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

raw_content:
PRINTED: 03/03/2025
FORM APPROVED
Division of Health Service Regulation

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

MHL001-281 B. WING _____ 02/26/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1227 WESTMORELAND DRIVE
BURLINGTON, NC 27217

(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)

A MOTHER'S LOVE

V 000} INITIAL COMMENTS Vv 000

An annual and follow up survey was completed
on 2/26/25. Deficiencies were cited.

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

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

V 107} 27G .0202 (A-E) Personnel Requirements Vv 107

10A NCAC 27G .0202 PERSONNEL
REQUIREMENTS

(a) All facilities shall have a written job
description for the director and each staff position
which:

(1) specifies the minimum level of education,
competency, work experience and other
qualifications for the position;

(2) specifies the duties and responsibilities of
the position;

(3) is signed by the staff member and the
supervisor; and

(4) is retained in the staff member's file.

(b) All facilities shall ensure that the director,
each staff member or any other person who
provides care or services to clients on behalf of
the facility:

(1) is at least 18 years of age;

(2) is able to read, write, understand and
follow directions;

(3) meets the minimum level of education,
competency, work experience, skills and other
qualifications for the position; and

(4) has no substantiated findings of abuse or
neglect listed on the North Carolina Health Care
Personnel Registry.

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

STATE FORM 6899 QDRS11 If continuation sheet 1 of 19

Division of Health Service Regulation

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

MHL001-281 B. WING

STREET ADDRESS, CITY, STATE, ZIP CODE

1227 WESTMORELAND DRIVE
BURLINGTON, NC 27217

NAME OF PROVIDER OR SUPPLIER

A MOTHER'S LOVE

PRINTED: 03/03/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

02/26/2025

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

(X4) ID
PREFIX
TAG

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

COMPLETE
DATE

DEFICIENCY)

V 107 | Continued From page 1 V 107

(c) All facilities or services shall require that all
applicants for employment disclose any criminal
conviction. The impact of this information on a
decision regarding employment shall be based
upon the offense in relationship to the job for
which the applicant is applying.

(d) Staff of a facility or a service shall be
currently licensed, registered or certified in
accordance with applicable state laws for the
services provided.

(e) A file shall be maintained for each individual
employed indicating the training, experience and
other qualifications for the position, including
verification of licensure, registration or
certification.

This Rule is not met as evidenced by:

Based on record review and interview, the facility
‘ailed to have a complete personnel record
affecting one of one audited paraprofessional
staff (#1). The findings are:

Review on 2/26/25 of the personnel record for
staff #1 revealed:

-No specific date of hire.

-No documentation of educational verification.

nterview on 2/26/25 with the Director/Qualified
Professional revealed:

-Staff #1 had been with her facility for a "little"

over a year.

-"We just had an accreditation review and all of
Division of Health Service Regulation

STATE FORM 6299

QDRS11

If continuation sheet 2 of 19

PRINTED: 03/03/2025

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL001-281 B. WING 02/26/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1227 WESTMORELAND DRIVE
A MOTHER'S LOVE
BURLINGTON, NC 27217
(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 107} Continued From page 2 V 107

the documentation was available for [staff #1]."
-She was unable to locate a copy of staff #1's
high school diploma.

-"I'm just going to have to take the hit for that
one."

-She confirmed the facility failed to have a
complete personnel record for staff #1.

V 118] 27G .0209 (C) Medication Requirements V 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

Division of Health Service Regulation
STATE FORM 6899 QDRS11 If continuation sheet 3 of 19

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL001-281 B. WING

NAME OF PROVIDER OR SUPPLIER

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE
1227 WESTMORELAND DRIVE

PRINTED: 03/03/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

02/26/2025

with a physician.

This Rule is not met as evidenced by:

Based on record review and interviews, the
facility failed to keep the MAR current affecting
one of three clients (#1). The findings are:

Observation on 2/26/25 at approximately 1:27 pm
of client #1's medication bin revealed:

-There was no Vitamin D3 50 micrograms (mcg)
(Bone health), Atorvastatin 20 milligrams (mg)
(High Cholesterol), Co-Enzyme Q10 200 mg
(Energy) and Omeprazole 20 mg (Heartburn)
available for client #1.

Review on 2/26/25 of client #1's record revealed:
-Admission date of 11/14/24.

-Diagnoses of Post-traumatic Stress Disorder,
Major Depressive Disorder and Oppositional
Defiant Disorder.

-She was 16 years old.

-Physician's orders dated 11/13/24 for the
following medications:

Vitamin D3 50 mcg, one tablet daily
Atorvastatin 20 mg, one tablet daily
Co-Enzyme Q10 200 mg, one capsule daily
Omeprazole 20 mg, one capsule daily

Review on 2/26/25 of MARs for client #1
revealed:

No staff initials to indicate the medication was
administered for the following:

Division of Health Service Regulation

STATE FORM 6899

QDRS11

A MOTHER'S LOVE
BURLINGTON, NC 27217
(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 3 V 118

If continuation sheet 4 of 19

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL001-281 B. WING

NAME OF PROVIDER OR SUPPLIER

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE
1227 WESTMORELAND DRIVE

PRINTED: 03/03/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

02/26/2025

February 2025-

-Vitamin D3 50 mcg on 2/1 thru 2/26
-Atorvastatin 20 mg on 2/7 thru 2/26
-Co-Enzyme Q10 200 mg on 2/7 thru 2/26
-Omeprazole 20 mg on 2/7 thru 2/26

-No documentation to indicate the medication
was not available for administration

January 2025-
-Vitamin D3 50 mcg on 1/1 thru 1/31
-No documentation to indicate the medication
was not available for administration

Interview on 2/26/25 with client #1 revealed:
-Some of her medications were not available
because she had to see the doctor to get refills.
-She had blood work completed about a week
ago in order to get one of those medications
refilled.

-She had not taken some of those medications
for most of the month (February 2025).

-She wasn't sure when she would be seeing the
doctor in order to have those medications refilled.

Interview on 2/26/25 with the Program Manager
revealed:

-Client #1's February and January 2025 MARs
had no staff initials for some of the medications
because she ran out of those medications.
-Some of client #1's medications were not
available because they were waiting on the doctor
to write an order to have those medications
refilled.

-Client #1 required lab work for one of those
medications, which they just recently had done
this month (February 2025).

-She (Program Manager) called the medical
office several times and tried to speak with the
doctor and/or schedule an appointment to get the
medication refilled.

Division of Health Service Regulation

STATE FORM

6899 QDRS11

A MOTHER'S LOVE
BURLINGTON, NC 27217
(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 V 118

If continuation sheet 5 of 19

Division of Health Service Regulation

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

MHL001-281 B. WING

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1227 WESTMORELAND DRIVE

A MOTHER'S LOVE BURLINGTON, NC 27217

PRINTED: 03/03/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

02/26/2025

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

(X4) ID
PREFIX
TAG

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

COMPLETE
DATE

DEFICIENCY)

V 118| Continued From page 5 V 118

-She was told the doctor was busy or seeing
another patient.

-Staff did not indicate the medication was not
available on the February and January 2025
MARs for client #1.

-She confirmed the MARs were not current client
#1.

Interview on 2/26/25 with the Director/Qualified
Professional revealed:

-She wasn't aware of some of client #1's
medications not being available.

-"| know medical appointments for clients can be
difficult to make."

-"It all boils down to Medicaid, they have to find
doctors that accept Medicaid."

-She confirmed the MARs were not current client
#1.

V 131

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

Verification

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

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

This Rule is not met as evidenced by:
Based on record review and interview, the facility
failed to ensure the Health Care Personnel

Division of Health Service Regulation

STATE FORM 6899 QDRS11

If continuation sheet 6 of 19

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL001-281 B. WING

NAME OF PROVIDER OR SUPPLIER

A MOTHER'S LOVE BURLINGTON, NC 27217

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE
1227 WESTMORELAND DRIVE

PRINTED: 03/03/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

02/26/2025

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

(X4) ID
PREFIX
TAG

ID
PREFIX
TAG

CROSS-REFERENCED TO THE APPROPRIATE

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE

(x5)
COMPLETE
DATE

DEFICIENCY)

V 131 V 131

Continued From page 6

Registry (HCPR) was accessed prior to
employment affecting one of one audited
paraprofessional staff (#1). The findings are:

Review on 2/26/25 of the personnel record for
staff #1 revealed:

-No specific date of hire.

-No documentation the HCPR was accessed
prior to hire.

Interview on 2/26/25 with the Director/Qualified
Professional revealed:

-Staff #1 had been with her facility for a little over
a year.

-"We just had an accreditation review and all of
the documentation was available for [staff #1]."
-She recalled doing the HCPR check for staff #1.
-She was not sure why the HCPR check was not
in staff #1's personnel record.

-She confirmed the facility failed to ensure the
HCPR was accessed for staff #1 prior to
employment.

V 179] 27G .1301 Residential Tx - Scope Vv 179
10A NCAC 27G .1301 SCOPE

(a) The rules of this Section apply only to a

residential treatment facility that provides

residential treatment, level Il, program type

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

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

Division of Health Service Regulation

STATE FORM 6899

QDRS11

If continuation sheet 7 of 19

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL001-281 B. WING

NAME OF PROVIDER OR SUPPLIER

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE
1227 WESTMORELAND DRIVE

PRINTED: 03/03/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

02/26/2025

may also have other disabilities.

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

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

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

This Rule is not met as evidenced by:

Based on observation, record review and
interviews, the facility failed to coordinate with
other individuals and agencies within the client's
system of care affecting one of three clients (#1).
The findings are:

Observation on 2/26/25 at approximately 1:27 pm
of client #1's medication bin revealed:

-There was no Vitamin D3 50 micrograms (mcg)
(Bone health), Atorvastatin 20 milligrams (mg)
(High Cholesterol), Co-Enzyme Q10 200 mg
(Energy) and Omeprazole 20 mg (Heartburn)
available for client #1.

Review on 2/26/25 of client #1's record revealed:
Division of Health Service Regulation

STATE FORM 6899

QDRS11

A MOTHER'S LOVE
BURLINGTON, NC 27217
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 179} Continued From page 7 Vv 179

If continuation sheet 8 of 19

PRINTED: 03/03/2025
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA. (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
MHL001-281 B. WING _____ 02/26/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1227 WESTMORELAND DRIVE

A MOTHER'S LOVE
BURLINGTON, NC 27217
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 179} Continued From page 8 Vv 179

-Admission date of 11/14/24.

-Diagnoses of Post-traumatic Stress Disorder,
Major Depressive Disorder and Oppositional
Defiant Disorder.

-She was 16 years old.

-Physician's orders dated 11/13/24 for the
following medications:

Vitamin D3 50 mcg, one tablet daily
Atorvastatin 20 mg, one tablet daily
Co-Enzyme Q10 200 mg, one capsule daily
Omeprazole 20 mg, one capsule daily

Review on 2/26/25 of MARs for client #1
revealed:

No staff initials to indicate the medication was
administered for the following:

February 2025-

-Vitamin D3 50 mcg on 2/1 thru 2/26
-Atorvastatin 20 mg on 2/7 thru 2/26
-Co-Enzyme Q10 200 mg on 2/7 thru 2/26
-Omeprazole 20 mg on 2/7 thru 2/26

January 2025-
-Vitamin D3 50 mcg on 1/1 thru 1/31

Interview on 2/26/25 with client #1 revealed:
-Some of her medications were not available
because she had to see the doctor to get refills.
-She had blood work completed about a week
ago in order to get one of those medications
refilled.

-She had not taken some of those medications
for most of the month (February 2025).

-She wasn't sure when she would be seeing the
doctor in order to have those medications refilled.

Interview on 2/26/25 with the Program Manager
revealed:

Division of Health Service Regulation

STATE FORM ad QDRS11 If continuation sheet 9 of 19

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA

AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
MHLO001-281
NAME OF PROVIDER OR SUPPLIER

A MOTHER'S LOVE

STREET ADDRESS, CITY, STATE, ZIP CODE
1227 WESTMORELAND DRIVE
BURLINGTON, NC 27217

PRINTED: 03/03/2025
FORM APPROVED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

B. WING 02/26/2025

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

(X4) ID
PREFIX
TAG

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

ID
PREFIX
TAG

(x5)
COMPLETE
DATE

V 179} Continued From page 9

-Client #1's February and January 2025 MARs
had no staff initials for some of the medications
because she ran out of those medications.
-Some of client #1's medications were not

to write an order to have those medications
refilled.

-Client #1 required lab work for one of those
medications, which they just recently had done
this month (February 2025).

-She (Program Manager) called the medical
office several times and tried to speak with the
doctor and/or schedule an appointment to get the
medication refilled.

-She was told the doctor was busy or seeing
another patient.

Interview on 2/26/25 with the Director/Qualified
Professional revealed:

-She wasn't aware of some of client #1's
medications not being available.

-"| know medical appointments for clients can be
difficult to make."

-"It all boils down to Medicaid, they have to find
doctors that accept Medicaid."

V 366} 27G .0603 Incident Response Requirements

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 I, 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

Division of Health Service Regulation
STATE FORM

available because they were waiting on the doctor

Vv 179

V 366

6899

QDRS11 If continuation sheet 10 of 19

PRINTED: 03/03/2025

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL001-281 B. WING 02/26/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1227 WESTMORELAND DRIVE
A MOTHER'S LOVE
BURLINGTON, NC 27217
(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 10 V 366

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 |.

(c) In addition to the requirements set forth in
Paragraph (a) of this Rule, Category A and B
providers, excluding ICF/MR providers, shall
develop and implement written policies governing
their response to a level III 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

Division of Health Service Regulation
STATE FORM 6899 QDRS11 If continuation sheet 11 of 19

Division of Health Service Regulation

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

MHL001-281 B. WING

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1227 WESTMORELAND DRIVE

A MOTHER'S LOVE BURLINGTON, NC 27217

PRINTED: 03/03/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

02/26/2025

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

(X4) ID
PREFIX
TAG

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

COMPLETE
DATE

DEFICIENCY)

V 366 | Continued From page 11 V 366

with direct professional oversight of the client's
services at the time of the incident. The internal
review team shall complete all of the activities as
follows:

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

(B) gather other information needed;

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

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

Division of Health Service Regulation

STATE FORM 6899 QDRS11

If continuation sheet 12 of 19

Division of Health Service Regulation

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

MHL001-281

NAME OF PROVIDER OR SUPPLIER

(X2) MULTIPLE CONSTRUCTION

A. BUILDING:

B. WING

STREET ADDRESS, CITY, STATE, ZIP CODE
1227 WESTMORELAND DRIVE

PRINTED: 03/03/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

02/26/2025

(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

response to Level II incidents as required. The
indings are:

Review on 2/26/25 of client #1's record revealed:
-Admission date of 11/14/24.

-Diagnoses of Post-traumatic Stress Disorder,
Major Depressive Disorder and Oppositional
Defiant Disorder.
-She was 16 years old.

Review on 2/26/25 of client #3's record revealed:
-Admission date of 10/1/24.

-Diagnoses of Adjustment Disorder, Anxiety
Disorder-Unspecified, Attention Deficit
Hyperactivity Disorder.
-She was 17 years old.

Review on 2/26/25 of an in-house incident report
dated 12/28/24 revealed:

-"On Saturday, December 28, 2024 at
approximately 3:50 PM, [client #1] and [client #3]
left the property without permission. Staff
checked the premises and staff searched the
surrounding area including neighborhoods, parks
and shopping centers. Staff contacted the [Name
of local police department] and provided dispatch
Division of Health Service Regulation

STATE FORM

acility failed to implement a policy governing their

A MOTHER'S LOVE
BURLINGTON, NC 27217
(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 12 V 366

6899 QDRS11

If continuation sheet 13 of 19

Division of Health Service Regulation

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

MHL001-281 B. WING

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1227 WESTMORELAND DRIVE

A MOTHER'S LOVE BURLINGTON, NC 27217

PRINTED: 03/03/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

02/26/2025

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

(X4) ID
PREFIX
TAG

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

COMPLETE
DATE

DEFICIENCY)

V 366 V 366

Continued From page 13

with the necessary information..."

Review on 2/26/25 of the North Carolina (NC)
Incident Response Improvement System (IRIS)
revealed:

-There was no level II incident report submitted
by the facility for clients #1 and #3 running away
from the facility and the police department being
called by staff.

-There was no documentation to determine: The
cause of the incident; If the facility developed and
implemented corrective measures according to
the provider specified timeframes not to exceed
45 days; no measures to prevent similar incidents
according to provider specified timeframes not to
exceed 45 days and assigning person(s) to be
responsible for implementation of the corrections
and preventive measures.

Interview on 2/26/25 with the Program Manager
revealed:

-Clients #1 and #3 ran away from the facility in
December 2024.

-Staff called the police department during that
incident.

-She would normally write up the incident and
email it to the Program Coordinator with their
former agency.

-The Program Coordinator with the former
agency would put the incident into IRIS.

-She confirmed the facility failed to implement a
policy governing their response to Level II
incidents as required.

Interview on 2/26/25 with the Director/Qualified
Professional revealed:

-She was aware the incident with clients #1 and

#3 running away from the facility in December

2024.

-The Program Coordinator with the former

Division of Health Service Regulation

STATE FORM 6299

QDRS11

If continuation sheet 14 of 19

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL001-281 B. WING

NAME OF PROVIDER OR SUPPLIER

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE
1227 WESTMORELAND DRIVE

PRINTED: 03/03/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

02/26/2025

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

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

(1) reporting provider contact and
identification information;

(2) client identification information;

(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

Division of Health Service Regulation

STATE FORM 6899

QDRS11

A MOTHER'S LOVE BURLINGTON, NC 27217
(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 14 V 366
agency was responsible for putting incidents into
IRIS.
-She confirmed the facility failed to implement a
policy governing their response to Level II
incidents as required.
This deficiency constitutes a re-cited deficiency
and must be corrected within 30 days.
V 367| 27G .0604 Incident Reporting Requirements V 367

If continuation sheet 15 of 19

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL001-281 B. WING

NAME OF PROVIDER OR SUPPLIER

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE
1227 WESTMORELAND DRIVE

PRINTED: 03/03/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

02/26/2025

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) he provider has reason to believe that
information provided in the report may be
erroneous, misleading or otherwise unreliable; or
(2) he 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) he provider's response to the incident.
(d) Category A and B providers shall send a copy
of all level III incident reports to the Division of
Mental Health, Developmental Disabilities and
Substance Abuse Services within 72 hours of
becoming aware of the incident. Category A
providers shall send a copy of all level III
incidents involving a client death to the Division of
Health Service Regulation within 72 hours of
becoming aware of the incident. In cases of
client death within seven days of use of seclusion
or restraint, the provider shall report the death
immediately, as required by 10A NCAC 26C
.0300 and 10A NCAC 27E .0104(e)(18).

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

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

(2) restrictive interventions that do not meet

Division of Health Service Regulation

STATE FORM 6899

QDRS11

A MOTHER'S LOVE
BURLINGTON, NC 27217
(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 15 V 367

If continuation sheet 16 of 19

Division of Health Service Regulation

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

MHL001-281 B. WING

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1227 WESTMORELAND DRIVE

A MOTHER'S LOVE BURLINGTON, NC 27217

PRINTED: 03/03/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

02/26/2025

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

(X4) ID
PREFIX
TAG

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

COMPLETE
DATE

DEFICIENCY)

V 367 | Continued From page 16 V 367

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
acility failed to ensure incidents were reported to
he Local Management Entity/Managed Care
Organization (LME/MCO) for the catchment area
where services are provided within 72 hours of
becoming aware of the incident. The findings are:

Review on 2/26/25 of client #1's record revealed:
-Admission date of 11/14/24.

-Diagnoses of Post-traumatic Stress Disorder,
Major Depressive Disorder and Oppositional
Defiant Disorder.

-She was 16 years old.

Review on 2/26/25 of client #3's record revealed:
-Admission date of 10/1/24.

-Diagnoses of Adjustment Disorder, Anxiety
Disorder-Unspecified, Attention Deficit

Hyperactivity Disorder.

Division of Health Service Regulation

STATE FORM 6299

QDRS11

If continuation sheet 17 of 19

PRINTED: 03/03/2025
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA. (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
MHL001-281 B. WING _____ 02/26/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1227 WESTMORELAND DRIVE

A MOTHER'S LOVE
BURLINGTON, NC 27217
(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 17 V 367

-She was 17 years old.

Review on 2/26/25 of an in-house incident report
dated 12/28/24 revealed:

-"On Saturday, December 28, 2024 at
approximately 3:50 PM, [client #1] and [client #3]
left the property without permission. Staff
checked the premises and staff searched the
surrounding area including neighborhoods, parks
and shopping centers. Staff contacted the [Name
of local police department] and provided dispatch
with the necessary information..."

Review on 2/26/25 of the North Carolina (NC)
ncident Response Improvement System (IRIS)
revealed:

-There was no level II incident report submitted
by the facility for clients #1 and #3 running away
rom the facility and the police department being
called by staff.

nterview on 2/26/25 with the Program Manager
revealed:

-Clients #1 and #3 ran away from the facility in
December 2024.

-Staff called the police department during that
incident.

-She would normally write up the incident and
email it to the Program Coordinator with their
former agency.

-The Program Coordinator with the former
agency would put the incident into IRIS.

-She wasn't sure why the incident with client #1
and #3 running away was not in IRIS.

-She confirmed the facility failed to report the
above incident to LME/MCO within 72 hours.

Interview on 2/26/25 with the Director/Qualified
Professional revealed:

-She was aware the incident with clients #1 and
Division of Health Service Regulation

STATE FORM ad QDRS11 If continuation sheet 18 of 19

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

MHL001-281

(X2) MULTIPLE CONSTRUCTION

A.

B.

BUILDING:

WING

STREET ADDRESS, CITY, STATE, ZIP CODE
1227 WESTMORELAND DRIVE

PRINTED: 03/03/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

02/26/2025

#3 running away from the facility in December
2024.

-The Program Coordinator with the former
agency was responsible for putting incidents into
IRIS.

-She was not sure why the incident with clients #1
and #3 was not in IRIS.

-"| just have to eat that citation."

-She confirmed the facility failed to report the
above incident to LME/MCO within 72 hours.

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

Division of Health Service Regulation
STATE FORM

6899

A MOTHER'S LOVE
BURLINGTON, NC 27217
(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 18 V 367

QDRS11

If continuation sheet 19 of 19

document_type: Statement of Deficiency


state: NC

facility_name: A Mother's Love

summary: Plan of Correction - MHLCS Annual and Complaint

raw_content:
‘This Rule is not met as evidenced
by: Based on record reviews and
interviews, the facility failed to
develop and implement strategies.
to meet the needs affecting one of
three audited current clients (#2)
land one of one audited former
client (FC #4).

This Rule is not met as evidenced
by: Based on record review and
interview, the facility failed to
implement a policy governing their
response to Level II incidents as
required.

A Mother's Love

Annual Survey Response
Date of Survey: January 19, 2024

Client #2's PCP and goals were
updated to reflect client's recent
needs and behaviors. Client's
doctor reviewed and signed off on
new goals.

Incidents will be reported within
the 72 hour timeframe.

Rounds are increased to every 15
minutes.

Secondary staff has been added
to the third shift.

Camers have been installed in the
common areas of the facility.

Incidents will be written for review
prior to the conclusion of staff
member's shift.

Incidents will be submitted to IRIS
within the 72 hour timeframe.

A printout of the submission will
be filed within the facility's filing
system.

Owner and AML Staff

Rounds have been increased to
levery 15 minutes.

PCPs are updated on a monthly
basis to review client's progress
with her goals. Updates to the
PCPs coincide with the montly
CFT meetings.

‘Within 24 hours of an incident, the
lowner will follow up with the on-
duty staff member to ensure
incident reports are submitted.

Monitoring will take place on an as
incidents occur.

‘This Rule is not met as evidenced
by: Based on record review and
interview, the facility failed to
ensure incidents were reported to
the Local Management
Entity/Managed Care
Organization (LME/MCO) for the
catchment area where services
are provided within 72 hours of
becoming aware of the incident.

Incidents will be reported within
the 72 hour timeframe.

Incidents will be written for review
prior to the conclusion of staff
member's shift.

Incidents will be submitted to IRIS
within the 72 hour timeframe.

A printout of the submission will
be filed within the facility's filing
system.

‘Within 24 hours of an incident, the
lowner will follow up with the on-
duty staff member to ensure
incident reports are submitted.

Monitoring will take place on an as
incidents occur.

RECEIVED BY

inspection_type: MHLCS Annual and Complaint

document_type: Plan of Correction


raw_content:
Division of Health Service Regulation

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

PRINTED: 11/03/2022

FORM APPROVED
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
A. BUILDING: COMPLETED
R
MHL001-259 10/27/2022

NAME OF PROVIDER OR SUPPLIER

1227 WESTI

A MOTHER'S LOVE

MORLAND DRIVE

BURLINGTON, NC 27215

STREET ADDRESS, CITY, STATE, ZIP CODE

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

ID
PREFIX
TAG

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

(xs)
COMPLETE
DATE

V 000} INITIAL COMMENTS

An annual and follow up survey was completed
on 10/27/22. Deficiencies were cited.

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

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

V 114) 27G .0207 Emergency Plans and Supplies

10A NCAC 27G .0207 EMERGENCY PLANS
AND SUPPLIES

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

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

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

This Rule is not met as evidenced by:

Based on record reviews and interviews the
facility failed to ensure fire and disaster drills were
done quarterly on each shift. The findings are:

Review on 10/27/22 of the facility's fire drill log
revealed:

V 000

Vv 114

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

STATE FORM

6808 DZ2E11

TITLE

(X6) DATE

If continuation sheet 1 of 4

Division of Health Service Regulation

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

MHL001-259

(X2) MULTIPLE CONSTRUCTION

PRINTED: 11/03/2022

A. BUILDING:

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

1227 WESTI

A MOTHER'S LOVE

MORLAND DRIVE

BURLINGTON, NC 27215

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R
10/27/2022

(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 114] Continued From page 1

-There was no 3rd shift fire drill for 1st quarter of
2022.

Review on 10/27/22 of the facility's disaster drill
log revealed:

-There was no 1st shift disaster drill for 3rd
quarter of 2022.

-There was no 3rd shift disaster drill for 1st
quarter of 2022.

Interview on 10/27/22 with client #1 revealed:
-She was admitted to the facility about a month
ago.

-Staff had not done any fire or disaster drills with
them.

Interview on 10/27/22 with client #3 revealed:
-She lived at the facility for about a year.
-They never did any fire or disaster drills with
staff.

Interview on 10/27/22 with the Program Manager
revealed:

-There were three separate shifts at the facility.
-She didn't know why staff were not doing the fire
and disaster drills consistently during their shifts.
-She confirmed staff failed to ensure fire and
disaster drills were done quarterly on each shift.

V 736] 27G .0303(c) Facility and Grounds Maintenance

10A NCAC 27G .0303 LOCATION AND
EXTERIOR REQUIREMENTS

(c) Each facility and its grounds shall be
maintained in a safe, clean, attractive and orderly
manner and shall be kept free from offensive
odor.

Vv 114

V 736

Division of Health Service Regulation
STATE FORM

6809

DZ2E11

If continuation sheet 2 of 4

Division of Health Service Regulation

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

MHL001-259

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

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

1227 WESTI

A MOTHER'S LOVE

MORLAND DRIVE

BURLINGTON, NC 27215

PRINTED: 11/03/2022

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R
10/27/2022

(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 736 | Continued From page 2 V 736

This Rule is not met as evidenced by:

Based on observation and interviews, the facility
failed to ensure facility grounds were maintained
in a safe, clean, attractive, orderly manner and
kept free from offensive odor. The findings are:

Observation on 10/26/22 at approximately 9:30
am revealed:

-Client #4's bedroom-Door was cracked around
the knob.

-Bathroom in hallway-Cabinet was peeling. Toilet
seat was faded. Walls were stained.

-Client #1's bedroom-A set of broken blinds.
Doorknob was loose. Carpet was stained.

-Client #3's bedroom-Carpet was stained. There
was a musty odor. Walls were stained. A set of
broken blinds. A knob was missing from her
dresser.

-Kitchen area-There were approximately 20 pin
sized hole in the wall. The walls were stained and
there was a patch of putty on the wall.

-Client #1's bedroom-Carpet was stained.

-Den area-Peeling paint on the walls.

Interview on 10/26/22 with staff #1 revealed:
-She thought management was aware of
maintenance issues with the facility.

-Staff are always talking to the clients about
keeping their room clean.

-She confirmed the facility failed to ensure facility
grounds were maintained in a safe, clean,
attractive, orderly manner and kept free from
offensive odor.

Interview on 10/26/22 with Program Manager
confirmed:

-The facility failed to ensure facility grounds were
maintained in a safe, clean, attractive, orderly

Division of Health Service Regulation
STATE FORM

6808 DZ2E11

If continuation sheet 3 of 4

PRINTED: 11/03/2022

FORM APPROVED
Division of Health Service Re
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL001-259 — 10/27/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1227 WESTMORLAND DRIVE
A MOTHER'S LOVE
BURLINGTON, NC 27215
(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 736 | Continued From page 3 V 736

manner and kept free from offensive odor.

Division of Health Service Regulation
STATE FORM 809 DZ2E11 If continuation sheet 4 of 4

inspection_type: MHLCS Annual and Follow-up


summary: Statement of Deficiency - MHLCS Annual and Complaint

raw_content:
Division of Health Service Regulation

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

MHL001-259

NAME OF PROVIDER OR SUPPLIER

1227 WESTI

A MOTHER'S LOVE

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

BURLINGTON, NC 27215

PRINTED: 12/29/2021

STREET ADDRESS, CITY, STATE, ZIP CODE
MORLAND DRIVE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

12/13/2021

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000} INITIAL COMMENTS V 000
An annual and complaint survey was completed
on December 13, 2021. The complaint (intake
#NC00183729) unsubstantiated. Deficiencies
cited.
This facility is licensed for the following service
category: 10A NCAC 27G. 1300
Residential Treatment for Children or Adolescents
V 112| 27G .0205 (C-D) v112

Assessment/Treatment/Habilitation Plan

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

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

(d) The plan shall include:

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

(2) strategies;

(3) staff responsible;

(4) 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

TITLE

(X6) DATE

Division of Health Service Re

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

NAME OF PROVIDER OR SUPPLIER

A MOTHER'S LOVE

MHL001-259

1227 WESTI

(X2) MULTIPLE CONSTRUCTION

PRINTED: 12/29/2021

A. BUILDING:

MORLAND DRIVE

BURLINGTON, NC 27215

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

12/13/2021

This Rule is not met as evidenced by:

Based on record review and interview, the facility
failed to assure one of three

client's (#1) treatment plans were reviewed and
updated at least annually. The findings are:

Review on 12/13/21 of client #1's record
revealed:

-She was admitted on 10/24/18

- diagnoses of Attention Deficit Disorder and
Oppositional Defiant Disorder. Further review
revealed a treatment plan with an expiration date
of 3/24/20.

During interview on 12/13/21 the Owner
confirmed;

- they didn't complete an annual update for client
#1.

Division of Health Service Regulation
STATE FORM

6809

7F2V11

(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

If continuation sheet 2 of 5

Division of Health Service Regulation

PRINTED: 12/29/2021

FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL001-259 12/13/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1227 WESTMORLAND DRIVE
A MOTHER'S LOVE
BURLINGTON, NC 27215
(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

Based on record reviews and interviews the
facility failed to develop and implement strategies
to address elopement affecting one of one
current clients (#1). The findings are:

Review on 6/18/2020 of client #1's record
revealed:

- Admission date of 12/28/18.

- Diagnosis of Schizophrenia

- Treatment Plan dated 4/23/19. Further review
revealed client #1's plan did not include
interventions nor strategies to address his
behaviors of elopement.

Review on 7/13/2020 of staff #1's record
revealed:
- Hire date of 11/27/09.

Review on 7/13/2020 of staff #2's record
revealed:
- Hire date of 8'20.

Review on 7/17/2020 of an incident report dated
6/26/20 revealed:

"[client #1] acting out we called the police at
8:21am. They talked to [client #1]. She needs
help they picked her up and she was hopitalized."

Review on 7/17/2020 of an incident report dated
6/29/20 revealed:

"Around 1:00pm [client #1] called the [police
department] and they talked to [client #1]. She
threaten to hurt staff."

Review on 7/17/2020 of an incident report dated
6/30/20 revealed:
"[client #1] was argue with her roomate [roomate]

Division of Health Service Regulation
STATE FORM

6808 7F2V11

If continuation sheet 3 of 5

Division of Health Service Regulation

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

MHL001-259

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

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

1227 WESTI

A MOTHER'S LOVE

MORLAND DRIVE

BURLINGTON, NC 27215

PRINTED: 12/29/2021

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

12/13/2021

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 112] Continued From page 3 Vv 112

about the phone. They both was arguing back
and forward, so | asked them both to calm down
and they did for a few minutes. Then [client #1]
called [roomate] a cuss word and said she word
hurt [roomate] so | got on the phone and call my
supervisor and repeat what was going on at the
group home and my supervisor told me what to
do and how to handle the situation."

During an interview on 7/1/2020 the Qualified
Professional stated :

- "[client #1] should have been gone. I've told
them she needed more resources."

- the following behaviors: verbal aggression,
elopement, and many hospitalizations.

- "When she is hospitalized she returns to the
facility with no other interventions."

- she's responsible for developing treatment
plans, but was unable to explain interventions to
safeguard client #1's behaviors.

- "It's not my business. You need to talk to them
about the strategies for her."

- No treatment team meetings to discuss
strategies.

- She was unable to explain why client #1's
treatment plan did not have any goals,
interventions, and strategies to address her
behaviors of elopement and frequent
hospitalizations.

During an interview on 7/1/2020 the House
Manager stated :

- She acknowledged client #1 had behaviors of
aggression, property distruction, and many
hospitalizations.

- "We are in the process in getting her
guardianship changed, which hopefully allow
more services for her."

- She confirmed no meetings to discuss
treatment strategies and interventions.

Division of Health Service Regulation
STATE FORM

6808 7F2V11

If continuation sheet 4 of 5

PRINTED: 12/29/2021

FORM APPROVED
Division of Health Service Re
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL001-259 12/13/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1227 WESTMORLAND DRIVE
A MOTHER'S LOVE
BURLINGTON, NC 27215
(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

control"

Division of Health Service Regulation
STATE FORM

V 112] Continued From page 4 Vv 112

- She confirmed an approximately 4
hospitalizations within the past months. No
meetings with the hospital prior to discharge to
discuss appropriate interventions.

-"We just call the police when she get's out of

6808 7F2V11

If continuation sheet 5 of 5