state: NC

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

raw_content:
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHL002-032

490 RADIO

GEORGIE'S HELPING HAND

A. BUILDING:

ROAD

(X2) MULTIPLE CONSTRUCTION

TAYLORSVILLE, NC 28681

PRINTED: 01/22/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

01/12/2026

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 000!

Vv 112

INITIAL COMMENTS

An annual and follow up survey was completed
on 1/12/26. Deficiencies were cited.

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

This facility is licensed for 5 and has a current
census of 4. The survey sample consisted of
audits of 3 current clients.

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

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

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

(d) The plan shall include:

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

(2) strategies;

(3) staff responsible;

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

(5) basis for evaluation or assessment of
outcome achievement; and

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

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

STATE FORM

V 000

Vv 112

6899

8JRO11

TITLE (X6) DATE

If continuation sheet 1 of 52

PRINTED: 01/22/2026

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
MHL002-032 01/12/2026
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
490 RADIO ROAD
GEORGIE'S HELPING HAND
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 1 Vv 112

This Rule is not met as evidenced by:

Based on record reviews and interviews, the
facility failed to develop and implement treatment
plans based on client needs within 30 days of
admission for 3 of 3 audited clients (Clients #1,
#2 and #3). The findings are:

Review on 12/22/25 of Client #1's record
revealed:

-Date of Admission 8/15/25.

-15 years old.

-Diagnoses of Oppositional Defiant Disorder
(ODD), Attention-Deficit Hyperactivity Disorder
(ADHD), Autism Spectrum Disorder and Anxiety
Disorder.

-No treatment plan.

Review on 12/22/25 of Client #2's record
revealed:

-Date of Admission 9/17/25.

-14 years old.

-Diagnoses of ODD and ADHD.

-No treatment plan.

Review on 12/22/25 of Client #3's record
revealed:

-Date of Admission 9/13/25.

-14 years old.

-Diagnoses of ADHD, Conduct Disorder and
Disruptive Mood Dysregulation Disorder.
-No treatment plan.
Division of Health Service Regulation
STATE FORM

6809

8JRO11

If continuation sheet 2 of 52

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL002-032

490 RADIO

GEORGIE'S HELPING HAND

A. BUILDING:

ROAD

(X2) MULTIPLE CONSTRUCTION

TAYLORSVILLE, NC 28681

PRINTED: 01/22/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

01/12/2026

Review on 1/6/26 of a Computer Aided Dispatch
(CAD) list dated 8/1/25-1/5/26 from the local
sheriff's department revealed:

-Law enforcement was called to Georgie's
Helping Hand Group Home for a "Missing
Person" on 11/6/25 and 12/3/25. When Client #3
eloped from the facility.

Interview on 1/5/26 with the Coordinator and
Behavior Specialist from the local school where
Clients #1, #2 and #3 attended revealed:

-"The facility does not share their (clients')
behaviors, violence tendency, triggers ...we have
learned about [Client #2's] sexual comments just
by him being here ...[Client #2] has made
statements of wanting to kill himself ...said he had
a gun or a bomb ...| don't know if this was a
problem prior to him coming here ...[Client #3] ran
away from the facility 2 times. If a kid (client) runs
from the group home on Saturday, we need to
know that on Monday ..."

Interviews on 12/22/25, 1/5/26 and 1/8/26 with the
Program Director revealed:

-He was "involved" with the treatment plan
meetings as they were “usually held at the
facility.”

-Goals and interventions were “usually in their
(clients') folder (record)."

Interview on 1/6/26 with the Qualified
Professional (QP) revealed:

-"| believe" the therapist was responsible for
development of the treatment plans.

-Treatment plan "recommendations come from
where they (clients) were before and what their
interactions were, but that's not part of my forte. |
am limited on what | can speak. | don't do that.
That's not what | do ..."

Division of Health Service Regulation
STATE FORM

6809

8JRO11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 112] Continued From page 2 Vv 112

If continuation sheet 3 of 52

Division of Health Service Regulation

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

NAME OF PROVIDER OR SUPPLIER

MHL002-032

490 RADIO

GEORGIE'S HELPING HAND

A. BUILDING:

ROAD

(X2) MULTIPLE CONSTRUCTION

TAYLORSVILLE, NC 28681

PRINTED: 01/22/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

01/12/2026

(x4) ID
PREFIX
TAG

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

ID
PREFIX
TAG

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

(xs)
COMPLETE
DATE

Vv 112

V 118)

Continued From page 3

Interview on 1/5/26 with the Director/Licensee
revealed:

-She would have to "pull up the computer for the
other service generated plans" that were kept in
another office.

Review on 1/6/26 of an e-mail correspondence to
the Division of Health Service Regulation
surveyors received from the Director/Licensee
and Executive Director/Licensee dated 1/6/26
revealed:

-Attachments to the e-mail were the
Person-Centered Plans (PCPs) (treatment plans)
for Clients #1, #2 and #3.

-Client #1's PCP was dated 12/28/25 and Client
#3's PCP was dated 1/5/26, both after survey
entrance.

-Client #2's PCP was dated 9/13/25 and last
updated 12/31/25.

Interview on 1/8/26 with the Director/Licensee
revealed:

-The PCPs were to be completed by the QP in
collaboration with the staff. "[QP] is responsible
...1 did the PCPs you received (1/6/26)."

Interviews on 1/6/26 and 1/12/26 with the
Executive Director/Licensee revealed:

-The Program Director, the Director/Licensee and
the therapist were responsible for developing
treatment plans.

This deficiency is cross referenced into 10A

NCAC 27G .1701 Scope (V293) for a Type B rule
violation and must be corrected within 45 days.

27G .0209 (C) Medication Requirements

Vv 112

V 118

Division of Health Service Regulation
STATE FORM

6809

8JRO11

If continuation sheet 4 of 52

PRINTED: 01/22/2026

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
MHL002-032 01/12/2026
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
490 RADIO ROAD
GEORGIE'S HELPING HAND
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 4 Vv 118

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
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 observation, record reviews, and
interviews, the facility failed to ensure prescription
Division of Health Service Regulation

STATE FORM

6809

8JRO11

If continuation sheet 5 of 52

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHL002-032

490 RADIO

GEORGIE'S HELPING HAND

A. BUILDING:

ROAD

(X2) MULTIPLE CONSTRUCTION

TAYLORSVILLE, NC 28681

PRINTED: 01/22/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

01/12/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

and non-prescription drugs were only
administered to a client on the written order of a
physician and the MARs were kept current for 3
of 3 audited clients (Clients #1, #2 and #3). The
findings are:

Cross Reference: 10A NCAC 27G.0209
Medication Requirements (V123). Based on
record reviews and interviews, the facility failed to
ensure drug administration errors were reported
immediately to a physician or pharmacist for 3 of
3 audited clients (Clients #1, #2 and #3).

Review on 12/22/25 of Client #1's record
revealed:
-Physician's orders dated 9/3/25 for:

-Cetirizine Hydrochloride (HCL)
(allergies) 10 milligrams (mg) 1 tablet by mouth
(PO) daily.

-Montelukast Sodium (asthma) 10 mg 1
tablet PO daily.

-Qelbree Extended Release (ER) (ADHD)
200 mg 1 capsule PO daily.

-Metformin HCL (prediabetes) 500 mg 1
tablet PO daily.

-Fluoxetine HCL (depression) 10 mg 1
capsule PO every morning.
-Physician's order dated 11/11/25 to discontinue
Lexapro/escitalopram oxalate 10 mg.
-No physician's orders for:

-Aripiprazole (agitation) 5 mg 1 tablet PO at
bedtime (HS).

-Guanfacine (impulsivity/ODD) 4 mg 1 tablet
PO every evening.

-Oxcarbazepine (ADHD) 300 mg 1 tablet
PO every evening.

-Levocetirizine (allergies) 5 mg 1 tablet PO
every evening.

-Fluoxetine HCL 20 mg 1 capsule PO daily.

Division of Health Service Regulation
STATE FORM

6809

8JRO11

(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 5 Vv 118

If continuation sheet 6 of 52

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHL002-032

490 RADIO

GEORGIE'S HELPING HAND

A. BUILDING:

ROAD

(X2) MULTIPLE CONSTRUCTION

TAYLORSVILLE, NC 28681

PRINTED: 01/22/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

01/12/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

Review on 12/23/25 of a dispense sheet dated
8/1/25-12/23/25 obtained by Division of Health
Service Regulation (DHSR) surveyors on
12/23/25 from the local pharmacy which
dispensed Client #1's medications revealed:
-Cetirizine 10 mg 1 tablet PO daily prescribed
11/5/25; Dispensed 11/5/25, 12/5/25.
-Montelukast 10 mg 1 tablet PO daily prescribed
11/5/25; Dispensed 11/5/25, and 12/5/25.
-Qelbree 200 mg 1 capsule PO daily prescribed
9/2/25; Dispensed 9/15/25, 10/23/25, 11/24/25,
and 12/23/25.

-Metformin 500 mg 1 tablet PO daily prescribed
9/2/25; Dispensed 9/4/25.

-Metformin 500 mg 1 tablet PO every evening
prescribed 11/5/25; Dispensed 12/16/25.
-Fluoxetine 10 mg 1 capsule PO every morning
prescribed 9/2/25; Dispensed 9/20/25.
-Fluoxetine 20 mg 1 capsule PO daily prescribed
11/5/25; Dispensed 12/16/25.

-Aripiprazole 5 mg 1 tablet PO at HS prescribed
11/5/25; Dispensed 11/5/25, and 12/5/25.
-Guanfacine 4 mg 1 tablet PO at HS prescribed
11/5/25; Dispensed 11/5/25 and 12/12/25.
-Oxcarbazepine 300 mg 1 tablet PO at HS
prescribed 11/17/25; Dispensed 11/18/25 and
12/16/25.

-Levocetirizine 5 mg 1 tablet PO every evening
prescribed 10/2/25; Dispensed 10/2/25, 11/10/25,
and 12/12/25.

Observation on 12/22/25 at 2:00 pm of Client #1's
medications revealed:

-Fluoxetine HCL 20 mg 1 PO daily dispensed
12/16/25.

-Cetirizine HCL 10 mg 1 PO daily dispensed
12/5/25.

-Montelukast Sodium 10 mg 1 PO daily
dispensed 12/5/25.

-Qelbree ER 200 mg 1 PO every morning

Division of Health Service Regulation

STATE FORM

6809

8JRO11

(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 6 Vv 118

If continuation sheet 7 of 52

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL002-032

490 RADIO

GEORGIE'S HELPING HAND

A. BUILDING:

ROAD

(X2) MULTIPLE CONSTRUCTION

TAYLORSVILLE, NC 28681

PRINTED: 01/22/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

01/12/2026

dispensed 11/24/25.

-Aripiprazole 5 mg 1 PO at HS dispensed
12/5/25.

-Guanfacine HCL ER 1 PO at HS dispensed
12/12/25.

-Oxcarbazepine 300 mg 1 PO at HS dispensed
12/16/25.

-Metformin HCL 500 mg 1 PO every evening
dispensed 12/16/25.

-Levocetirizine 5 mg 1 PO every evening
dispensed 12/12/25.

Review on 12/22/25 at 12:30 pm-2:00 pm of
Client #1's MARs dated 10/1/25-12/22/25
revealed:

-There were no consistent specified
administration time for cetirizine, montelukast,
Qelbree, or Fluoxetine. The time slots on the
October 2025 MARs were left blank, the
November 2025 MARs listed administration times
of 6:30 am and 7:00 am, and the December 2025
MARs listed administration times of 6:30 am, 7:30
am, and 8:00 am.

-October:

-Cetirizine was marked with an "X"
10/1/25-10/6/25 and left blank 10/7/25- 11/5/25.
-Montelukast was marked with an "X"
10/1/25-10/2/25 and left blank 10/3/25-10/31/25.
-Aripiprazole and guanfacine were listed, but
neither were documented as administered
10/1/25-10/31/25.

-Oxcarbazepine was listed but not documented
as administered 10/1/25-10/31/25.
-Levocetirizine was marked with an "X" from
10/1/25-10/2/25 and documented as
administered 10/3/25-10/31/25.

-November:

-Montelukast was left blank 11/1/25-11/5/25.
-Metformin was not documented as administered
11/30/25.

Division of Health Service Regulation
STATE FORM

6809

8JRO11

(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 7 Vv 118

If continuation sheet 8 of 52

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHL002-032

490 RADIO

GEORGIE'S HELPING HAND

PRINTED: 01/22/2026

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

STREET ADDRESS, CITY, STATE, ZIP CODE

ROAD

TAYLORSVILLE, NC 28681

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

01/12/2026

-Fluoxetine 20 mg was not listed and fluoxetine
10 mg continued be documented as administered
11/5/25-11/30/25.

-Aripiprazole and guanfacine were listed, but
neither were documented as administered from
11/1/25-11/4/25. Both were documented as
administered 11/5/25-11/30/25.

-Both oxcarbazepine and its brand-name
formulation, Oxtellar, were listed concurrently on
the MAR. Oxcarbazepine was not documented as
administered 11/1/25-11/30/25 and Oxtellar was
marked with an "X" from 11/1/25-11/23/25 and
was initialed as administered from
11/24/25-11/30/25.

-Levocetirizine was documented as administered
11/1/25-11/30/25.

-December:

-Fluoxetine 10 mg (instead of 20 mg) continued
to be documented as administered
12/1/25-12/15/25. Fluoxetine 10 mg was marked
with an "X" from 12/16/25-12/31/25. Fluoxetine 20
mg was documented as administered from
12/16/25-12/21/25. No administration was
documented on 12/22/25.

-Montelukast was marked with a circle and no
staff initials on 12/5/25 and 12/22/25. On 12/6/25
montelukast was documented as administered at
6:30 am, left blank for 7:30 am and marked with a
circle and no staff initials for 8:00 am.

-Qelbree was not documented as administered
12/22/25. The 6:30 am and 8:00 am time slots
were left blank and the 7:30 am time slot was
marked with a circle and no staff initials.
-Metformin was not documented as administered
12/21/25.

-Aripiprazole and guanfacine were documented
as administered 12/1/25-12/21/25.

-Oxtellar was not listed on the MAR; only the
generic medication oxcarbazepine was listed, and
it was not documented as administered

Division of Health Service Regulation
STATE FORM

6808 8JRO11

(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 8 Vv 118

If continuation sheet 9 of 52

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL002-032

490 RADIO

GEORGIE'S HELPING HAND

A. BUILDING:

ROAD

(X2) MULTIPLE CONSTRUCTION

TAYLORSVILLE, NC 28681

PRINTED: 01/22/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

01/12/2026

12/1/25-12/21/25.

-Levocetirizine was documented as administered
12/1/25-12/19/25 and on 12/21/25. On 12/20/25
no administration was documented as the
corresponding entry was left blank.

Review on 12/22/25 of Client #2's record
revealed:

-No physician's order for any administered
medications.

Review on 12/23/25 of a dispense sheet dated
8/1/25-12/23/25 obtained by DHSR surveyors on
12/23/25 from the local pharmacy which
dispensed Client #2's medications revealed:
-Desvenlafaxine succinate ER (depression) 100
mg 1 tablet PO daily prescribed 4/13/25;
Dispensed 9/29/25, 11/19/25, and 12/15/25.
-Lurasidone (mood disorder) 60 mg 1 tablet PO
every evening prescribed 6/29/25; Dispensed
9/29/25.

-Clonidine (ADHD) ER 0.1 mg 1 tablet PO twice
daily (BID) in the morning and afternoon
prescribed 8/3/25; Dispensed 10/1/25, 11/10/25.
-Clonidine 0.1 mg 1 tablet PO in the morning and
1 tablet PO in the evening prescribed 11/19/25;
Dispensed 11/19/25.

-Clonidine 0.3 mg 1 tablet PO at HS prescribed
11/19/25; Dispensed 11/19/25.

-Trazodone (insomnia) 50 mg 1 tablet PO at HS
prescribed 9/29/25; Dispensed 9/29/25.
-Trazodone 50 mg 1 to 1 1/2 tablets PO at HS
prescribed 11/19/25; Dispensed 11/19/25.
-Qelbree ER 200 mg 1 capsule PO every morning
prescribed 10/30/25; Dispensed 10/30/25.
-Qelbree ER 200 mg 1 capsule PO daily at 1:00
pm prescribed 11/19/25; Dispensed 11/26/25.
-Omeprazole (heartburn) 20 mg 1 capsule PO
daily prescribed 11/19/25; Dispensed 11/19/25,
and 12/15/25.

Division of Health Service Regulation
STATE FORM

6809

8JRO11

(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 9 Vv 118

If continuation sheet 10 of 52

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHL002-032

490 RADIO

GEORGIE'S HELPING HAND

A. BUILDING:

ROAD

(X2) MULTIPLE CONSTRUCTION

TAYLORSVILLE, NC 28681

PRINTED: 01/22/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

01/12/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

-Vyvanse (ADHD) 60 mg 1 capsule PO every
morning prescribed 11/19/25; Dispensed
11/21/25.

-Vitamin D3 (supplement) 50 micrograms (mcg) 1
capsule PO daily prescribed 11/19/25; Dispensed
11/19/25 and 12/18/25.

Observation on 12/22/25 at 2:23 p.m. of Client
#2's medications revealed:

-Vyvanse 60 mg 1 PO every morning dispensed
11/21/25.

-Desvenlafaxine succinate 1 PO daily dispensed
12/15/25.

-Omeprazole 20 mg 1 PO daily dispensed
12/15/25.

-Vitamin D3 50 mcg 1 PO daily dispensed
12/18/25.

-Clonidine 0.1 mg 1 PO in the morning and 1 PO
in the evening dispensed 11/19/25.

-Trazodone 50 mg 1-1 1/2 tablets PO at HS
dispensed 11/19/25

-The following medications were not provided:
-Qelbree 200 mg .

-Clonidine 0.3 mg.

-Lurasidone HCL 60 mg.

Review on 12/22/25 at 12:30 pm-2:00 pm of
Client #2's MARs dated 10/1/25-12/22/25
revealed:

-October:

-Desvenlafaxine was documented as
administered at 6:30 am 10/1/25-10/31/25.
-Lurasidone was documented as administered at
5:00 pm 10/1/25-10/31/25.

-Clonidine 0.1 mg 1 tablet in the morning and
afternoon was documented as administered at
6:30 am and 1:00 pm except for 10/10/25 and
10/30/25 in which the 1:00 pm doses were left
blank.

-Clonidine 0.2 mg 1 tablet at HS was documented

Division of Health Service Regulation

STATE FORM

6809

8JRO11

(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 10 Vv 118

If continuation sheet 11 of 52

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL002-032

490 RADIO

GEORGIE'S HELPING HAND

A. BUILDING:

ROAD

(X2) MULTIPLE CONSTRUCTION

TAYLORSVILLE, NC 28681

PRINTED: 01/22/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

01/12/2026

as administered 10/1/25-10/5/25,
10/7/25-10/8/25, and 10/10/25-10/13/25.
Clonidine 0.2 mg was marked with an "X" on
10/6/25, 10/9/25, and 10/14/25-10/31/25.
-Trazodone 1 tablet at HS was documented as
administered 10/1/25-10/31/25.

-Qelbree 200 mg 2 capsules daily at 1:00 pm was
documented as administered 10/1/25-10/9/25
and 10/11/25/-10/30/25. Documentation on
10/10/25 was left blank, and entries on 10/30/25
and 10/31/25 were marked with a cross without
any accompanying explanation.

-Omeprazole was listed but left blank and not
documented as administered from
10/1/25-10/31/25.

-Vyvanse was documented as administered at
6:30 am from 10/1/25-10/9/25 and from
10/18/25-10/31/25. Entries from
10/10/25-10/17/25 were marked with an "X"
without further explanation.

-Vitamin D3 was listed with no specified
administration time and was not documented as
administered from 10/1/25-10/31/25.
-Dextroamphetamine (ADHD) 5 mg was listed
with instructions to take 1 tablet PO daily at 1:00
pm and was documented as administered
10/1/25-10/3/25, marked with an "X"
10/4/25-10/6/25, and left blank 10/7/25-10/31/25.
-November:

-Desvenlafaxine was documented as
administered at 6:30 am 11/1/25-11/29/25, and at
7:00 pm 11/30/25.

-Lurasidone was listed twice on the MAR. On one
page, the administration time was blank, and no
doses were documented as administered from
11/1/25-11/30/25. On another page, the
administration time was listed as 8:00 pm, with
doses documented as administered on
11/1/25-11/4/25 and left blank from
11/5/25-11/30/25.

Division of Health Service Regulation
STATE FORM

6809

8JRO11

(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 11 Vv 118

If continuation sheet 12 of 52

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL002-032

490 RADIO

GEORGIE'S HELPING HAND

A. BUILDING:

ROAD

(X2) MULTIPLE CONSTRUCTION

TAYLORSVILLE, NC 28681

PRINTED: 01/22/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

01/12/2026

PROVIDER'S PLAN OF CORRECTION

-Clonidine 0.1 mg was listed twice on the MAR.
On one page, instructions for 1 tablet in the
morning and 1 tablet in the afternoon were
documented as administered from
11/1/25-11/19/25 at 6:30 am and at an additional
illegible time which appeared to read "3X5." On
another page, clonidine 0.1 mg was listed with
administration times of 6:30 am and 4:00 pm,
with doses documented as administered from
11/20/25- 11/28/25. On 11/29/25, the 6:30 am
dose was documented as administered, and the
4:00 pm dose contained an entry consisting of a
circled mark without initials. On 11/30/25, a dose
was documented as administered at 7:00 am,
and the 4:00 pm dose was left blank.

-Clonidine 0.2 mg 1 tablet at HS was documented
as administered 11/1/25-11/3/25. On
11/4/25-11/10/25, the corresponding MAR entry
boxes were traced on the edges in ink without
initials or documentation in the boxes. No
administration was documented from
11/11/25-11/30/25, as the entries were left blank.
-Clonidine 0.3 mg was documented as
administered 11/20/25-11/30/25.

-Trazodone 1 tablet at HS was documented as
administered 11/1/25-11/19/25. Trazodone 1 to 1
1/2 tablet at HS was documented as administered
11/20/25- 11/30/25 and did not specify the number
of tablets administered for each dose.

-Qelbree 200 mg 1 capsule each morning was
documented as administered from
11/1/25-11/19/25 and left blank from
11/20/25-11/30/25.

-Qelbree 200 mg 1 capsule once daily at 1:00 pm
was left blank from 11/1/25-11/19/25 and
documented as administered 11/20/25-11/30/25.
-Omeprazole was listed twice on the MAR. On
one page the medication time slot was left blank,
and there was no documentation of
administration from 11/1/25-11/30/25. Ona

Division of Health Service Regulation
STATE FORM

6809

8JRO11

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118) Continued From page 12 Vv 118

If continuation sheet 13 of 52

Division of Health Service Regulation

PRINTED: 01/22/2026

FORM APPROVED

separate page, omeprazole was listed with
instructions to take 1 capsule once daily, with two
administration times specified (6:30 am and 7:00
am). Documentation indicated the medication
was not administered at either time from
11/1/25-11/19/25, administered at 6:30 am on
11/20/25-11/21/25 and 11/23/25-11/29/25, and
administered at 7:00 am on 11/22/25 and
11/30/25.

-Vyvanse was listed twice on the MAR. On one
page, Vyvanse was listed with a specified
administration time of 6:30 am and documented
as administered from 11/1/25-11/19/25.
Documentation was left blank from

11/20/25- 11/30/25. On a separate page, Vyvanse
was listed with instructions to take 1 capsule once
daily, with two administration times specified
(6:30 am and 7:00 am). Documentation on this
page was left blank 11/1/25-11/19/25 and
documented as administered at 6:30 am
11/20/25- 11/29/25 and at 7:00 am on 11/30/25.
The 6:30 am entry for 11/30/25 had been initialed
by staff and subsequently scribbled out with black
ink, without explanation.

-Vitamin D3 was listed twice on the MAR. On one
page, Vitamin D3 was listed without a specified
administration time and was marked with an "X"
from 11/1/25-11/19/25. Documentation was left
blank from 11/20/25-11/30/25. On a separate
page, Vitamin D3 was listed with instructions to
take 1 capsule once daily, with two administration
times specified (6:30 am and 7:00 am).
Documentation on this page indicated the
medication was not administered at either time
from 11/1/25-11/19/25 and was documented as
administered at 6:30 am 11/20/25-11/21/25 and
11/23/25- 11/29/25, and at 7:00 am 11/22/25 and
11/30/25.

-Dextroamphetamine was not listed on the MAR.
-December:

Division of Health Service Regulation
STATE FORM

6809

8JRO11

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL002-032 01/12/2026
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
490 RADIO ROAD
GEORGIE'S HELPING HAND
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 13 Vv 118

If continuation sheet 14 of 52

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL002-032

490 RADIO

GEORGIE'S HELPING HAND

A. BUILDING:

ROAD

(X2) MULTIPLE CONSTRUCTION

TAYLORSVILLE, NC 28681

PRINTED: 01/22/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

01/12/2026

-Desvenlafaxine was documented as
administered at 6:30 am 12/1/25-12/11/25,
12/13/25-12/14/25, and 12/16/25-12/19/25. It was
documented as administered at 8:00 am on
12/15/25 and 12/20/25-12/22/25. Desvenlafaxine
was not documented as administered on
12/12/25.

-Lurasidone was listed with no administration
time, and doses were not documented as
administered from 12/1/25-12/22/25.

-Clonidine 0.1 mg was listed once with
instructions to administer 1 tablet in the morning
and 1 tablet in the evening. The administration
times were listed as 6:30 am, 4:00 pm and 8:00
am. Doses were documented as administered as
follows: On 12/1/25-12/4/25, 12/7/25-12/11/25,
and 12/16/25 at 6:30 am and 4:00 pm. On
12/5/25 at 4:00 pm only (no am dose). On
12/6/25, 12/12/25-12/14/25, and
12/17/25-12/19/25 at 6:30 am only (no pm
doses). On 12/20/25 and 12/22/25 at 8:00 am
only (no pm doses). On 12/21/25 at 4:00 pm and
8:00 am. On 12/15/25 the 6:30 am slot was left
blank, the 4:00 pm entry contained a circled mark
without initials, and the 8:00 am dose was
initialed as administered.

-Clonidine 0.3 mg was documented as
administered 12/1/25-12/19/25, left blank on
12/20/25, and marked with an "X" on 12/21/25.
-Trazodone 1 to 1 1/2 tablet at HS was
documented as administered 12/1//25-12/21/25
and did not specify the number of tablets
administered for each dose.

-Qelbree 200 mg 1 capsule once daily at 1:00 pm
was documented as administered
12/1/25-12/21/25.

-Omeprazole was listed with instructions to take 1
capsule once daily, with two administration times
specified (6:30 am and 8:00 am). The medication
was documented as administered at 6:30 am

Division of Health Service Regulation
STATE FORM

6809

8JRO11

(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 14 Vv 118

If continuation sheet 15 of 52

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHL002-032

490 RADIO

GEORGIE'S HELPING HAND

A. BUILDING:

ROAD

(X2) MULTIPLE CONSTRUCTION

TAYLORSVILLE, NC 28681

PRINTED: 01/22/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

01/12/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

from 12/1/25-12/14/25 and from
12/16/25-12/19/25 and documented as
administered at 8:00 am on 12/15/25 and from
12/20/25-12/22/25.

-Vyvanse was listed once with instructions to take
1 capsule in the morning, with two administration
times specified (6:30 am and 8:00 am). Vyvanse
was documented as administered at 6:30 am
12/1/25-12/11/25, 12/13/25-12/14/25, and
12/16/25-12/19/25. Documented as administered
at 8:00 am on 12/15/25 and 12/20/25-12/21/25.
Documentation for 12/12/25 was left blank with
no record of administration.

-Vitamin D3 was listed with instructions to take 1
capsule once daily with two specified
administration times (6:30 am and 8:00 am).
Vitamin D3 was documented as administered at
6:30 am 12/1/25-12/11/25, 12/13/25-12/14/25,
and 12/16/25-12/19/25, and documented as
administered at 8:00 am 12/15/25 and
12/20/25-12/22/25.

-Dextroamphetamine was not listed on the MAR.

Review on 12/22/25 of Client #3's record
revealed:

-No physician's order for any administered
medications.

Review on 12/23/25 of a dispense sheet dated
8/1/25-12/23/25 obtained by DHSR surveyors on
12/23/25 from the local pharmacy which
dispensed Client #3's medications revealed:
-Desmopressin (bedwetting) 0.2 mg 1 tablet PO
at HS prescribed 9/19/25; Dispensed 9/21/25.
-Desmopressin 0.2 mg 4 tablets PO at HS
prescribed 10/16/25; Dispensed 10/16/25.
-Carbamazepine (seizures) 100 mg Chew and
swallow 2 tablets PO at 8:00 am and 2 tablets at
8:00 pm prescribed 9/19/25; Dispensed 10/30/25.
-Carbamazepine 100 mg chew and swallow 2

Division of Health Service Regulation

STATE FORM

6809

8JRO11

(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 15 Vv 118

If continuation sheet 16 of 52

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHL002-032

490 RADIO

GEORGIE'S HELPING HAND

A. BUILDING:

ROAD

(X2) MULTIPLE CONSTRUCTION

TAYLORSVILLE, NC 28681

PRINTED: 01/22/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

01/12/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

tablets PO BID prescribed 9/22/25 and 12/12/25;
Dispensed 9/22/25 and 12/15/25.

-Concerta (ADHD) 27 mg 2 tablet PO in the
morning (Do Not Exceed 1 per 24 hours)
prescribed 9/22/25; Dispensed 9/22/25.
-Concerta 36 mg 1 tablet PO in the morning (Do
Not Exceed 1 per 24 hours) prescribed 10/16/25;
Dispensed 10/16/25 and 12/2/25.

-Melatonin (insomnia) 3 mg Dissolve 1-2 tablets
PO at HS prescribed 9/22/25; Dispensed 9/22/25.

Observation on 12/22/25 at 2:49 p.m. of Client
#3's medications revealed:

-Desmopressin 0.2 mg 4 tablets PO at HS
dispensed 10/16/25.

-Methylphenidate ER 36 mg 1 PO in the morning
dispensed 12/2/25.

-Fluticasone 27.5 mcg nasal spray 1 ml spray into
each nostril daily dispensed 3/28/25.

-The following medications were not provided:
-Carbamazepine 100 mg.

-Melatonin 3 mg.

-Docusate Sodium 50 mg.

Review on 12/22/25 at 12:30 pm-2:00 pm of
Client #3's MARs dated 10/1/25-12/22/25
revealed:

-Fluticasone nasal spray (allergy symptoms) 27.5
mcg was listed on the October 2025, November
2025, and December 2025 MARs with
instructions to take 1 milliliter (ml) of nasal spray
daily and was not documented as administered
from 10/1/25-12/22/25.

-Docusate sodium (constipation) 50 mg was
listed on the October 2025 and November 2025
MARs with instructions to take 1 capsule PO BID
at 8:00 am and 8:00 pm and was not documented
as administered for either dose from
10/1/25-11/30/25.

-Carbamazepine had written instructions on the

Division of Health Service Regulation

STATE FORM

6809

8JRO11

(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 16 Vv 118

If continuation sheet 17 of 52

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHL002-032

490 RADIO

GEORGIE'S HELPING HAND

A. BUILDING:

ROAD

(X2) MULTIPLE CONSTRUCTION

TAYLORSVILLE, NC 28681

PRINTED: 01/22/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

01/12/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

October 2025, November 2025 and December
2025 MARs to take 2 tablets "twice daily (8am,
8pm)" but had specified administration times for
8:00 am, 6:30 am, and 8:00 pm.

October:

-Carbamazepine was left blank for the 8:00 am
dose from 10/1/25-10/31/25. Carbamazepine was
documented as administered at 6:30 am and 8:00
pm on 10/1/25-10/8/25, 10/10/25-10/11/25, and
10/13/25-10/27/25. On 10/9/25, the 6:30 am dose
was documented as administered, and the 8:00
pm dose was left blank. On 10/12/25 and
10/31/25, the 6:30 am dose was documented as
administered, and the 8:00 pm dose was marked
with an "X." From 10/28/25-10/30/25, both the
6:30 am and 8:00 pm doses were marked with an
-Desmopressin 0.2 mg 1 tablet (instead 4 tablets
as instructed on the label) at HS was documented
as administered from 10/1/25-10/31/25.
-Concerta 27 mg was documented administered
10/1/25-10/19/25 and marked with an "X" from
10/20/25-10/31/25.

-Concerta (methylphenidate) 36 mg with
instructions was blacked out with ink from
10/1/25-10/19/25 and documented as
administered at 6:30 am 10/20/25-10/31/25.
-Melatonin 1-2 tablets at HS was documented as
administered 10/1/25-10/31/25 but the number of
tablets administered were not specified.
November:

-Carbamazepine was documented as
administered at 8:00 am and 8:00 pm on
11/1/25-11/2/25 and 11/16/25. It was documented
at 6:30 am and 8:00 pm from 11/3/25-11/7/25,
11/10/25-11/14/25, 11/17/25-11/21/25, and
11/24/25- 11/25/25. On 11/8/25 and 11/9/25, the
8:00 am and 8:00 pm doses were documented as
administered, and the 6:30 am doses were
marked with circles over what appeared to be

Division of Health Service Regulation

STATE FORM

6809

8JRO11

(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 17 Vv 118

If continuation sheet 18 of 52

PRINTED: 01/22/2026

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
MHL002-032 01/12/2026
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
490 RADIO ROAD
GEORGIE'S HELPING HAND
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 18 Vv 118

whited-out initials. On 11/15/25, the 8:00 am and
8:00 pm doses were documented as
administered, and the 6:30 am doses were left
blank, and the 8:00 pm doses were marked with
an "X." On 11/27/25, the 8:00 am dose was
documented as administered, and the 6:30 am
and 8:00 pm doses were left blank. On 11/28/25,
the 8:00 pm dose was documented as
administered, and the 6:30 am and 8:00 am
doses were left blank.

-Desmopressin 0.2 mg 1 tablet (instead 4 tablets
as instructed on the label) at HS was documented
as administered from 11/1/25-11/30/25.

-Concerta (methylphenidate) 36 mg with
instructions "DO NOT EXCEED 1 PER 24
HOURS' was blacked out with ink from
10/1/25-10/19/25, documented as administered
at 6:30 am 11/1/25-11/15/25, at 8:00 am 11/16/25
(22 % hours from previous dose), and at 6:30 am
11/17/25-11/22/25, then marked with an "X" from
11/23/25-11/30/25.

-Melatonin 1-2 tablets at HS was documented as
administered 11/1/25-11/26 and 11/28/25 but the
number of tablets administered were not
specified. Melatonin was marked with an "X" on
11/29/25- 11/30/25 and was left blank on 11/27/25.
December:

-Carbamazepine doses were documented as
follows: On 12/1/25, an""R" was documented at
8:00 am, the 6:30 am dose was left blank, and
the 8:00 pm dose was documented as
administered. On 12/2/25, the 6:30 am dose was
documented as administered, and the 8:00 am
and 8:00 pm doses were left blank. On 12/3/25,
the 6:30 am and 8:00 am doses were left blank,
and the 8:00 pm dose was marked with an "R"
and initials without further explanation. On
12/4/25, the 8:00 am dose was left blank, and the
6:30 am and 8:00 pm doses were marked with an
"R" and initials. On 12/5/25, the 8:00 am and 8:00

Division of Health Service Regulation
STATE FORM

6809

8JRO11

If continuation sheet 19 of 52

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL002-032

490 RADIO

GEORGIE'S HELPING HAND

A. BUILDING:

ROAD

(X2) MULTIPLE CONSTRUCTION

TAYLORSVILLE, NC 28681

PRINTED: 01/22/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

01/12/2026

pm doses were documented as administered,
and the 6:30 am dose contained scribbled-out
initials. On 12/6/25, the 6:30 am and 8:00 am
doses were marked with an "X," and the 8:00 pm
dose was left blank. On 12/7/25, the 8:00 am and
8:00 pm doses were left blank, and the 6:30 am
dose was marked with an "R" and initials.
Carbamazepine was documented as
administered at 6:30 am and 8:00 pm on 12/8/25,
12/10/25, and 12/11/25. On 12/9/25, the 6:30 am
and 8:00 pm doses were documented as
administered, and the 8:00 am dose was marked
with an "R" and initials. On 12/12/25, the 6:30 am
dose was documented as administered, the 8:00
am dose was left blank, and the 8:00 pm dose
was marked with a "?." From 12/13/25 through
12/16/25, on 12/18/25 through 12/19/25, and on
12/21/25, doses were documented as
administered at 8:00 am and 8:00 pm. On
12/17/25, the 6:30 am and 8:00 pm doses were
documented as administered. On 12/20/25, all
doses were left blank. On 12/22/25, the 8:00 am
dose was documented as administered.
Desmopressin 0.2 mg 1 tablet (instead 4 tablets
as instructed on the label) at HS was documented
as administered from 12/1/25-12/19/25 and
12/21/25. Administration was not documented for
12/20/25 as the entry was left blank.
-Methylphenidate 36 mg was listed with specified
administration times of 6:30 am and 8:00 am.
Methylphenidate was left blank on
12/1/25-12/2/25 and 12/20/25. It was documented
as administered at 6:30 am on 12/3/25-12/4/25,
12/6/25-12/8/25, 12/11/25-12/12/25, and
12/16/25-12/17/25. It was documented as
administered at 8:00 am on 12/5/25,
12/9/25-12/10/25, 12/13/25-12/15/25,
12/18/25-12/19/25, and 12/21/25-12/22/25.
-Melatonin 1-2 tablets at HS was left blank
12/1/25-12/22/25.

(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 19 Vv 118

Division of Health Service Regulation
STATE FORM

6809

8JRO11

If continuation sheet 20 of 52

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHL002-032

490 RADIO

GEORGIE'S HELPING HAND

A. BUILDING:

ROAD

(X2) MULTIPLE CONSTRUCTION

TAYLORSVILLE, NC 28681

PRINTED: 01/22/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

01/12/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

Interviews on 12/22/25, 1/5/26 and 1/8/26 with the
Program Director revealed:

-"| don't have medication certification. I'm not
trained in that. Am | in trouble?"

-He initialed and circled his initials on the MAR to
indicate the medication was administered.

-"We (staff) are taught to not use white out on the
MAR."

Interviews on 12/23/25 and 1/8/26 with the
Director/Licensee revealed:

-The Program Director did have medication
administration training by a Registered Nurse
(RN), "I don't know why he would say that (he
didn't have training)."

-On 12/22/25 the Program Director "didn't give
you all of the (clients') medications. The rest is
kept in a different cabinet drawer."

-The Executive Director/Licensee transcribed the
new MARs each month, reviewed them at the
end of the month and was responsible for
obtaining the physician's orders.

Interview on 1/6/26 with the Executive
Director/Licensee revealed:

-He listed all the medications on the MARs for
each client every month.

-He and the facility RN reviewed the MARs for
accuracy at the end of each month.

-"| didn't know if you circle it (the box on the MAR)
it means they didn't receive their medications and
| didn't know that just a circle did that. There's
nothing down there (bottom of MAR) telling what
an "O" is and what an "R" is. | found out when you
(DHSR surveyors) came here and then the
(facility) nurse came and said | shouldn't circle it.
It was an unknowledgeable mistake."

-"| should have let you (DHSR surveyors) in the
Office (on 12/22/25). Some of the medications

Division of Health Service Regulation

STATE FORM

6809

8JRO11

(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 20 Vv 118

If continuation sheet 21 of 52

Division of Health Service Regulation

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

MHL002-032

NAME OF PROVIDER OR SUPPLIER

GEORGIE'S HELPING HAND

A. BUILDING:

ROAD

(X2) MULTIPLE CONSTRUCTION

TAYLORSVILLE, NC 28681

PRINTED: 01/22/2026

STREET ADDRESS, CITY, STATE, ZIP CODE
490 RADIO

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

01/12/2026

(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 21 Vv 118

were on the right-hand side and you have to go
on the left hand side to get those medications and
when he (the Program Director) brought it out he
forgot to take the boxes out and that's rare but
they (clients) get their medications."

-An 'X' on the MAR meant the client did not
receive the medication, " ...that means they didn't
getit ...It's a careless mistake, nothing behind it
...but you can't do that."

-The physician's orders were sent directly to the
pharmacy. "We don't touch it (physician's orders)
...We don't have copies (of physician's orders) in
the facility."

-He picked up the medications from the
pharmacy.

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 12/23/25 of the Plan of Protection
dated 12/23/25 written by the Director/Licensee
revealed:

"What immediate action will the facility take to
ensure the safety of the consumers in your care?
GHH (Georgie's Helping Hand) Administrative
Staff will immediately review all Physicians’
Medication Orders for all consumers (clients) in
our care, as well as contact the prescribing
physicians to request a listing and review of the
medication profiles for each of the consumers; to
assure we have the most current and accurate
listings of the consumers prescribed medications.
GHH Adnministrators will have a Staff Meeting on
this date to review the MARS document for
omissions; missing documentation to be
addressed with late entries noted.

Medication administration to be temporarily
restricted to Staff with verified medication

Division of Health Service Regulation
STATE FORM

6809

8JRO11

If continuation sheet 22 of 52

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHL002-032

490 RADIO

GEORGIE'S HELPING HAND

A. BUILDING:

ROAD

(X2) MULTIPLE CONSTRUCTION

TAYLORSVILLE, NC 28681

PRINTED: 01/22/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

01/12/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

management competency until corrective training
is completed.

GHH Administrator have contacted our
Registered Nurse Medication Management
Trainer today, 12/23/2025, who will avail herself
to conduct a Mandatory Medication Management
Training, her earliest available date being
Monday, 12/29/2025 or an immediate date
thereafter.

Describe your plans to make sure the above
happens.

Discrepancies identified are to be acknowledged
and corrected immediately for future references.
Updated, verified medication lists to be placed in
the consumers’ records and medication
administration area. GHH Staff will undergo
immediate training today on how to properly fill
out the MARS document, as well as the required
follow-up documents necessary to be submitted
in the event that medications are not
administered as expected, which would include
consumer refusals, out of the GH (group home),
and any other situations that may apply.

Daily review audits of the MARS documents to be
conducted by GHH Administrators; Executive
Director (Licensee) and Director (Licensee)."

This deficiency constitutes a re-cited deficiency.

The facility served clients with diagnoses that
included but were not limited to Oppositional
Defiant Disorder, Attention-Deficit Hyperactivity
Disorder, Autism Spectrum Disorder, Anxiety
Disorder, Conduct Disorder, and Disruptive Mood
Dysregulation Disorder. Client #1 had at least 5
missing physician's orders. Client #2 and Client
#3 had no documented physician's orders for any
medications administered. For Client #1, at least
94 medication doses were documented as
administered without a corresponding physician's

Division of Health Service Regulation

STATE FORM

6809

8JRO11

(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 22 Vv 118

If continuation sheet 23 of 52

Division of Health Service Regulation

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

MHL002-032

NAME OF PROVIDER OR SUPPLIER

GEORGIE'S HELPING HAND

A. BUILDING:

ROAD

(X2) MULTIPLE CONSTRUCTION

TAYLORSVILLE, NC 28681

PRINTED: 01/22/2026

STREET ADDRESS, CITY, STATE, ZIP CODE
490 RADIO

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

01/12/2026

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

ID
PREFIX
TAG

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

(xs)
COMPLETE
DATE

V 118) Continued From page 23

order and at least 72 physician-ordered doses of
medication lacked documentation of
administration. For Client #2, at least 1,200
medication doses were documented as
administered without a corresponding physician's
order and at least 210 doses were marked with
an "X," circles without initials, altered entries, or
blank fields were present on Client #2's MARs.
These doses included psychotropics, stimulants,
and supplement medications. For Client #3, at
least 980 medication doses were documented as
administered without a corresponding physician's
order and at least at least 265 medication doses
were marked with an "X,""R," ""?," crossed-out
entry, or left blank. The facility did not maintain
documentation to indicate a physician or
pharmacist had been notified of medication
errors. Across all three clients, the facility
documented at least 2,274 medication doses
administered without physician orders and at
least 547 missed or undocumented doses from
10/1/25 through 12/22/25. This deficiency
constitutes a Type A1 rule violation for serious
neglect and must be corrected within 23 days.

V 123} 27G .0209 (H) Medication Requirements

10A NCAC 27G .0209 MEDICATION
REQUIREMENTS

(h) Medication errors. Drug administration errors
and significant adverse drug reactions shall be
reported immediately to a physician or
pharmacist. An entry of the drug administered
and the drug reaction shall be properly recorded
in the drug record. A client's refusal of a drug
shall be charted.

V 118

V 123

Division of Health Service Regulation
STATE FORM

6809

8JRO11

If continuation sheet 24 of 52

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHL002-032

490 RADIO

GEORGIE'S HELPING HAND

ROAD

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

TAYLORSVILLE, NC 28681

PRINTED: 01/22/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

01/12/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

This Rule is not met as evidenced by:

Based on record reviews and interviews, the
facility failed to ensure drug administration errors
were reported immediately to a physician or
pharmacist for 3 of 3 audited clients (Clients #1,
#2 and #3). The findings are:

Review on 12/23/25 and 1/5/26 of facility records
between 10/1/25 and 1/5/26 requested from the
Director/Licensee and the Executive
Director/Licensee revealed:

-No documentation that medication errors had
been reported to a physician or pharmacist.

Review on 12/22/25 of Client #1's record
revealed:

-Date of Admission 8/15/25.

-15 years old.

-Diagnoses of Oppositional Defiant Disorder
(ODD), Attention-Deficit Hyperactivity Disorder
(ADHD), Autism Spectrum Disorder and Anxiety
Disorder.

Review on 12/22/25 at 12:30 pm-2:00 pm of
Client #1's MARs dated 10/1/25-12/22/25
revealed the following medications had dates that
were documented with an "X", left blank, or
circled:

-Cetirizine HCL (allergies) 10 mg - between
10/1/25 and 11/5/25 - 35 doses.

-Montelukast Sodium (asthma) 10 mg - between
10/1/25 and 12/22/25 - 54 doses.

-Qelbree ER (ADHD) 200 mg - 12/22/25 - 1 dose.
-Metformin HCL (prediabetes) 500 mg - on
11/30/25 and 12/21/25 - 2 doses.

-Fluoxetine HCL (depression) 10 mg - between

Division of Health Service Regulation

STATE FORM

6809

8JRO11

(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 123] Continued From page 24 Vv 123

If continuation sheet 25 of 52

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL002-032

490 RADIO

GEORGIE'S HELPING HAND

A. BUILDING:

ROAD

(X2) MULTIPLE CONSTRUCTION

TAYLORSVILLE, NC 28681

PRINTED: 01/22/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

01/12/2026

12/16/25 - 12/31/25 - 16 doses.

-Aripiprazole (agitation) 5 mg - between 10/1/25 -
10/31/25 - 31 doses.

-Guanfacine (impulsivity/ODD) 4 mg - between
10/1/25 - 10/31/25 - 31 doses.

-Oxcarbazepine (ADHD) 300 mg - between
10/1/25 - 12/22/25 - 83 doses.

-Levocetirizine (allergies) 5 mg - on 10/1/25,
10/2/25 and 12/20/25 - 3 doses.

-Fluoxetine HCL 20 mg - on 11/6/25 and between
11/30/25 and 12/22/25 - 26 doses.

Review on 12/22/25 of Client #2's record
revealed:

-Date of Admission 9/17/25.

-14 years old.

-Diagnoses of ODD and ADHD.

Review on 12/22/25 at 12:30 pm-2:00 pm of
Client #2's MARs dated 10/1/25-12/22/25
revealed the following medications had dates that
were documented with an "X", left blank, outlined
or circled:

-Desvenlafaxine succinate ER (depression) 100
mg - 12/12/25 - 1 dose.

-Lurasidone (mood disorder) 60 mg - between
11/5/25 - 11/30/25, and 12/1/25 - 12/22/25 - 47
doses.

-Clonidine (ADHD) 0.1 mg - 1 tablet in the am
and 1 tablet in the pm - 11/29/25, and 12/15/25
am and pm - 3 doses.

-Clonidine 0.2 mg -1 tablet at HS - 10/6/25,
10/9/25, between 10/14/25 - 10/31/25, 11/4/25 -
11/30/25, 12/20/25 and 12/21/25 - 49 doses.
-Clonidine 0.3 mg 1 tablet at HS - 12/20/25 and
12/21/25 - 2 doses.

-Qelbree ER 200 mg 1 capsule in am - between
11/20/25 - 11/30/25 - 10 doses.

-Qelbree ER 200 mg 1 capsule at 1:00 pm -
between 11/1/25 - 11/19/25 - 19 doses.

Division of Health Service Regulation
STATE FORM

6809

8JRO11

(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 123] Continued From page 25 Vv 123

If continuation sheet 26 of 52

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHL002-032

490 RADIO

GEORGIE'S HELPING HAND

A. BUILDING:

ROAD

(X2) MULTIPLE CONSTRUCTION

TAYLORSVILLE, NC 28681

PRINTED: 01/22/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

01/12/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

-Qelbree ER 200 mg 2 capsules at 1:00 pm -
10/10/25, 10/30/25, 10/31/25 - 3 doses.

-Vyvanse (ADHD) 60 mg - between 10/10/25 -
10/17/25, 11/1/25 - 11/19/25, 12/12/25 - 27 doses.
-Vitamin D3 (supplement) 50 micrograms -
between 10/1/25 - 10/31/25, 11/1/25 - 11/19/25 -
50 doses.

-Dextroamphetamine (ADHD) 5 mg - between
10/4/25 - 10/31/25 - 28 doses.

Review on 12/22/25 of Client #3's record
revealed:

-Date of Admission 9/13/25.

-14 years old.

-Diagnoses of ADHD, Conduct Disorder and
Disruptive Mood Dysregulation Disorder.

Review on 12/22/25 at 12:30 pm-2:00 pm of
Client #3's MARs dated 10/1/25-12/22/25
revealed the following medications had dates that
were documented with an "X", ""R", left blank, or
circled:

-Desmopressin (bedwetting) 0.2 mg - 12/20/25 -
1 dose.

-Carbamazepine (seizures) 100 mg - am -
10/28/25 - 10/30/25, 11/28/25, 12/1/25, 12/3/25,
12/4/25, 12/6/25, 12/7/25, 12/20/25 for a total of 9
doses; pm - 10/9/25, 10/12/25, 10/28/25 -
10/31/25, 11/15/25, 11/27/25, 12/2/25, 12/3/25,
12/4/25, 12/6/25, 12/7/25, 12/12/25, 12/20/25 - a
total of 15 doses.

-Concerta (ADHD) 36 mg - between 10/1/25 -
10/19/25, 11/23/25 - 11/30/25 - 27 doses.
-Melatonin (insomnia) 3 mg - 11/27/25, 11/29/25,
11/30/25, between 12/1/25 - 12/22/25 - 25 doses.
-Fluticasone nasal spray (allergy symptoms) 27.5
mcg - between 10/1/25 - 12/22/25 - 83 doses.
-Docusate sodium (constipation) 50 mg - am and
pm - between 10/1/25 - 11/30/25 - 122 doses.

Division of Health Service Regulation
STATE FORM

6809

8JRO11

(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 123] Continued From page 26 Vv 123

If continuation sheet 27 of 52

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 01/22/2026
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL002-032 01/12/2026
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
490 RADIO ROAD
GEORGIE'S HELPING HAND
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 123] Continued From page 27 Vv 123

Interviews on 12/22/25, 1/5/26 and 1/8/26 with the
Program Director revealed:

-His duties included administration of medications
to the clients.

-If a client refused their medications "we are to
indicate it on the back of the MAR but we were
doing an 'X' or just leaving it blank."

Interview on 1/6/26 with the Qualified
Professional revealed:

-"| just do (administer) the medications.
[Executive Director/Licensee] is over it (MARs)
and talks over it with the nurse ...again that is not
my forte."

-Reported medication errors to the Executive
Director/Licensee, "it's verbal and written. It's
written on the MARs on the opposite side there's
a place if there is an error that occurs, we put it
on the back ..."

Interview on 1/6/26 with the Executive
Director/Licensee revealed:

-An 'X' on the MAR meant the client did not
receive the medication. "If there's blanks, | want
to find out why there's blanks and | look back and
see who was on shift and ask why there's blanks
on the medication and there's a big discussion.
You might have a sheet (MAR) but they aren't
getting that medication anymore. | need to get
behind that and make sure | am getting letters
(physician's orders) stating that medication has
been discontinued."

-If there's an error that has been made "I will
contact the (client's physician's) office, the
(client's physician's) nurse and let her know and
she will get in touch with the doctor (client's
physician) and get back to me."

-"No," there was no medication errors made in
the past 3 months (October, November and
December 2025).

Division of Health Service Regulation
STATE FORM

6809

8JRO11

If continuation sheet 28 of 52

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 01/22/2026
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL002-032 01/12/2026
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
490 RADIO ROAD
GEORGIE'S HELPING HAND
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 123] Continued From page 28 Vv 123
This deficiency is cross-referenced into 10A
NCAC 27G.0209 Medication Requirements
(V118) for a Type A1 rule violation and must be
corrected within 23 days.
V 293] 27G .1701 Residential Tx. Child/Adol - Scope V 293

10A NCAC 27G .1701 SCOPE

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

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

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

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

(2) treatment in a staff secure setting.

(e) Services shall be designed to:

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

(2) minimize the occurrence of behaviors
related to functional deficits;

(3) ensure safety and deescalate out of

Division of Health Service Regulation
STATE FORM

6809

8JRO11

If continuation sheet 29 of 52

PRINTED: 01/22/2026

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
MHL002-032 01/12/2026
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
490 RADIO ROAD
GEORGIE'S HELPING HAND
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 293] Continued From page 29 V 293

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

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

This Rule is not met as evidenced by:

Based on observation, record reviews and
interviews, the facility failed to operate within the
scope of their license to include individualized
supervision and structure of daily living, ensure
safety, assist in the acquisition of adaptive
functioning, and support in gaining skills needed
to step-down to a less intensive treatment setting
and failed to ensure an individual who was not a
client did not maintain their primary residence at
the facility. The findings are:

Cross Reference: 10A NCAC 27G.0205
Assessment and Treatment/Habilitation or
Service Plan (V112): Based on record reviews
and interviews, the facility failed to develop and
implement treatment plans based on client needs
Division of Health Service Regulation

STATE FORM

6809

8JRO11

If continuation sheet 30 of 52

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 01/22/2026
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL002-032 01/12/2026
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
490 RADIO ROAD
GEORGIE'S HELPING HAND
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 293] Continued From page 30 V 293

within 30 days of admission for 3 of 3 audited
clients (Clients #1, #2 and #3).

Cross Reference: 10A NCAC 27G.1702
Requirements of Qualified Professionals (V294):
Based on record reviews and interviews, the
Qualified Professional (QP) failed to perform
clinical and administrative responsibilities at a
minimum to include the supervision of the
Associate Professional (AP), oversight of
emergencies, provision of direct
psychoeducational services, participation and
coordination of treatment plans, and provision of
case management functions.

Cross Reference: 10A NCAC 27G.1703
Requirements for Associate Professionals
(V295): Based on record reviews and interviews,
the facility failed to employ a full-time Associate
Professional (AP) who ensured management of
the daily operations of the facility, supervision of
paraprofessionals, and participation in service
planning meetings.

Cross Reference: 10A NCAC 27G.1704 Minimum
Staffing Requirements (V296): Based on
observation, record reviews and interviews, the
facility failed to ensure the required minimum
number of 2 direct care staff for 1 to 4 clients
were present.

Review on 12/30/25 of the Program Director's
record revealed:

-Date of Hire: 7/6/21.

-North Carolina (NC) driver's license listed the
facility address as his residence.

Interviews on 12/22/25 and 1/5/26 with Client #1
revealed:
-The Program Director "sleeps (at the facility) on

Division of Health Service Regulation
STATE FORM

6809

8JRO11

If continuation sheet 31 of 52

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHL002-032

490 RADIO

GEORGIE'S HELPING HAND

A. BUILDING:

ROAD

(X2) MULTIPLE CONSTRUCTION

TAYLORSVILLE, NC 28681

PRINTED: 01/22/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

01/12/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

the couch."

Interview on 12/30/25 with Client #4 revealed:
-"[Program Director] stays here (facility) pretty
much."

Interviews on 12/22/25, 1/5/26 and 1/8/26 with the
Program Director revealed:

-"| work all shifts. | am here (facility) pretty much
around the clock. | am in and out but here every
shift. | don't live here. | have another home. | just
use this address on my license. My address is in
(another state). | am a traveler ...l have no home
in North Carolina. | don't need sleep ...just kind of
rest ...| sleep in the office, there's a recliner
...When we work, 1 (staff) is allowed to sleep ...1
(staff) awake and 1 asleep."

Review on 1/9/26 of the Plan of Protection dated
1/9/26 written by the Director/Licensee revealed:
"What immediate action will the facility take to
ensure the safety of the consumers in your care?
(V293) GHH (Georgie's Helping Hand) current
Program Director does spend a great amount of
time at the Group Home, fulfilling his duties, as
well as filling in as needed when there's a
shortage of staff. However, the facility is not his
place of domicile.

(V294) GHH Administrative Staff will meet with
current QP immediately, at least by 01/10/2026,
to review, explain and reiterate the duties and
responsibilities of the QP position for which he
was hired for.

(V295) GHH Administrative Staff will identify
and/or hire an Associate Professional, as
required, to fulfill their duties in this position,
which would include their participation and input
with the Residents' Service (treatment) Plans and
Staff Meetings, as well as addressing the daily
operation of the facility, and the supervision of

Division of Health Service Regulation

STATE FORM

6809

8JRO11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 293] Continued From page 31 V 293

If continuation sheet 32 of 52

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHL002-032

490 RADIO

GEORGIE'S HELPING HAND

A. BUILDING:

ROAD

(X2) MULTIPLE CONSTRUCTION

TAYLORSVILLE, NC 28681

PRINTED: 01/22/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

01/12/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

Direct Support Staff.
(V296) GHH Administrators will ensure that at
least the Minimum Staff Ratio is satisfied on all
shifts going forward by scheduling Staff to work
and provide coverage for the shifts accordingly.
(V112) GHH do have Treatment Plans for all
current Residents. Even though all were not
initially presented to the Surveyors upon request,
they were later produced as evidence that these
documents had been prepared and are available.
Describe your plans to make sure the above
happens.

(V293) Program Director does have a separate
residency in the State of North Carolina, which
has been confirmed by GHH Administrators.
Program Director will obtain a new ID
(identification), confirming his current NC
residence.

(V294) GHH Administrators will get the necessary
feedback from the QP, after having a meeting
with him to assure that he has a full
understanding and is still willing and capable of
performing the duties and responsibilities of the
QP Position. We will have the QP sign a new job
description form to review his roles and
responsibilities. QP will be place on a
Performance Improvement Plan as well.

(V295) GHH Administrators will offer an internal
hire for the AP position. In the event it cannot be
filled internally, we will post the position and seek
an external hire.

296) GHH Adnministrators will maintain a log
which will identify and indicate the staff member's
time in and time out for the clinical day, thereby
maintaining at least two staff members at the
facility at all times.

(V112) GHH Administrators will make sure that all
the Residents’ (clients') Treatment Plans are kept
in their folders, or at least on-site to be readily
available if necessary."

Division of Health Service Regulation

STATE FORM

6809

8JRO11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 293] Continued From page 32 V 293

If continuation sheet 33 of 52

Division of Health Service Regulation

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

MHL002-032

NAME OF PROVIDER OR SUPPLIER

GEORGIE'S HELPING HAND

A. BUILDING:

ROAD

(X2) MULTIPLE CONSTRUCTION

TAYLORSVILLE, NC 28681

PRINTED: 01/22/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

01/12/2026

STREET ADDRESS, CITY, STATE, ZIP CODE
490 RADIO

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

ID
PREFIX
TAG

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

CROSS-REFERENCED TO THE APPROPRIATE, DATE
DEFICIENCY)

V 293] Continued From page 33

Clients served by the facility were adolescents
who had mental health diagnoses including but
not limited to Oppositional Defiant Disorder,
Attention-Deficit Hyperactivity Disorder, Autism
Spectrum Disorder, Anxiety Disorder, Conduct
Disorder and Disruptive Mood Dysregulation
Disorder. The facility did not ensure the Program
Director did not maintain their primary residence
at the facility. The Program Director routinely
stayed overnight and used the facility address as
his residence. Client #1, Client #2 and Client #3
did not have individualized treatment plans within
30 days of admission and treatment strategies
were not documented or implemented based on
assessed client needs. The Qualified
Professional did not fulfill required clinical and
administrative responsibilities, including
supervision of staff, participation in treatment
planning, coordination of services, emergency
oversight, and case management. The facility did
not employ an Associate Professional responsible
for daily operations, supervision of
paraprofessionals, and participation in service
planning meetings. The facility did not maintain
required minimum staffing ratios, as fewer than
two direct care staff were present which limited
supervision and support.

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 294] 27G .1702 Residential Tx. Child/Adol -Req. for Q
Pp

10A NCAC 27G .1702 REQUIREMENTS OF
QUALIFIED PROFESSIONALS

Division of Health Service Regulation
STATE FORM

V 293

V 294

6809

8JRO11

If continuation sheet 34 of 52

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 01/22/2026
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL002-032 01/12/2026
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
490 RADIO ROAD
GEORGIE'S HELPING HAND
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 294] Continued From page 34 V 294

(a) Each facility shall utilize at least one direct
care staff who meets the requirements of a
qualified professional as set forth in 10A NCAC
27G .0104(18). In addition, this qualified
professional shall have two years of direct client
care experience.

(b) For each facility of five or less beds:

(1) the qualified professional specified in
Paragraph (a) of this Rule shall perform clinical
and administrative responsibilities a minimum of
10 hours each week; and

(2) 70% of the time shall occur when
children or adolescents are awake and present in
the facility.

(c) For each facility of six or more beds:

(1) the qualified professional specified in
Paragraph (a) of this Rule shall perform clinical
and administrative responsibilities a minimum of
32 hours each week; and

(2) 70% of the time shall occur when
children or adolescents are awake and present in
the facility.

(d) The governing body responsible for each
facility shall develop and implement written
policies that specify the clinical and administrative
responsibilities of its qualified professional(s). At
a minimum these policies shall include:

(1) supervision of its associate
professional(s) as set forth in Rule .1703 of this
Section;

(2) oversight of emergencies;

(3) provision of direct psychoeducational
services to children or adolescents;

(4) participation in treatment planning
meetings;

(5) coordination of each child or
adolescent's treatment plan; and

(6) provision of basic case management
functions.

Division of Health Service Regulation
STATE FORM

6809

8JRO11

If continuation sheet 35 of 52

Division of Health Service Re

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

NAME OF PROVIDER OR SUPPLIER

MHL002-032

490 RADIO

GEORGIE'S HELPING HAND
TAYLORSVILLE, NC 28681

(X2) MULTIPLE CONSTRUCTION

A. BUILDING:

ROAD

PRINTED: 01/22/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY
COMPLETED

01/12/2026

This Rule is not met as evidenced by:

Based on record reviews and interviews, the
Qualified Professional (QP) failed to perform
clinical and administrative responsibilities at a
minimum to include the supervision of the
Associate Professional (AP), oversight of
emergencies, provision of direct
psychoeducational services, participation and
coordination of treatment plans, and provision of
case management functions. The findings are:

Review on 12/30/25 of the QP's record revealed:
-Date of Hire: 11/19/21.

-A job description signed by the QP on 9/29, but
lacked a legible year of signature: " ...Duties:
...Develops, supervises and updates a client plan
of care to include type of services needed,
frequency of services needed, days services are
needed, and time of day services are needed
...Completes and records assessment, client's
plan of care for physician's, or other sources’
approval, including physicians orders plan for
treatment ...return upon completion all documents
to facility premises ...Completes supervision
standards, including Evaluations of all clients to
include at a minimum: Any and all changes to be
noted in clients current plan of care ...Document
any safety concerns regarding client's current
condition related to mental, physical, emotional,
or living conditions. Document any suggestions in
resolving the concern ...Delegates tasks and
supervises Staff ..."

Division of Health Service Regulation
STATE FORM

6809

If continuation sheet 36 of 52

(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 294] Continued From page 35 V 294

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 01/22/2026
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL002-032 01/12/2026
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
490 RADIO ROAD
GEORGIE'S HELPING HAND
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 294] Continued From page 36 V 294
Review on 12/22/25 of Client #1's record
revealed:
-Date of Admission 8/15/25.
-15 years old.

-Diagnoses of Oppositional Defiant Disorder
(ODD), Attention-Deficit Hyperactivity Disorder
(ADHD), Autism Spectrum Disorder and Anxiety
Disorder.

-No treatment plan.

Review on 12/22/25 of Client #2's record
revealed:

-Date of Admission 9/17/25.

-14 years old.

-Diagnoses of ODD and ADHD.

-No treatment plan.

Review on 12/22/25 of Client #3's record
revealed:

-Date of Admission 9/13/25.

-14 years old.

-Diagnoses of ADHD, Conduct Disorder and
Disruptive Mood Dysregulation Disorder.
-No treatment plan.

Review on 12/22/25 and 1/5/26 of facility records
revealed:

-No documentation that the QP provided
supervision to an Associate Professional (AP),
oversight of emergencies, psychoeducational
services, case management functions, or
participation and coordination of treatment plans.

Review on 1/6/26 of a Computer Aided Dispatch
(CAD) list dated 8/1/25-1/5/26 from the local
sheriff's department revealed:

-Law enforcement was called to Georgie's
Helping Hand Group Home for a "Missing
Person" on 11/6/25 and 12/3/25. When Client #3
eloped from the facility.

Division of Health Service Regulation
STATE FORM

6809

8JRO11

If continuation sheet 37 of 52

Division of Health Service Regulation

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

MHL002-032

NAME OF PROVIDER OR SUPPLIER

GEORGIE'S HELPING HAND

A. BUILDING:

ROAD

(X2) MULTIPLE CONSTRUCTION

TAYLORSVILLE, NC 28681

PRINTED: 01/22/2026

STREET ADDRESS, CITY, STATE, ZIP CODE
490 RADIO

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

01/12/2026

(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 294] Continued From page 37 V 294

Interview on 1/5/26 with the Coordinator and
Behavior Specialist from the local school where
Clients #1, #2 and #3 attended revealed:

-"The facility does not share their (clients')
behaviors, violence tendency, triggers ...we have
learned about [Client #2's] sexual comments just
by him being here ...[Client #2] has made
statements of wanting to kill himself ...said he had
a gun or a bomb ...| don't know if this was a
problem prior to him coming here ...[Client #3] ran
away from the facility 2 times. If a kid (client) runs
from the group home on Saturday, we need to
know that on Monday ..."

Interview on 1/6/26 with the QP revealed:
-Unable to identify who was designated as the AP
for the facility.

-Regarding interventions and follow up to
incidents involving Client #3's elopements from
the facility on 11/6/25 and 12/23/25, "I wouldn't
call it an incident, but it's part of [Client #3's]
diagnosis that he runs away at times, but it wasn't
on my shift so | can't speak so much about it
because | wasn't there and | don't speak on
things that | didn't witness ..."

-Treatment plan "recommendations come from
where they (clients) were before and what their
interactions were, but that's not part of my forte. |
am limited on what | can speak. | don't do that.
That's not what | do ..."

-Coordination with educational services "That's
not my job. | stay in my lane ..."

Interview on 1/6/26 with the Executive
Director/Licensee revealed:
-The QP was "still learning" his responsibilities.

Interviews on 1/12/26 with the Director/Licensee
and the Executive Director/Licensee revealed:

Division of Health Service Regulation
STATE FORM

6809

8JRO11

If continuation sheet 38 of 52

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHL002-032

490 RADIO

GEORGIE'S HELPING HAND

A. BUILDING:

ROAD

(X2) MULTIPLE CONSTRUCTION

TAYLORSVILLE, NC 28681

PRINTED: 01/22/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

01/12/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

p

10A NCAC 27G .1703 REQUIREMENTS FOR
ASSOCIATE PROFESSIONALS.

(a) In addition to the qualified professional
specified in Rule .1702 of this Section, each
facility shall have at least one full-time direct care
staff who meets or exceeds the requirements of
an associate professional as set forth in 10A
NCAC 27G .0104(1).

(b) The governing body responsible for each
facility shall develop and implement written
policies that specify the responsibilities of its
associate professional(s). At a minimum these
policies shall address the following:

(1) management of the day to day
day-to-day operations of the facility;

(2) supervision of paraprofessionals
regarding responsibilities related to the
implementation of each child or adolescent's
treatment plan; and

(3) participation in service planning
meetings.

This Rule is not met as evidenced by:
Based on record reviews and interviews, the

Division of Health Service Regulation
STATE FORM

6809

8JRO11

(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 294] Continued From page 38 V 294
-The QP had been in his role for "about 2 years."
This deficiency constitutes a re-cited deficiency.
This deficiency is cross referenced into 10A
NCAC 27G .1701 Scope (V293) for a Type B rule
violation and must be corrected within 45 days.
V 295} 27G .1703 Residential Tx. Child/Adol - Req. for A V 295

If continuation sheet 39 of 52

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 01/22/2026
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL002-032 01/12/2026
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
490 RADIO ROAD
GEORGIE'S HELPING HAND
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 295] Continued From page 39 V 295

facility failed to employ a full-time Associate
Professional (AP) who ensured management of
the daily operations of the facility, supervision of
paraprofessionals, and participation in service
planning meetings. The findings are:

Review on 12/22/25 of the facility's Client and
Staff Census completed by the Program Director
on 12/22/25 revealed:

-An AP was not identified.

Interview on 1/5/26 with the Program Director
revealed:

-He was not familiar with the term "AP" and
sought clarification.

-He could not confirm that an AP worked for the
facility.

Interview on 1/6/26 with the Qualified
Professional revealed:

-He was unable to identify who was designated
as the AP for the facility.

Interview on 12/23/25 with the Director/Licensee
revealed:
-An AP for the facility had not been hired yet.

Interview on 1/6/26 with the Executive
Director/Licensee revealed:
-The facility did not have an AP.

Interviews on 1/12/26 with the Director/Licensee
and the Executive Director/Licensee revealed:
-There had not been an AP for the facility since
August 2025.

This deficiency is cross referenced into 10A
NCAC 27G .1701 Scope (V293) for a Type B rule
violation and must be corrected within 45 days.

Division of Health Service Regulation
STATE FORM

6809

8JRO11

If continuation sheet 40 of 52

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHL002-032

490 RADIO

GEORGIE'S HELPING HAND

A. BUILDING:

ROAD

(X2) MULTIPLE CONSTRUCTION

TAYLORSVILLE, NC 28681

PRINTED: 01/22/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

01/12/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

Staffing

10A NCAC 27G .1704
REQUIREMENTS

(a) A qualified professional shall be available by
telephone or page. A direct care staff shall be
able to reach the facility within 30 minutes at all
times.

(b) The minimum number of direct care staff
required when children or adolescents are
present and awake is as follows:

(1) two direct care staff shall be present for
one, two, three or four children or adolescents;
(2) three direct care staff shall be present
for five, six, seven or eight children or
adolescents; and

(3) four direct care staff shall be present for
nine, ten, eleven or twelve children or
adolescents.

(c) The minimum number of direct care staff
during child or adolescent sleep hours is as
follows:

(1) two direct care staff shall be present
and one shall be awake for one through four
children or adolescents;

(2) two direct care staff shall be present
and both shall be awake for five through eight
children or adolescents; and

(3) three direct care staff shall be present
of which two shall be awake and the third may be
asleep for nine, ten, eleven or twelve children or
adolescents.

(d) In addition to the minimum number of direct
care staff set forth in Paragraphs (a)-(c) of this
Rule, more direct care staff shall be required in
the facility based on the child or adolescent's
individual needs as specified in the treatment
plan.

MINIMUM STAFFING

Division of Health Service Regulation
STATE FORM

6809

8JRO11

(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 296 | Continued From page 40 V 296
V 296] 27G .1704 Residential Tx. Child/Adol - Min. V 296

If continuation sheet 41 of 52

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 01/22/2026
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL002-032 01/12/2026
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
490 RADIO ROAD
GEORGIE'S HELPING HAND
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 296 | Continued From page 41 V 296

(e) Each facility shall be responsible for ensuring
supervision of children or adolescents when they
are away from the facility in accordance with the
child or adolescent's individual strengths and
needs as specified in the treatment plan.

This Rule is not met as evidenced by:

Based on observation, record reviews and
interviews, the facility failed to ensure the
required minimum number of 2 direct care staff
for 1 to 4 clients were present. The findings are:

Review on 1/6/26 of the facility staff schedule
sheets from 8/1/25 through 12/31/25 revealed:
-The Director/Licensee and the Executive
Director/Licensee were scheduled to work
12/22/25 from 7:00 am - 3:00 pm.

Observation on 12/22/25 at 11:55 am revealed:
-Clients' #1, #2 and #3 were in the living room
playing video games.

-The Program Manager was present and worked
alone with the 3 clients.

-At 12:58 pm Staff #1 arrived at the facility and
asked clients’ if they wanted a snack.

Interviews on 12/22/25 and 1/5/26 with Client #1
revealed:

-There were "always 2 staff" present on all 3
shifts.

-"Today (12/22/25) was the first day (1 staff on
shift) ..."

Division of Health Service Regulation
STATE FORM

6809

8JRO11

If continuation sheet 42 of 52

PRINTED: 01/22/2026

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
MHL002-032 01/12/2026
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
490 RADIO ROAD
GEORGIE'S HELPING HAND
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 296] Continued From page 42 V 296

Attempted interviews on 12/22/25, 12/30/25 and
1/5/26 with Clients #2 and #3 were unsuccessful
as both clients refused to be interviewed.

Interview on 12/22/25 with Staff #1 revealed:
-Worked the second shift, 3:00 pm - 11:00 pm.
-"| wasn't at the facility earlier (upon arrival)
because | ran to the store ..."

Interviews on 12/22/25, 1/5/26 and 1/8/26 with the
Program Director revealed:

-The Executive Director/Licensee made the staff
schedule.

-"No set person (scheduled for a shift). | rotate
with everybody. | work all shifts. | am here pretty
much around the clock. | am in and out but here
every shift."

-"We always schedule 2 staff to be present with
the boys (clients)."

Interview on 1/6/26 with the Qualified
Professional revealed:

-Worked "mostly" the 3:00 pm - 11:00 pm shift
and the weekends; "There is no set time slots."
-"The house (facility) has to be covered by 2 staff
members, and [Executive Director/Licensee]
does the best that he can to make sure there is
always 2 people (staff) there ...If staff are not
available, then I've got to fill it, but there's no void
of staff at any given moment."

Interviews on 1/6/26 and 1/12/26 with the
Executive Director/Licensee revealed:

-"| have a schedule sheet and it's indicated on my
schedule sheet ...l am here almost 24/7 and
make sure the staff are here ...and if staff don't
come in, | have to fill in for them ..."

-"| was at the store when you (Division of Health
Service Regulation surveyors) all came
Division of Health Service Regulation

STATE FORM

6809

8JRO11

If continuation sheet 43 of 52

Division of Health Service Regulation

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

MHL002-032

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 01/22/2026

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

490 RADIO
TAYLORSVILLE, NC 28681

GEORGIE'S HELPING HAND

ROAD

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

01/12/2026

(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 296 | Continued From page 43 V 296
(12/22/25).
This deficiency is cross referenced into 10A
NCAC 27G .1701 Scope (V293) for a Type B rule
violation and must be corrected within 45 days.
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

Division of Health Service Regulation
STATE FORM

6809

If continuation sheet 44 of 52

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHL002-032

490 RADIO

GEORGIE'S HELPING HAND

A. BUILDING:

ROAD

(X2) MULTIPLE CONSTRUCTION

TAYLORSVILLE, NC 28681

PRINTED: 01/22/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

01/12/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

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:
(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

Division of Health Service Regulation
STATE FORM

6809

8JRO11

(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 44 V 366

If continuation sheet 45 of 52

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHL002-032

490 RADIO

GEORGIE'S HELPING HAND

A. BUILDING:

ROAD

(X2) MULTIPLE CONSTRUCTION

TAYLORSVILLE, NC 28681

PRINTED: 01/22/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

01/12/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

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
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 reviews and interviews, the
facility failed to implement policies regarding
documentation of Level II incidents. The findings
are:

Review on 12/22/25 of Client #3's record
revealed:

-Date of Admission 9/13/25.

-14 years old.

Division of Health Service Regulation

STATE FORM

6809

8JRO11

(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 45 V 366

If continuation sheet 46 of 52

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 01/22/2026
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL002-032 01/12/2026
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
490 RADIO ROAD
GEORGIE'S HELPING HAND
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 46 V 366

-Diagnoses of Attention Deficit Hyperactivity
Disorder, Conduct Disorder and Disruptive Mood
Dysregulation Disorder.

Review on 1/5/26 of facility incident reports from
10/1/25 - 1/5/26 revealed:

-11/6/25 at 6:00 p.m. and 12/3/25 at 6:40 p.m. -
Client #3 ran away from the facility and law
enforcement was called.

-No analysis of determining the cause of the
incident, developing and implementing measures
to prevent similar incidents, or assigning a staff
member to be responsible for correction and
prevention measures.

-No documentation Client #3's guardian and the
Local Management Entity were notified for each
incident.

Attempted interviews on 12/22/25, 12/30/25 and
1/5/26 with Client #3 were unsuccessful as the
client refused to be interviewed.

Interview on 1/5/26 with the Program Director
revealed:

-Completed incident reports and "primarily it's
been with [Client #3]."

-After he completed the report he gave it to the
Executive Director/Licensee.

-The Executive Director/Licensee "reviews
internal incident reports and determines the levels
(of incidents)."

Interview on 1/6/26 with the Qualified
Professional revealed:

-"| wouldn't call it (incidents on 11/6/25 and
12/3/25) an incident, but it's part of [Client #3's]
diagnosis that he runs away at times, but it wasn't
on my shift, so | can't speak so much about it
because | wasn't there and | don't speak on
things that | didn't witness."

Division of Health Service Regulation
STATE FORM

6809

8JRO11

If continuation sheet 47 of 52

Division of Health Service Regulation

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

MHL002-032

NAME OF PROVIDER OR SUPPLIER

GEORGIE'S HELPING HAND

A. BUILDING:

ROAD

(X2) MULTIPLE CONSTRUCTION

TAYLORSVILLE, NC 28681

PRINTED: 01/22/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

01/12/2026

STREET ADDRESS, CITY, STATE, ZIP CODE
490 RADIO

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

ID
PREFIX
TAG

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

CROSS-REFERENCED TO THE APPROPRIATE, DATE
DEFICIENCY)

V 366 | Continued From page 47

Interview on 1/6/26 with the Executive
Director/Licensee revealed:

-The Director/Licensee was responsible to review
incidents and determine any actions needed.

-"| may glimpse them..."

Interview on 1/8/26 with the Director/Licensee
revealed:

-The staff who were on shift during an incident
were "responsible for filling out incident reports
and it comes to [Executive Director/Licensee]."
-She and the Executive Director/Licensee
determined what actions were needed when an
incident was received.

-She was unaware of notifications needed when
an incident occurred.

This deficiency constitutes a re-cited deficiency
and must be corrected within 30 days.

V 367] 27G .0604 Incident Reporting Requirements

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

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

Division of Health Service Regulation
STATE FORM

V 366

V 367

6809

8JRO11

If continuation sheet 48 of 52

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 01/22/2026
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL002-032 01/12/2026
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
490 RADIO ROAD
GEORGIE'S HELPING HAND
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 48 V 367

means. The report shall include the following

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

Division of Health Service Regulation
STATE FORM

6809

8JRO11

If continuation sheet 49 of 52

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHL002-032

490 RADIO

GEORGIE'S HELPING HAND

A. BUILDING:

ROAD

(X2) MULTIPLE CONSTRUCTION

TAYLORSVILLE, NC 28681

PRINTED: 01/22/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

01/12/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

or restraint, the provider shall report the death
immediately, as required by 10A NCAC 26C.
.0300 and 10A NCAC 27E .0104(e)(18).

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

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

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

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

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

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

This Rule is not met as evidenced by:
Based on record reviews and interviews, the
facility failed to report all level II incidents in the
Incident Response Improvement System (IRIS),
failed to notify the Local Management Entity
(LME)/Managed Care Organization (MCO)
responsible for the catchment area where
services were provided within 72 hours of

Division of Health Service Regulation

STATE FORM

6809

8JRO11

(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 49 V 367

If continuation sheet 50 of 52

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHL002-032

490 RADIO

GEORGIE'S HELPING HAND

A. BUILDING:

ROAD

(X2) MULTIPLE CONSTRUCTION

TAYLORSVILLE, NC 28681

PRINTED: 01/22/2026
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

01/12/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

becoming aware of the incident. The findings are:

Review on 12/22/25 of Client #3's record
revealed:

-Date of Admission 9/13/25.

-14 years old.

-Diagnoses of Attention Deficit Hyperactivity
Disorder, Conduct Disorder and Disruptive Mood
Dysregulation Disorder.

Review on 12/22/25 and 1/5/26 of the IRIS from
10/1/25 - 1/5/26 revealed:
-No incidents were reported.

Review on 1/5/26 of facility incident reports from
10/1/25 - 1/5/26 revealed:

-11/6/25 at 6:00 p.m. and 12/3/25 at 6:40 p.m. -
Client #3 ran away from the facility and law
enforcement was called.

Attempted interviews on 12/22/25, 12/30/25 and
1/5/26 with Client #3 were unsuccessful as the
client refused to be interviewed.

Interview on 1/5/26 with the Program Director
revealed:

-Completed incident reports and "primarily it's
been with [Client #3]."

-After he completed the report he gave it to the
Executive Director/Licensee.

-The Executive Director/Licensee "reviews
internal incident reports and determines the levels
(of incidents)."

Interview on 1/6/26 with the Executive
Director/Licensee revealed:

-The Director/Licensee was responsible to review
incidents and determine any actions needed.

-"| may glimpse them..."

Division of Health Service Regulation
STATE FORM

6809

8JRO11

(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 50 V 367

If continuation sheet 51 of 52

Division of Health Service Re

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

NAME OF PROVIDER OR SUPPLIER

GEORGIE'S HELPING HAND

MHL002-032

490 RADIO

ROAD

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

TAYLORSVILLE, NC 28681

PRINTED: 01/22/2026

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY
COMPLETED

FORM APPROVED

01/12/2026

Interview on 1/8/26 with the Director/Licensee
revealed:

-The staff who were on shift during an incident
were "responsible for filling out incident reports
and it comes to [Executive Director/Licensee]."
-She and the Executive Director/Licensee
determined if incidents should be entered into
IRIS.

-She was not aware contacts to law enforcement
needed to be entered into IRIS.

This deficiency constitutes a re-cited deficiency
and must be corrected within 30 days.

Division of Health Service Regulation
STATE FORM

6809

8JRO11

(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 51 V 367

If continuation sheet 52 of 52

inspection_type: MHLCS Annual and Follow-up

document_type: Statement of Deficiency