Health Service Regulation

STATE FORM

6809

7MO411

LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118) Continued From page 27 Vv 118

If continuation sheet 28 of 64

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/27/2025
FORM APPROVED

(X3) DATE SURVEY

the medication.
Finding #2:

Review on 9/26/25 of Staff #1's record revealed:
-Date of Hire: 9/6/23.
-Medication administration training dated 4/30/25
signed by the Registered Nurse (RN) Medication
Training Consultant.

Review on 9/26/25 of Staff #2's record revealed:
-Date of Hire: 12/13/23.

-Medication administration training dated 4/30/25
signed by the RN Medication Training Consultant.

Interview on 9/29/25 with Staff #1 revealed:
-Was trained in medication administration "...it
was earlier this year (4/30/25)...She (RN
Medication Training Consultant) came in (to the
facility) and we talked about it (medication
administration) and everything...and then after we
talked about it, we would take the test, and she
would go over any questions we had."

-Could not recall the individual who observed his
return demonstration in medication
administration.

Interview on 9/25/25 and 10/8/25 with Staff #2
revealed:

-Received training in medication administration
on 4/30/25 from the RN Medication Training
Consultant.

-The 4/30/25 training did not include a return
demonstration by staff.

Interview on 9/22/25 with the RN Medication
Training Consultant revealed:

-Conducted medication administration training for
Luca's Hope Ill and Sister Facility A.

-"| rely some on [CEO/D/L]. She ensures me she

Division of Health Service Regulation

STATE FORM

6809

7MO411

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL002-028 10/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
\ 243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118) Continued From page 28 Vv 118

If continuation sheet 29 of 64

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/27/2025
FORM APPROVED

(X3) DATE SURVEY

works with them (facility staff) individually before
they can give medications...| didn't realize they
(facility staff) needed observed when trained."
-"| haven't ever actually observed a med
(medication pass)..."

Interview on 9/23/25 and 10/6/25 with the Vice
President/Licensee/Qualified Professional
(VP/L/QP) revealed:

-"No new staff are on by themselves, we don't
just throw them in...A senior staff will make sure
they can do it (medication administration). Most of
the time it is [CEO/D/L]. Staff are watched
passing (administering) medications on shift for
about 5 days, or however many days they are on
that week..."

-"... The PRNs are not listed (pre-typed) on the
MARs...If the client doesn't have any allergies
they are allowed over the counter (OTC)
medications. If an over the counter is given to a
client it should be charted on the back of the
MAR..."

-"| do review and look at MARs...but that's not my
wheelhouse or ownership, but I've done it. That
(reviewing MARs) could be me or [CEO/D/L].
Usually it's her (CEO/DIL)..."

Interview on 10/6/25 with the CEO/D/L revealed:
-"| had it (medication administration training)
years ago, and normally the nurse (Registered
Nurse) would come and go over things and test
us, but | never knew we had to demonstrate
(medication administration), do the pass as part
of the training."

-Responsible for completing the MARs monthly
and ensuring they were accurately updated in
accordance with physician's orders. "Normally it's
me, but it was one of the duties | gave to [Staff
#2], but | am going to go back to doing it. She
(Staff #2) was actually printing them (MARs) and

Division of Health Service Regulation

STATE FORM

6809

7MO411

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL002-028 10/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
\ 243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118) Continued From page 29 Vv 118

If continuation sheet 30 of 64

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/27/2025
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL002-028 10/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
\ 243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118) Continued From page 30 Vv 118

using the previous one...she would just update it,
pull it up and print them out. | will ensure they are
accurate."

-Facility staff were supposed to obtain a copy of
the physician's order whenever a client's
medication was changed. "| am going to tell them
(staff) to make sure we get a copy...We (facility
staff) have gotten slack at it..."

-OTC medications were administered to clients
as needed (PRN) based on known allergies
documented in their record.

-Moving forward, an authorization form would be
completed for all PRN OTC medications. The
form would be signed by both the prescribing
physician and the client's legal guardian.

Due to the failure to accurately document
medication administration, it could not be
determined if clients received their medications
as ordered by the physician.

Review on 10/6/25 of the Plan of Protection dated
10/6/25 written by the CEO/D/L revealed:

-"What immediate action will the facility take to
ensure the safety of the consumers in your care?
(V118) The facility has already completed a new
class with the nurse on 9/30/2025. The class was
Medication Administration that included staff
performing a pass demonstration of the
medication to be given to clients. The medication
class was preformed in front of a licensed
(Registered) Nurse. The facility will set in place a
checklist that will be utilized moving forward that
will have a list of items that must be provided
prior to completing an intake for a new client. This
new practice will ensure that a physician order is
present to indicate accuracy of the medication
that the new client should be taking. This
checklist will prevent clients being enrolled into
the facility without physician orders. Moving

Division of Health Service Regulation
STATE FORM

6809

7MO411

If continuation sheet 31 of 64

Division of Health Service Regulation

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

MHLO002-028

NAME OF PROVIDER OR SUPPLIER

A. BUILDING:

243 LILEDOUN ROAD

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/27/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

R-C
10/10/2025

LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118] Continued From page 31 Vv 118

forward we will ensure that all medications are
reviewed on a regular monthly basis so that
expired medications and med (medication) errors
are monitored so that this will not be an issue
moving forward. The facility will review/check all
medications to ensure that they are not out of
date. The facility will also ensure that medications
are reviewed and checked to ensure that the
prescription and mars are accurate and match
the doctor's order. The reviews and checks will
be done monthly, including the mars prevention
any medication errors. The facility has already set
in place a checklist that will include someone
reviewing and monitoring the medications, both
psychotropic and regular medications being
tracked and updated on a 6-month basis to
ensure that mediation is being given appropriately
as prescribed. The QP (VP/L/QP) will assist the
Director (CEO/D/L) with oversight of this being
set in place and implemented including followed
through. The medication errors will include when
a client refuses to take the medication or if the
staff fails to give medication within the window
timeframe, staff will call the pharmacy or the
doctor and inform them of the client not getting
their medication and get instructions on possible
side effects, what to look for because of client not
getting their medication as prescribed whether it's
from them refusing or staff forgetting to give the
medication.

Describe your plans to make sure the above
happens.

The facility has already created forms to include
the QP & Director who will monitor and document
that these practices mentioned above are being
met on a regular basis. There will be more new
forms created that will be signed on a
weekly/monthly basis effective immediately to
ensure that the above areas that are out of

Division of Health Service Regulation
STATE FORM

6809

7MO411

If continuation sheet 32 of 64

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/27/2025
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL002-028 10/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
\ 243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118) Continued From page 32 Vv 118

compliance are being met and moving forward
will not be an issue. This will be completed on a
weekly/monthly basis to show that we are back in
compliance."

Review on 10/7/25 of the addendum to the Plan
of Protection dated 10/7/25 written by the
CEO/DIL revealed:

-"What immediate action will the facility take to
ensure the safety of the consumers in your care?
... The facility completed a class on 9/30/2025 that
involved each employee performing a simulated
return demonstration on how to give medication
to clients. The facility staff demonstrated the
return of medication administration while being
monitored by a licensed nurse...a list of items that
must be provided prior to completing an intake for
all new clients being enrolled into the

program. ..enrolled into the facility without
physician orders for their prescribe
medications...Moving forward the facility will
ensure that all medications are reviewed...The
reviews will be completed by the QP or the
Director...including the Mars in order to prevent
any possible medication errors... The QP or
Director reviewing client medications...showing
that they are being tracked and updated on a
6-month basis... The QP will assist the Director
with oversight regarding the checklist and
monitoring. The Mar will also reflect if a client
refuses to take their prescribed medication...

Describe your plans to make sure the above
happens.

..created forms to include the QP & Director
whom will monitor and document...as stated.
There will be more new forms created...effective
immediately. To ensure...moving forward will no
longer be an issue..."

Division of Health Service Regulation
STATE FORM

6809

7MO411

If continuation sheet 33 of 64

Division of Health Service Regulation

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

MHLO002-028

NAME OF PROVIDER OR SUPPLIER

A. BUILDING:

243 LILEDOUN ROAD
TAYLORSVILLE, NC 28681

LUCA'S HOPE III

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/27/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R-C
10/10/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

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

(x4) ID
PREFIX
TAG

ID
PREFIX
TAG

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

CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

V 118) Continued From page 33

FC #5 was 11 years old with diagnoses which
included Disruptive Mood Disorder and ADHD.
While residing at the facility, FC #5 was
administered aripiprazole daily from
7/16/25-8/8/25 for a total of 24 doses, clonidine
twice daily from 7/16/25-8/13/25 for a total of 57
doses, and allergy relief medication from
9/2/25-9/4/25 for a total of 3 doses, without
evidence of a physician's order. A physician's
order for FC #5 dated 8/13/25, authorized that
clonidine be administered twice daily. FC #5's
MAR for the period of 9/1/25-9/5/25 listed
instructions to administer one tablet nightly. FC
#5's MAR was initialed to indicate the clonidine
was administered twice daily, reflecting a
discrepancy between the prescribed dosage and
the documented administration. Staff #1 and Staff
#2 received formal medication administration
training conducted by a Registered Nurse.
However, they did not complete a return skills
demonstration observed by a Registered Nurse
following the training to validate their competency
in safely and accurately administering
medications.

This deficiency constitutes a Type B rule violation
which is detrimental to the health, safety and
welfare of the clients and must be corrected
within 45 days.

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

Verification

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

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

Division of Health Service Regulation
STATE FORM

V 118

Vv 131

6809

7MO411

If continuation sheet 34 of 64

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/27/2025
FORM APPROVED

(X3) DATE SURVEY

of access in the appropriate business files.

This Rule is not met as evidenced by:

Based on record review and interview, the facility
failed to access the Health Care Personnel
Registry (HCPR) prior to an offer of employment
for 3 of 6 audited staff (Staff #1, Staff #2, and the
Vice President/Licensee/Qualified Professional
(VP/L/QP)). The findings are:

Review on 9/26/25 of Staff #1's record revealed:
-Date of Hire: 9/6/23.
-HCPR accessed on 10/5/23.

Review on 9/26/25 of Staff #2's record revealed:
-Date of Hire: 12/13/23.
-HCPR accessed on 12/14/23.

Review on 9/26/25 of the VP/L/QP's record
revealed:

-Date of Hire: 8/7/23.

-HCPR accessed on 9/8/24.

Interview on 9/23/25 with the VP/L/QP revealed:
-"[Chief Executive Officer/Director/Licensee
(CEO/D/L)] is responsible for HCPR...I have
helped in the past but it is [CEO/D/L] who is
accountable."

Interview on 10/6/25 with the CEO/D/L revealed:
-"| am responsible for...HCPR (checks)... go in
and request the information...it was a mistake on
my part, that's my fault...! was responsible for
that...| know it should be done prior to being

Division of Health Service Regulation

STATE FORM

6809

7MO411

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL002-028 10/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
\ 243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 131] Continued From page 34 Vv 131

If continuation sheet 35 of 64

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHLO002-028

A. BUILDING:

243 LILEDOUN ROAD

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/27/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

R-C
10/10/2025

Allegations, & Protection

G.S. §131E-256 HEALTH CARE PERSONNEL
REGISTRY
(g) Health care facilities shall ensure that the
Department is notified of all allegations against
health care personnel, including injuries of
unknown source, which appear to be related to
any act listed in subdivision (a)(1) of this section.
(which includes:

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

c. Misappropriation of the property of a
healthcare facility.

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

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.

Division of Health Service Regulation
STATE FORM

6809

7MO411

LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 131] Continued From page 35 Vv 131
hired. It just happened. | was responsible for
that...| don't know what happened..."
V 132} G.S. 131E-256(G) HCPR-Notification, V 132

If continuation sheet 36 of 64

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHLO002-028

PRINTED: 10/27/2025

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

STREET ADDRESS, CITY, STATE, ZIP CODE

243 LILEDOUN ROAD

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R-C
10/10/2025

This Rule is not met as evidenced by:

Based on record review and interview, the facility
failed to protect clients from harm during an
investigation and failed to report, within 5 working
days, the results of the investigation to the
Department. The findings are:

Reviews on 9/25/25 and 10/8/25 of the North
Carolina Incident Response and Reporting (IRIS)
revealed:

-Former Client (FC) #2's allegation of abuse
against Staff #1 on 8/27/25 had a submission
date of 8/30/25. No internal investigation was
attached.

-FC #3 allegation of abuse against Staff #1 on
8/28/25 had a submission date of 9/1/25. Internal
investigation was submitted on 10/8/25.

Interview on 9/29/25 with the local Department of
Social Services (DSS) Investigator revealed:
-8/27/25 - FC #2 alleged "...[Staff #1]...slapped
him (FC #2) across the face...he had pretty
significant bruising on his ear..."

-8/28/25 - FC #3 alleged "[Staff #1] slammed his
head on the ground...he (FC #3) did have a bump
on his head..."

-On the evening of 8/27/25 FC #2 was removed
from the facility by DSS due to the abuse
allegation.

-Staff #1 continued to work on shift when she left
the evening of 8/27/25 (after the first allegation).
-On 8/28/25 FC #3 was removed from the facility
by DSS due to the abuse allegation.

-On 8/28/25 the Chief Executive
Officer/Director/Licensee (CEO/D/L) "...made the
decision to remove [Staff #1] and said 'He (Staff
#1) would no longer be employed at the home
(facility).""

Interview on 9/26/25 with the Vice

Division of Health Service Regulation
STATE FORM

6808 7MO411

LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 132] Continued From page 36 V 132

If continuation sheet 37 of 64

Division of Health Service Regulation

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

MHLO002-028

NAME OF PROVIDER OR SUPPLIER

A. BUILDING:

243 LILEDOUN ROAD
TAYLORSVILLE, NC 28681

LUCA'S HOPE III

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/27/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R-C
10/10/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

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

(x4) ID
PREFIX
TAG

ID
PREFIX
TAG

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

CROSS-REFERENCED TO THE APPROPRIATE, DATE
DEFICIENCY)

V 132] Continued From page 37

President/Licensee/Qualified Professional
(VP/L/QP) revealed:

-On the evening of 8/27/25 the CEO/D/L called to
inform her FC #2 made an allegation of abuse
against Staff #1.

-On 8/28/25 she was notified FC #3 made an
allegation of abuse against Staff #1.

-Staff #1 continued to work throughout the night
shift on 8/27/25 into the morning of 8/28/25.
-"After the 28th (8/28/25) we (she and the
CEO/D/L) went ahead and suspended (Staff
#1)..."

-The abuse investigations for FC #2 and FC #3
were completed on 9/1/25.

Interviews on 9/26/25, 9/29/25 and 10/7/25 with
the CEO/D/L revealed:

-On 8/27/25 at 7:00 p.m. she received a call from
Staff #2 that DSS was there and FC #2 made an
abuse allegation against Staff #1.

-On the evening of 8/28/25, DSS returned due to
FC #3 allegation of abuse against Staff #1.
-Staff #1 was working on 8/27/25 (after the first
allegation) and continued to work into the
morning of 8/28/25. He walked the clients to
school that morning.

-The IRIS reports were not submitted, "I started it
(IRIS), but | didn't save it..."

V 133] G.S. 122C-80 Criminal History Record Check
G.S. §122C-80 CRIMINAL HISTORY RECORD
CHECK REQUIRED FOR CERTAIN
APPLICANTS FOR EMPLOYMENT.

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

V 132

V 133

Division of Health Service Regulation
STATE FORM

6808 7MO411

If continuation sheet 38 of 64

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/27/2025
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL002-028 10/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
\ 243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 133] Continued From page 38 V 133

Chapter.

(b) Requirement. - An offer of employment by a
provider licensed under this Chapter to an
applicant to fill a position that does not require the
applicant to have an occupational license is
conditioned on consent to a State and national
criminal history record check of the applicant. If
the applicant has been a resident of this State for
less than five years, then the offer of employment
is conditioned on consent to a State and national
criminal history record check of the applicant. The
national criminal history record check shall
include a check of the applicant's fingerprints. If
the applicant has been a resident of this State for
five years or more, then the offer is conditioned
on consent to a State criminal history record
check of the applicant. A provider shall not
employ an applicant who refuses to consent to a
criminal history record check required by this
section. Except as otherwise provided in this
subsection, within five business days of making
the conditional offer of employment, a provider
shall submit a request to the Department of
Justice under G.S. 114-19.10 to conduct a
criminal history record check required by this
section or shall submit a request to a private
entity to conduct a State criminal history record
check required by this section. Notwithstanding
G.S. 114-19.10, the Department of Justice shall
return the results of national criminal history
record checks for employment positions not
covered by Public Law 105-277 to the
Department of Health and Human Services,
Criminal Records Check Unit. Within five
business days of receipt of the national criminal
history of the person, the Department of Health
and Human Services, Criminal Records Check
Unit, shall notify the provider as to whether the
information received may affect the employability

Division of Health Service Regulation
STATE FORM

6809

7MO411

If continuation sheet 39 of 64

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/27/2025
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL002-028 10/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
\ 243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 133] Continued From page 39 V 133

of the applicant. In no case shall the results of the
national criminal history record check be shared
with the provider. Providers shall make available
upon request verification that a criminal history
check has been completed on any staff covered
by this section. A county that has adopted an
appropriate local ordinance and has access to
the Division of Criminal Information data bank
may conduct on behalf of a provider a State
criminal history record check required by this
section without the provider having to submit a
request to the Department of Justice. In such a
case, the county shall commence with the State
criminal history record check required by this
section within five business days of the
conditional offer of employment by the provider.
All criminal history information received by the
provider is confidential and may not be disclosed,
except to the applicant as provided in subsection
(c) of this section. For purposes of this
subsection, the term "private entity" means a
business regularly engaged in conducting
criminal history record checks utilizing public
records obtained from a State agency.

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

(1) The level and seriousness of the crime.

(2) The date of the crime.

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

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

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

(6) The prison, jail, probation, parole,

Division of Health Service Regulation
STATE FORM

6809

7MO411

If continuation sheet 40 of 64

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/27/2025
FORM APPROVED

(X3) DATE SURVEY

rehabilitation, and employment records of the
person since the date the crime was committed.
(7) The subsequent commission by the person of
a relevant offense.

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

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

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

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

Division of Health Service Regulation
STATE FORM

6809

7MO411

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL002-028 10/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
\ 243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 133] Continued From page 40 V 133

If continuation sheet 41 of 64

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/27/2025
FORM APPROVED

(X3) DATE SURVEY

Sex Offenses; Article 8, Assaults; Article 10,
Kidnapping and Abduction; Article 13, Malicious
Injury or Damage by Use of Explosive or
Incendiary Device or Material; Article 14, Burglary
and Other Housebreakings; Article 15, Arson and
Other Burnings; Article 16, Larceny; Article 17,
Robbery; Article 18, Embezzlement; Article 19,
False Pretenses and Cheats; Article 19A,
Obtaining Property or Services by False or
Fraudulent Use of Credit Device or Other Means;
Article 19B, Financial Transaction Card Crime
Act; Article 20, Frauds; Article 21, Forgery; Article
26, Offenses Against Public Morality and
Decency; Article 26A, Adult Establishments;
Article 27, Prostitution; Article 28, Perjury; Article
29, Bribery; Article 31, Misconduct in Public
Office; Article 35, Offenses Against the Public
Peace; Article 36A, Riots and Civil Disorders;
Article 39, Protection of Minors; Article 40,
Protection of the Family; Article 59, Public
Intoxication; and Article 60, Computer-Related
Crime. These crimes also include possession or
sale of drugs in violation of the North Carolina
Controlled Substances Act, Article 5 of Chapter
90 of the General Statutes, and alcohol-related
offenses such as sale to underage persons in
violation of G.S. 18B-302 or driving while
impaired in violation of G.S. 20-138.1 through
G.S. 20-138.5.

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

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

Division of Health Service Regulation
STATE FORM

6809

7MO411

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL002-028 10/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
\ 243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 133] Continued From page 41 V 133

If continuation sheet 42 of 64

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/27/2025
FORM APPROVED

(X3) DATE SURVEY

following requirements are met:

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

This Rule is not met as evidenced by:

Based on record review and interview, the facility
failed to request a criminal history record check
within 5 days of making the conditional offer of
employment for 1 of 6 audited staff (Staff #1).
The findings are:

Review on 9/26/25 of Staff #1's record revealed:
-Date of Hire: 9/6/23.

-Criminal history record check requested
10/12/23.

Interview on 9/23/25 with the Vice
President/Licensee/Qualified Professional
revealed:

-"[Chief Executive Officer/Director/Licensee
(CEO/D/L)] is responsible for...background
checks. | have helped in the past but it is
[CEO/D/L] who is accountable."

Interview on 10/6/25 with the CEO/D/L revealed:
-"| am responsible for background checks...1 go in

Division of Health Service Regulation

STATE FORM

6809

7MO411

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL002-028 10/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
\ 243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 133] Continued From page 42 V 133

If continuation sheet 43 of 64

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/27/2025
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL002-028 10/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 133] Continued From page 43 V 133
and request the information. It takes a day or
two...it was a mistake on my part, that's my
fault... know it should be done prior to being
hired. It just happened. | was responsible for that.
[Staff #1] was hired before (in 2019)...He left and
got rehired...He came back in 2023...1 don't know
what happened..."
V 179] 27G .1301 Residential Tx - Scope Vv 179

10A NCAC 27G .1301 SCOPE

(a) The rules of this Section apply only to a
residential treatment facility that provides
residential treatment, level Il, program type
service.

(b) Aresidential treatment facility providing
residential treatment, level III service, shall be
licensed as set forth in 10A NCAC 27G .1700.

(c) Aresidential treatment facility for children and
adolescents is a free-standing residential facility
which provides a structured living environment
within a system of care approach for children or
adolescents who have a primary diagnosis of
mental illness or emotional disturbance and who
may also have other disabilities.

(d) Services shall be designed to address the
functioning level of the child or adolescent and
include training in self-control, communication
skills, social skills, and recreational skills.
Children or adolescents may receive services in a
day treatment facility, have a job placement, or
attend school.

(e) Services shall be designed to support the
child or adolescent in gaining the skills necessary
to return to the natural, or therapeutic home
setting.

(f) The residential treatment facility shall
coordinate with other individuals and agencies
within the client's system of care.

Division of Health Service Regulation
STATE FORM

6809

7MO411

If continuation sheet 44 of 64

PRINTED: 10/27/2025

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL002-028 TT 10/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
\ 243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 179] Continued From page 44 v 179

This Rule is not met as evidenced by:

Based on record review and interview, the facility
failed to provide a structured living environment
within a system of care approach for children or
adolescents who have a primary diagnoses of
mental illness, emotional disturbance and who
may have other disabilities, affecting 1 of 1
current client (Client #1) and 1 of 1 former client
(FC #5). The findings are:

Cross reference: 10A NCAC 27G.0201 Governing
Body Policies (V105). Based on record review
and interview, the facilty failed to ensure
admission screenings for potential clients were
conducted to include the clients presenting
problems and whether or not the facility can
provide the services the clients need.

Cross reference: 10A NCAC 27G.0202 Personnel
Requirements (V108). Based on record review
and interview, the facility failed to provide training
to meet the mh/dd/sa needs of the clients
affecting 2 of 3 audited paraprofessional staff
(Staff #1 and #2).

Cross reference: 10A NCAC 27G.0203
Competencies of Qualified Professionals &
Associate Professionals (V109). Based on record
review and interview, 1 of 1 Qualified Professional
(Vice President/Licensee/Qualified Professional
(VP/L/QP)) failed to demonstrate the knowledge,
Division of Health Service Regulation

STATE FORM 6899 7MO411 If continuation sheet 45 of 64

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHLO002-028

A. BUILDING:

243 LILEDOUN ROAD

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/27/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

R-C
10/10/2025

skills and abilities required by the population
served.

Cross reference: 10A NCAC 27G.0204
Competencies and Supervision of
Paraprofessionals (V110). Based on record
review and interview, 1 of 3 paraprofessional staff
(Chief Executive Officer/Director/Licensee
(CEO/D/L)) failed to demonstrate the knowledge,
skills and abilities required by the population
served.

Cross reference: 10A NCAC 27G.0205
Assessment and Treatment/Habilitation or
Service Plan (V111). Based on record review and
interview, the facilty failed to ensure prior to the
establishment and implementation of the
treatment/habilitation plan strategies were
identified to address the client's presenting
problem for 1 of 1 former client (FC #5).

Cross reference: 10A NCAC 27G.0205
Assessment and Treatment/Habilitation or
Service Plan (V112). Based on record review and
interview, the facilty failed to develop and
implement treatment strategies based on client
needs within 30 days of admission for 1 of 1
former client (FC #5).

Cross reference: 10A NCAC 27G.0206 Client
Records (V113). Based on record review and
interview, the facilty failed to maintain complete
client records for 1 of 1 former client (FC #5).

Cross reference: 10A NCAC 27G.1302 Staff
(V180). Based on record review and interview,
the facility failed to ensure that clinical
consultation was provided by a qualified mental
health professional (QMHP) at least twice a
month and failed to ensure at least one direct

Division of Health Service Regulation
STATE FORM

6809

7MO411

LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 179] Continued From page 45 v 179

If continuation sheet 46 of 64

Division of Health Service Regulation

PRINTED: 10/27/2025

FORM APPROVED

care staff was present and providing supervision
at all times affecting 1 of 1 current client (Client
#1) and 1 of 1 former client (FC #5).

Review on 10/10/25 of the plan of protection date
10/10/25 written by the CEO/D/L revealed:
-"What immediate action will the facility take to
ensure the safety of the consumers in your care?
(V179/V105) The facility will utilize its admissions
and intake criteria to screen and determine if a
potential client meets our inclusionary criteria for
the overall program. This process will determine
whether the program can meet the clients needs.
All applicants or potential new admissions will be
required to go through the facility screening
process. The screening process includes;
submitting an application, updated
Comprehensive clinical assessment for review, a
signed service order, including a current PCP
(Person Centered Plan). These documents will be
reviewed by the Director (CEO/D/L) and the
QMHP (Qualified Mental Health Professional
(VP/L/QP)) to determine if the potential client can
be accepted into the program. Upon determining
whether a client can be admitted, the facility must
receive the following documents; Birth Certificate,
social security card, copy of insurance or
medicaid card. All documents mentioned above
must be received by the facility before the intake
process takes place and the client is admitted.
(V108) The facility will ensure that all staff will
receive upon and maintain annually training for
CPR (cardiopulmonary resuscitation), First Aide
training, Bloodborne Pathogens training,
Emergency Action Procedures, Safety classes,
clients rights, confidentiality, EBPI (Evidence
Based Protective Interventions), Medication
Administration, seizure management, Client
specific, Documentation, and goal planning.
There will also be a minimum of 12 in-service

Division of Health Service Regulation
STATE FORM

6809

7MO411

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL002-028 10/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
\ 243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 179] Continued From page 46 v 179

If continuation sheet 47 of 64

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/27/2025
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL002-028 10/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
\ 243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 179] Continued From page 47 v 179

training hours required per year. This also
includes continuing education that may be
necessary in areas that will benefit the care of
clients and quality of the facility. This will be
monitored by the Director and the QMHP.
Quarterly Record reviews will be completed on all
staff training records ensuring that all required
classes and training are kept current.
(V109/V110) The facility will ensure that the the
Qualified Professional will meet the requirements
and demonstrate knowledge and competence by
exhibiting the following skills: technical
knowledge, cultural awareness, analytical skills,
decision-making, interpersonal skills,
communication skills, and clinical skills. The
director will monitor and supervise the Qualified
Mental Health Professional. Ensuring all
responsibilities are being accurately completed
within the required timeframe. This will be done
by weekly administrative meetings and monthly
staff meetings that are mandatory.

(V111/112) The facility will ensure that all
assessments and treatment plans will be
completed within 30 days of admission and will
continue being updated on a monthly basis by the
QMHP and supervised by the Director.

(V113) The facility will ensure that all records and
documentation for any client in need of respite
and emergency services must provide all required
documentation that is required to be in their file.
This includes a copy of a physician's order for
medication, copy of birth certificate, Copy of
Insurance or medicaid card, Emergency contact
and a completed application.

(V180) The facility will ensure that all clients
receiving services will be enrolled with mental
health provider for clinical consultation within 30
days of admission. The QMHP will initiate this
process. The director will supervise.
Describe you plans to make sure the above

Division of Health Service Regulation
STATE FORM

6809

7MO411

If continuation sheet 48 of 64

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/27/2025
FORM APPROVED

(X3) DATE SURVEY

happens.

The facility will contact and begin utilizing an
outside professional consultant by October 17th,
2025. The facility will work with the consultant to
monitor our progress with meeting the
requirements in the plan of protection. The facility
will also schedule a staff training as a refresher
on Safety, clients rights, confidentiality, Client
specific, and Documentation focusing on incident
reports and writing incident reports within the
required time frame by October 17th."

Review on 10/10/25 of the addendum to the plan
of protection dated 10/10/25 written by the
CEO/DIL revealed:

-"What immediate action will the facility take to
ensure the safety of the consumers in your care?
...(V109/V110) The hired consultant will ensure
that the Qualified Professional (VP/L/QP) will
meet the requirements and demonstrate
knowledge and competence...The consultant will
monitor and supervise the Qualified Mental
Health Professional and the director.
(V113)...The facility will ensure that all records
and documentation for any client in need of
services must provide all required documentation
(V180)...The clients will receive services from a
licensed clinical therapist. The clients will receive
clinical services 2 times monthly...All clients
receiving services

Describe you plans to make sure the above
happens.

.. The Professional consultant must be a licensed
professional for example certified in MS (Master
of Science), LCAS (Licensed Clinical Addiction
Specialist), LCMHC (Licensed Clinical Mental
Health Counselor)-QS (Qualified Supervisor),
TFCBT (Trauma Focused Cognitive Behavioral
Therapy), CCSI (Clinical Supervisor Intern),
C-DBT (Child Dialectical Behavior Therapy). The

Division of Health Service Regulation

STATE FORM

6809

7MO411

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL002-028 10/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
\ 243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 179] Continued From page 48 v 179

If continuation sheet 49 of 64

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/27/2025
FORM APPROVED

(X3) DATE SURVEY

professional consultant will monitor the facility 2
times a month."

Clients served by the facility were children and
adolescents who had mental health diagnoses
including but not limited to Disruptive Mood
Disorder, Attention Deficit Hyperactivity Disorder
and Reactive Attachment Disorder of Childhood.
The CEO/D/L and the VP/L/QP did not complete
and maintain accurate client records and did not
complete screening assessments for potential
clients. This impaired the staff's ability to
effectively support the population served,
affecting the quality of care and client safety.

FC #5 was admitted without an initial evaluation,
which resulted in services being provided without
a comprehensive understanding of the FC #5's
specific needs or appropriate care planning. The
CEO/DI/L and VP/L/QP failed to develop
individualized treatment plans for FC #5 and did
not establish therapeutic goals or interventions
essential for client progress. Staff were not
trained to address client-specific needs, which
further limited the effectiveness of care. FC #5
had no treatment strategies to address his
incontinence.

Client #1 and FC #5 did not receive the required
clinical consultation at least twice monthly by a
qualified mental health professional, which
resulted in limited professional oversight.

The CEO/D/L and VP/L/QP did not ensure clients
were always under direct supervision and
neglected client safety, as staff were permitted to
sleep during their shifts. The facility demonstrated
systemic deficiencies that reflected a collective
failure to deliver quality client treatment.

This deficiency constitutes a Type A1 rule
violation for serious neglect and must be
corrected within 23 days.

Division of Health Service Regulation

STATE FORM

6809

7MO411

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL002-028 10/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
\ 243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 179] Continued From page 49 v 179

If continuation sheet 50 of 64

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/27/2025
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL002-028 10/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
\ 243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 180] 27G .1302 Residential Tx - Staff Vv 180

10A NCAC 27G .1302 STAFF

(a) Each facility shall have a director who has a
minimum of two years experience in child or
adolescent services and who has educational
preparation in administration, education, social
work, nursing, psychology or a related field.

(b) At all times, at least one direct care staff
member shall be present with every four children
or adolescents. If children or adolescents are
cared for in separate buildings, the ratios shall
apply to each building.

(c) When two or more clients are in the facility,
an emergency on-call staff shall be readily
available by telephone or page and able to reach
the facility within 30 minutes.

(d) Psychiatric consultation shall be available as
needed for each client.

(e) Clinical consultation shall be provided by a
qualified mental health professional to each
facility at least twice a month.

This Rule is not met as evidenced by:

Based on record review and interview, the facility
failed to ensure that clinical consultation was
provided by a qualified mental health professional
(QMHP) at least twice a month and failed to
ensure at least one direct care staff was present
and providing supervision at all times affecting 1
of 1 current client (Client #1) and 1 of 1 former
client (FC #5). The findings are:

Review on 9/26/25 of Client #1's record revealed:
-Date of Admission: 7/10/23.

-Age: 13 years old.

-Diagnoses: Reactive Attachment Disorder of

Division of Health Service Regulation
STATE FORM

6809

7MO411

If continuation sheet 51 of 64

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/27/2025
FORM APPROVED

(X3) DATE SURVEY

Childhood.
-No documentation of clinical consultation by a
QMHP.

Review on 9/26/25 of FC #5's record revealed:
-Age 11 years old and diagnoses of Disruptive
Mood Disorder and Attention Deficit Hyperactivity
Disorder.

-There was no client record to include an
identification face sheet, a client record number,
date of birth, race, gender, admission and
discharge dates, diagnoses, screening,
assessment, and treatment plan.

-No evidence of clinical consultation by a QMHP.

Attempted review on 9/23/25 of documentation of
clinical consultation by a QMHP was
unsuccessful. No documentation was provided
prior to the exit of the survey on 10/10/25.

Interview on 10/7/25 with FC #5's Department of
Social Services (DSS) legal guardian and DSS
Supervisor revealed:

-DSS and the Local Management Entity/Managed
Care Organization (LME/MCO) visited the facility
on 8/8/25. "...It took a long time for [Staff #1] to
come to the door. | think he was asleep in the
back (of the facility)..."

Interview on 9/29/25 with Staff #1 revealed:
-The facility, "...It's a sleep program. Of course
you can sleep..."

-Sometimes he worked the "whole weekend, like
a Friday through Monday morning."

-He "wouldn't stay awake the entire time. | would
doze off in the middle of the night and set my
alarm for every 30 minutes to wake back up and
check on the boys (clients) and make sure they
were good."

Division of Health Service Regulation
STATE FORM

6809

7MO411

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL002-028 10/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
\ 243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 180] Continued From page 51 Vv 180

If continuation sheet 52 of 64

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHLO002-028

A. BUILDING:

243 LILEDOUN ROAD

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/27/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R-C
10/10/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Interview on 9/23/25 and 10/6/25 with the Vice
President/Licensee/Qualified Professional
(VP/L/QP) revealed:

-Clients were on a waiting list for therapy.

-DSS and the Local Management Entity/Managed
Care Organization (LME/MCO) Case Manager
“has been really helping us, trying to find a
therapist."

-"This is an asleep program...from my
understanding, staff can have their bedroom and
sleep as long as they are checking (making
rounds on clients)..."

-There was no documentation of staff making
rounds on clients.

Interview on 10/6/25 with the Chief Executive
Officer/Director/Licensee (CEO/D/L) revealed:
-Clients "should be monitored at all times..."
-Staff worked as a "live-in for the whole
weekend..."

-"We are a level III which is an asleep program,
but they (staff) have to get up multiple times per
night, especially during 12 hours (shifts)."

-Staff "can't just sleep all night. they are to get up
and monitor (clients) at least 4 times
(overnight)..."

-Staff "used to have to fill out the times
(document making rounds)" but maintaining
records became challenging when she
experienced health issues.

-Clients "didn't have therapy because of being on
a waiting list. It's not just us (Luca's Hope III and
sister facility A). It's just hard to get..."

-"| set appointments... am responsible for
therapy sessions. | am aware they (clients) need
bi-monthly sessions..."

This deficiency is cross referenced into 10A
NCAC 27G.1301 Scope (V179) for a Type A1 rule
violation and must be corrected within 23 days.

Division of Health Service Regulation

STATE FORM

6809

7MO411

LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 180] Continued From page 52 Vv 180

If continuation sheet 53 of 64

PRINTED: 10/27/2025

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL002-028 10/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
\ 243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 366} 27G .0603 Incident Response Requirements V 366

10A NCAC 27G .0603 INCIDENT
RESPONSE REQUIREMENTS FOR

CATEGORY AAND B PROVIDERS

(a) Category A and B providers shall develop and
implement written policies governing their
response to level |, Il or Ill incidents. The policies
shall require the provider to respond by:

(1) attending to the health and safety needs
of individuals involved in the incident;

(2) determining the cause of the incident;
(3) developing and implementing corrective

measures according to provider specified
timeframes not to exceed 45 days;

(4) developing and implementing measures
to prevent similar incidents according to provider
specified timeframes not to exceed 45 days;

(5) assigning person(s) to be responsible
for implementation of the corrections and
preventive measures;

(6) adhering to confidentiality requirements
set forth in G.S. 75, Article 2A, 10A NCAC 26B,
42 CFR Parts 2 and 3 and 45 CFR Parts 160 and
164; and

(7) maintaining documentation regarding
Subparagraphs (a)(1) through (a)(6) of this Rule.
(b) In addition to the requirements set forth in
Paragraph (a) of this Rule, ICF/MR providers
shall address incidents as required by the federal
regulations in 42 CFR Part 483 Subpart I.

(c) In addition to the requirements set forth in
Paragraph (a) of this Rule, Category A and B
providers, excluding ICF/MR providers, shall
develop and implement written policies governing
their response to a level Ill incident that occurs
while the provider is delivering a billable service
or while the client is on the provider's premises.
The policies shall require the provider to respond
by:

Division of Health Service Regulation
STATE FORM

6809

7MO411

If continuation sheet 54 of 64

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/27/2025
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL002-028 10/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
\ 243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 366 | Continued From page 54 V 366

(1) immediately securing the client record
by:

(A) obtaining the client record;

(B) making a photocopy;

(C) certifying the copy's completeness; and
(D) transferring the copy to an internal
review team;

(2) convening a meeting of an internal

review team within 24 hours of the incident. The
internal review team shall consist of individuals
who were not involved in the incident and who
were not responsible for the client's direct care or
with direct professional oversight of the client's
services at the time of the incident. The internal
review team shall complete all of the activities as
follows:

(A) review the copy of the client record to
determine the facts and causes of the incident
and make recommendations for minimizing the
occurrence of future incidents;

(B) gather other information needed;

(C) issue written preliminary findings of fact
within five working days of the incident. The
preliminary findings of fact shall be sent to the
LME in whose catchment area the provider is
located and to the LME where the client resides,
if different; and

(D) issue a final written report signed by the
owner within three months of the incident. The
final report shall be sent to the LME in whose
catchment area the provider is located and to the
LME where the client resides, if different. The
final written report shall address the issues
identified by the internal review team, shall
include all public documents pertinent to the
incident, and shall make recommendations for
minimizing the occurrence of future incidents. If
all documents needed for the report are not
available within three months of the incident, the

Division of Health Service Regulation
STATE FORM

6809

7MO411

If continuation sheet 55 of 64

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/27/2025
FORM APPROVED

(X3) DATE SURVEY

LME may give the provider an extension of up to
three months to submit the final report; and

(3) immediately notifying the following:

(A) the LME responsible for the catchment
area where the services are provided pursuant to
Rule .0604;

(B) the LME where the client resides, if
different;

(C) the provider agency with responsibility
for maintaining and updating the client's
treatment plan, if different from the reporting
provider;

(D) the Department;

(E) the client's legal guardian, as
applicable; and

(F) any other authorities required by law.

This Rule is not met as evidenced by:

Based on record review and interview, the facility
failed to implement written policies governing
their response to Level Il and Level Ill incidents.
The findings are:

Review on 9/26/25 of internal level | facility
incident reports from 6/8/25 through 9/26/25
revealed:

-8/26/25 - Former Client (FC) #2 - was banging
on walls, pulling down blinds, breaking and
throwing items, and fighting with a peer (Client
#1) "...his peer ended up slamming client (FC #2)
on the floor while they were both fighting causing
client to hit his head on the floor...Client was
removed from the facility on 8/26/2025
by...guardian (Department of Social Services)

Division of Health Service Regulation

STATE FORM

6809

7MO411

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL002-028 10/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
\ 243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 366 | Continued From page 55 V 366

If continuation sheet 56 of 64

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/27/2025
FORM APPROVED

(X3) DATE SURVEY

and placed in another location...[Local
Management Entity/Managed Care Organization
(LME/MCO)] was notified and they did speak to
the facility regarding the incident asked if the
incident was entered into the IRIS (Incident
Response and Reporting System) system..."
-8/27/25 - FC #3 - "...Staff (Staff #1) instructed
client to go to his room and put on
underwear...Client started laughing and playing
because he thought that it was funny that he
didn't have on underwear. Client jumped on his
bed while laughing and got into a fetal position
laughing and then he rolled over on his back and
hit his head on the wall...Client was taken out of
the facility on the 8/27/2025 the same day that the
client made the report...[Local County
Department of Social Services transported client
to another location...[LME/MCO] was notified and
did speak to the facility regarding the incident and
if the incident was entered into the IRIS system
(North Carolina Incident Response Improvement
System)..."

Review on 10/7/25 of the local police
Computer-Aided Dispatch (CAD) list from 6/1/25
through 10/7/25 revealed:

-All the following law enforcement calls involved
FC #6:

-7/1/25 - police responded to a missing person -
Absent Without Official Leave (AWOL) for 15
minutes prior to the call.

-7/2/25 - civil dispute - property damage has
occurred.

-7/3/25 - civil dispute - asking another client
where he could buy a gun.

-7/4/25 - AWOL -"...grabbed his things and he
stated he is going to get a gun and come back
and shoot up the group home. He was also trying
to attack some of the other boys (clients)."

Division of Health Service Regulation
STATE FORM

6809

7MO411

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL002-028 10/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
\ 243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 366 | Continued From page 56 V 366

If continuation sheet 57 of 64

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHLO002-028

A. BUILDING:

243 LILEDOUN ROAD

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/27/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R-C
10/10/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Reviews on 9/25/25 and 10/8/25 of IRIS revealed:
-Level Ill incident for FC #2 was originally
submitted 8/30/25 (72 hours after allegation of
abuse).

-On 9/29/25 FC #2's incident was re-submitted,
the "internal investigation" attached was the
internal incident report and the Department of
Health and Human Services (DHHS) Criteria for
determining incident levels.

-Level Ill incident report for FC #3 originally
submitted 9/1/25 (4 days after allegation of
abuse).

-On 10/8/25 FC #3's incident was re-submitted
with the internal investigation attached.

-No level Il incident reports for FC #6 had been
submitted regarding law enforcement visits to the
facility on 7/1/25, 7/2/25, 7/3/25 and 7/4/25.

Review on 9/26/25 of the facility's documented
response to incidents revealed:

-No documentation the facility attended to the
health and safety needs of clients involved in the
incidents above.

-No documentation the facility determined the
cause of the incident.

-No documentation the facility developed and
implemented corrective measures.

-No documentation of person(s) responsible for
implementation of corrections and preventive
measures.

Interview on 9/29/25 with the local DSS
Investigator revealed:

-8/27/25 - FC #2 alleged "...[Staff #1]...slapped
him (FC #2) across the face...he had pretty
significant bruising on his ear..."

-8/28/25 - FC #3 alleged "[Staff #1] slammed his
head on the ground...he (FC #3) did have a bump
on his head..."

-On the evening of 8/27/25 FC #2 was removed

Division of Health Service Regulation

STATE FORM

6809

7MO411

LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 366 | Continued From page 57 V 366

If continuation sheet 58 of 64

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/27/2025
FORM APPROVED

(X3) DATE SURVEY

from the facility due to the abuse allegation.
-Staff #1 was still working on shift when she left
the evening of 8/27/25 (after the first allegation).
-On 8/28/25 FC #3 was removed from the facility
due to the abuse allegation.

-On 8/28/25 the Chief Executive
Officer/Director/Licensee (CEO/D/L) "...made the
decision to remove [Staff #1] and said 'He (Staff
#1) would no longer be employed at the home
(facility).""

Interview on 9/26/25 with the Vice
President/Licensee/Qualified Professional
(VP/L/QP) revealed:

-She provided oversight for the facility at the time
of the incident.

-She was responsible to conduct the investigation
of abuse for both FC #2 and FC #3 which was
done on 9/1/25.

-The CEO/D/L was responsible to enter level II
and level III incidents into IRIS.

-On the evening of 8/27/25 the CEO/D/L called to
inform her FC #2 made an allegation of abuse
against Staff #1.

-On 8/28/25 she was notified FC #3 made an
allegation of abuse against Staff #1.

-Staff #1 continued to work throughout the night
shift on 8/27/25 into the morning of 8/28/25.
-"After the 28th (8/28/25) we (she and the
CEO/D/L) went ahead and suspended (Staff
#1)..."

-On 9/1/25 she did an internal investigation by
interviewing Staff #1.

-No other staff and no clients were interviewed.
-"...Knowing the staff (Staff #1) and the kids
(clients), | determined it (abuse) didn't happen..."

Interviews on 9/26/25, 9/29/25 and 10/7/25 with
the CEO/D/L revealed:
-On 8/27/25 at 7:00 p.m. she received a call from

Division of Health Service Regulation

STATE FORM

6809

7MO411

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL002-028 10/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
\ 243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 366 | Continued From page 58 V 366

If continuation sheet 59 of 64

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHLO002-028

A. BUILDING:

243 LILEDOUN ROAD
TAYLORSVILLE, NC 28681

LUCA'S HOPE III

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/27/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R-C
10/10/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

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

CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

V 366

V 367|

Continued From page 59

Staff #2 that DSS was there and FC #2 made an
allegation of abuse against Staff #1.

-On the evening of 8/28/25, DSS returned due to
FC #3 alleging abuse against Staff #1.

-The VP/L/QP was responsible to investigate both
abuse allegations.

-There was no internal review team who did not
provide oversight to the clients involved in the
investigation.

-Awritten preliminary findings of fact was not
submitted to the LME/MCO within five working
days.

-Staff #1 was working on 8/27/25 (after the first
allegation) and continued to work into the
morning of 8/28/25; He walked the clients to
school that morning.

-She called the police for FC #6 "...just to pick
him up and bring him back (to the facility)...each
time he would be at the end of the road..."

27G .0604 Incident Reporting Requirements

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

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

Division of Health Service Regulation
STATE FORM

V 366

V 367

6809

7MO411

If continuation sheet 60 of 64

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/27/2025
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED
R-C
MHL002-028 10/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 367 | Continued From page 60 V 367
information:
(1) reporting provider contact and
identification information;
(2) client identification information;
(3) type of incident;
(4) description of incident;
(5) status of the effort to determine the
cause of the incident; and
(6) other individuals or authorities notified

or responding.

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

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

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

(1) hospital records including confidential
information;

(2) reports by other authorities; and

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

(d) Category A and B providers shall send a copy
of all level III incident reports to the Division of
Mental Health, Developmental Disabilities and
Substance Abuse Services within 72 hours of
becoming aware of the incident. Category A
providers shall send a copy of all level III
incidents involving a client death to the Division of
Health Service Regulation within 72 hours of
becoming aware of the incident. In cases of
client death within seven days of use of seclusion
or restraint, the provider shall report the death

Division of Health Service Regulation
STATE FORM

6809

7MO411

If continuation sheet 61 of 64

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHLO002-028

A. BUILDING:

243 LILEDOUN ROAD

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/27/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R-C
10/10/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

immediately, as required by 10A NCAC 26C.
.0300 and 10A NCAC 27E .0104(e)(18).

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

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

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

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

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

(6) a statement indicating that there have

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

This Rule is not met as evidenced by:

Based on record review and interview, the facility
failed to notify the LME/MCO (Local Management
Entity/Managed Care Organization) of level II and
level III incident reports. The findings are:

Review on 10/7/25 of the local police
Computer-Aided Dispatch (CAD) list from 6/1/25
through 10/7/25 revealed:

Division of Health Service Regulation

STATE FORM

6809

7MO411

LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 367| Continued From page 61 V 367

If continuation sheet 62 of 64

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/27/2025
FORM APPROVED

(X3) DATE SURVEY

-All the following law enforcement calls involved
Former Client (FC) #6:

-7/1/25 - police responded to a missing person -
Absent Without Official Leave (AWOL) for 15
minutes prior to the call.

-7/2/25 - civil dispute - property damage has
occurred.

-7/3/25 - civil dispute - asking another client
where he could buy a gun.

-7/4/25 - AWOL -"...grabbed his things and he
stated he is going to get a gun and come back
and shoot up the group home. He was also trying
to attack some of the other boys (clients)."

Reviews on 9/25/25 and 10/8/25 of the North
Carolina Incident Response Improvement System
(IRIS) revealed:

-Level Ill incident for FC #2 was originally
submitted 8/30/25 (72 hours after allegation of
abuse).

-On 9/29/25 FC #2's incident was re-submitted,
the "internal investigation" attached was the
internal incident report and the Department of
Health and Human Services Criteria for
determining incident levels.

-Level Ill incident report for FC #3 originally
submitted 9/1/25 (4 days after allegation of
abuse).

-On 10/8/25 FC #3's incident was re-submitted
with the internal investigation attached.

-No level Il incident reports for FC #6 had been
submitted regarding law enforcement officer's
visits to the facility on 7/1/25, 7/2/25, 7/3/25 and
7/4/25.

Interview on 9/29/25 with the local Department of
Social Services (DSS) social worker revealed:
-8/27/25 - FC #2 was removed from the facility
due to an abuse allegation against Staff #1.

-8/28/25 - FC #3 was removed from the facility

Division of Health Service Regulation

STATE FORM

6809

7MO411

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL002-028 10/10/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
\ 243 LILEDOUN ROAD
LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 367 | Continued From page 62 V 367

If continuation sheet 63 of 64

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHLO002-028

A. BUILDING:

243 LILEDOUN ROAD

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/27/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R-C
10/10/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

due to an abuse allegation against Staff #1.

Interview on 9/26/25 with the Vice
President/Licensee/Qualified Professional
(VP/L/QP) revealed:

-She was the QP who provided oversight for the
facility at the time of the incident.

-The Chief Executive Officer/Director/Licensee
(CEO/D/L) was responsible to enter level Il and
level III incidents into IRIS.

Interview on 9/29/25 with the CEO/D/L revealed:
-She was responsible to submit IRIS reports.

-FC #2 and FC #3's IRIS reports were not
submitted timely, "| started it (IRIS), but | didn't
save it..."

-She did not complete IRIS reports when the
police were called for FC #6.

-On 8/27/25 at 7:00 p.m. she received a call from
Staff #2 that DSS was there and FC #2 made an
allegation of abuse against Staff #1.

-On the evening of 8/28/25, DSS returned due to
FC #3 alleging abuse against Staff #1.

-The VP/Licensee/QP was responsible to
investigate both abuse allegations.

-There was not an internal review team who did
not provide oversight to the clients involved in the
investigation.

-Awritten preliminary findings of fact was not
submitted to the Local Management
Entity/Managed Care Organization within five
working days.

-After the first allegation, Staff #1 was working on
8/27/25 and continued to work into the morning of
8/28/25; He walked the clients to school that
morning.

-She called the police for FC #6 "...just to pick
him up and bring him back (to the facility)...each
time he would be at the end of the road..."

Division of Health Service Regulation
STATE FORM

6809

7MO411

LUCA'S HOPE III
TAYLORSVILLE, NC 28681
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 367 | Continued From page 63 V 367

If continuation sheet 64 of 64

document_type: Statement of Deficiency