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

raw_content:
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDERISUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER;

A. BUILDING:

B. WING

(X2} MULTIPLE CONSTRUCTION

TINUN DL, Uren:

FORM APPROVED

(X3} DATE SURVEY
COMPLETED

R-C
07/30/2024

This facility is licensed for the following service
category: 10A NCAC 27G .5600C Supervised
Living for Adults with Developmental! Disabilities.

The facility is licensed for 6 and currently has a
census of 6. The survey sampie consisted of
audits of 4 current clients.

V 118 27G .0209 (C) Medication Requirements V118

10A NCAC 27G .0208 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 ifaw 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

MHL001-086 ——
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2150 HAW RIVER-HOPEDALE ROAD
HAW RIVER GROUP HOME HAW RIVER, NC 27258
(x4) iD SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION s)
PREFIX (EACH DEFICIENCY MUST 8 PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS SEECAENGED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000 INITIAL COMMENTS V 000
Acomplaint and follow up survey was completed
on July 30, 2024. The complaint was
substantiated (intake #NC00219675). |
Deficiencies were cited.
V118:

On 7/16/2024, RSL RN completed an
immediate RSL universal medical
monitoring training for aJJ residential
administrative staff. By 8/21/2024,
medical monitoring will consist of
ensuring staff are following the
appropriate medication order, the
appropriate dose, with the
appropriate individual. RSL RN will
also retrain Haw River staff on
medication pass and documentation
on MAR. After training is completed,
all residential admin will complete 2
universal medical monitoring
observation at least twice a week then
fade to monthly as needed. A copy of
monitoring documentation will be
forwarded to Directors of Residential.

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

Dincetre Res:demtiel Forres

TITLE (X6) DATE,

VENLA

vee STEFI

{f continuation sheet 1 of 9

RECEIVED BY
MHL & C

8-13-24

PRINTED: 07/31/2024
FORM APPROVED

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

(X3} DATE SURVEY
COMPLETED

R-C
MHL001-086 B. WING 9 07/30/2024

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

2150 HAW RIVER-HOPEDALE ROAD
HAW RIVER GROUP HOME HAW RIVER, NC 27258

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES iD PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE

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

V118 Continued From page 2 Vv 118

-1 clonidine 0.1 milligram (mg).
-1 fenofibrate.

-1 fiber-lax.

-1 levetiracetam 750 mg.

-1 lorazepam 1 mg.

-1 sodium chloride 1 gram.

-1 vitamin B12 mg.

-The patient also is on a clonidine patch for
his high blood pressure control. This was
removed once it was realized that he had gotten
the other medication. The patient himself denies
any symptoms currently. He states he does not
feel dizzy or lightheaded, denies any acute pain,
difficulty breathing, palpitations, weakness or
nausea.”

Review on 7/30/24 of a Medication Error report
dated 6/26/24 revealed:
-Report completed by the Qualified Professional |
and Staff #5. |
-Type of Error: Wrong Medication.
-Describe what happened-include medication
names and doses: “Staff administered [Client
#3}'s medication to [Client #1]. 2 carbamazepine
400 mg, 1 clonidine 0.1 mg, 1 fenofibrate 145 mg,
1 fiber-lax, 1 levetiracetam 750 mg, 1 lorazepam
1 mg, 1 sodium chloride 1 gram, 1 vitamin B12
mg.
-Notifications: Pharmacist.
-Level Determination: Level 1. Error does not
threaten person's health or safety. |
-Staff Committing Error: [Staff #5). |
-Further Action Needed: “Individual was taken to
the ER for further results of medication error. No
further action needed. Staff was told to be sure to
follow proper protocol they learned in med pass |
to prevent further errors. Staff was also told that
during med training that they should focus in
giving meds and to do one individual at a time to
prevent errors. Staff was also to make sure that

Division of Health Service Regulation

STATE FORM saga OTEF11

If continuation sheet 3 of 9

PRINTED: 07/31/2024
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:
R-C
MHL001-086 BaWViNG 07/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2150 HAW RIVER-HOPEDALE ROAD
HAW RIVER GROUP HOME
AW RIVER GR HAW RIVER, NC 27258
(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 Vv 118

only one individual should be in the med room at
a time and that should be the one to whom you
are giving meds to. Nurse was also contacted
about med error and staff will be retrained on
administering meds."

-Note from the Nurse: "RN has developed a
remedial class to be implemented. Additional
training will take place 7/16/- 17/2024 to assist in
med admin and monitoring."

Review on 7/30/24 of Client #2's record revealed:
-Admission date of 8/17/17.
-Diagnoses of Autism Spectrum Disorder,
Obsessive Compulsive Disorder, Attention Deficit
Hyperactive Disorder and Asthma.
-Physician orders dated 11/14/23.

-Amantadine 100 mg- Take two capsules
twice daily.

-Clonidine 0.1 mg- Take two tablets twice
daily.

-Olanzapine 15 mg- Take one tablet twice
daily.

-Divalproex 250 mg- Take one tablet daily at
night.

Observation on 7/30/24 at about 12:05 pm of
Client #2's medications revealed:
-All medications aforementioned were available.

Review on 7/30/24 of Client #2's MARs for June
2024 through July 2024 revealed:
-July:
-Amantadine 100 mg- Was not initialed as
given by staff on 7/26 (evening) and 7/29
(evening).
-Clonidine 0.1 mg- Was not initialed as given |
by staff on 7/29 (evening). |
-Olanzapine 15 mg- Was not initialed as
given by staff on 7/29 (evening).
-Divalproex 250 mg- Was not initialed as
Division of Health Service Regulation
STATE FORM 69a STEF11 {f continuation sheet 4 of 9

PRINTED: 07/31/2024

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 COMPLETED
R-C
MHL001-086 B, WING 07/30/2024

NAME OF PROVIDER OR SUPPLIER. STREET ADDRESS, CITY, STATE, ZiP CODE

2150 HAW RIVER-HOPEDALE ROAD
JAW RIVER GROUP HOME
BEY RNERSEOU HAW RIVER, NG 27258
(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 1418 Continued From page 4 V 118

given by staff on 7/29 (evening).

-Due to the failure to accurately document |
medication administration, it could not be
determined if the client received his medications
as ordered by the physician.

Interview on 7/30/24 with Staff #5 revealed:
-Regarding medication error: “On 6/26/24, | came
and pulled the wrong client's medications out the
box. | felt in a hurry. | felt like | was running late. |
was working by myself. | was trying to get in the
schedule to get the guys ready and out of the
home to their program."

-When she realized her error, she contacted her
supervisor and the nurse.

-She was informed to contact emergency
services.

-Client #1 went to the local emergency
department to be checked.

-Client #1 was checked, did not have any
problems and was returned home that same day.
-An incident medication error report was made.
-She was also retrained by the Nurse regarding
“Medication Pass.”

Interview on 7/30/24 with the Vice President of

Operations revealed:

-He knew why the state had received a complaint.

-One individual had received another client's |
medications in error.

-When the medication error occurred, [Staff #5]

noticed the error right away.

-Staff #5 notified her supervisor, pharmacist was

contacted, emergency personnel was contacted

and attended the home, Client #1 went to the |
emergency department to be checked. He was
fine and returned to the facility later that same
day.

-An incident report was made. Staff #5 and others
Division of Health Service Regulation

STATE FORM ea99 9TEF11 If continuation sheet 5 of 9

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

PRINTED: 07/31/2024
FORM APPROVED

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

MHLOO1-086

NAME OF PROVIDER OR SUPPLIER

HAW RIVER GROUP HOME

STREET ADDRESS, CITY, STATE, ZIP CODE

2150 HAW RIVER-HOPEDALE ROAD
HAW RIVER, NC 27258

(X3) DATE SURVEY.

(X2) MULTIPLE CONSTRUCTION
COMPLETED

A. BUILDING:

R-C
07/30/2024

B. WING

(X4) ID
PREFIX
TAG

Vv 118

Vv 291

SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (%5)
(EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
Continued From page 5 Vv 118
in the agency were retrained. |
-Regarding some medications not being initialed
by staff on the MAR: He was not aware of
missing initials.
-He acknowledged Client #1 received another
client's medications which he did not have
physician's orders for and the MAR was not being |
kept current.
Vv 291

27G .5603 Supervised Living - Operations

140A NCAC 27G .5603 OPERATIONS

(a) Capacity. A facility shall serve no more than
six clients when the clients have mental illness or
developmental disabilities. Any facility licensed
on June 15, 2001, and providing services to more
than six clients at that time, may continue to
provide services at no more than the facility's
licensed capacity.

(b) Service Coordination. Coordination shall be
maintained between the facility operator and the
qualified professionals who are responsible for
treatment/habilitation or case management.

(c) Participation of the Family or Legally
Responsible Person. Each client shall be
provided the opportunity to maintain an ongoing
relationship with her or his family through such
means as visits to the facility and visits outside
the facility. Reports shall be submitted at least
annually to the parent of a minor resident, or the
legally responsible person of an adult resident.
Reports may be in writing or take the form of a
conference and shall focus on the client's
progress toward meeting individual goals.

(d) Program Activities. Each client shall have
activity opportunities based on her/his choices,
needs and the treatment/habilitation plan.
Activities shall be designed to foster community
inclusion, Choices may be limited when the court

V291:

By 8/21/2024 RSL Residential
Administrative professionals will
ensure that all medical monitoring
is completed and documented as
ordered. Medical observations wilt
be forwarded to the Directors of
Residential Services, then will be
sent to RN for review.

Division of Health Service Regulation
STATE FORM

099 STEF11 If continuation sheet 6 of 9

PRINTED: 07/31/2024
FORM APPROVED

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

R-C
MHL001-086 B. WING ____ 07/30/2024

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

2150 HAW RIVER-HOPEDALE ROAD
HAW RIVER GROUP HOME HAW RIVER, NC 27258

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

V 291 Continued From page 6 Vv 291

or legal system is involved or when health or
safety issues become a primary concern.

This Rule is not met as evidenced by:

Based on record reviews and interviews the
facility failed to coordinate with other qualified
professionals who are responsible for the
treatment/habilitation for 4 of 4 audited clients (#1
and #3). The findings are:

Review on 7/30/24 af client #1’s record revealed:
-Admisison date of 11/15/13.

-Diagnoses of Autism Spectrum Disorder;
Generalized Anxiety Disorder; Depression;
Intellectual and Developmental Disabilities,
Moderate; Epilepsy, Unspecified, Not Intractable,
Without Status Epilepticus; Hyperlipidemia;
Hypertension; Allergic Rhinitis; Hemorrhoids;
Migraines.

-FL2 dated 2/8/24: check blood pressure weekly.

Review on 7/30/24 of client #1's Medication
Administration Record (MAR) for the months of
June and July of 2024 revealed:
~Check Blood Pressure:

-June =There were no recordings from 6/2-
6/30.

-July = Hand written instructions to check
them daily. There were no recordings from 7/1-
7/10; 7/19-7/23, 7/26-7/31.

Observation on 7/30/24 at about 12:00 pm of the
facility's medication room revealed:
-There was a blood pressure monitor on site.

Review on 7/30/24 of client #3's record revealed:
-Admisison date of 4/13/91. .

Division of Health Service Regulation
STATE FORM 5899 STEF14 If continuation sheet 7 of 9

PRINTED: 07/31/2024
FORM APPROVED

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED
R-C
MHL001-086 BAWING 07/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2150 HAW RIVER-HOPEDALE ROAD
HAW RIVER GROUP HOME
HAW RIVER, NC 27258
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION os}
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 291 Continued From page 7 Vv 291

~Diagnoses of Moderate Intellectual and
Developmental Disabilities; Benign Essential
Hypertension; Seizures; Anxiety; B12 Deficiency;
Other Hyperlipidemia; Urethra Stricture; Anemia;
Psoriasis, Unspecified Allergies.

-FL2 dated 8/13/24: check blood pressure
weekly.

Review on 7/30/24 of client #3's MAR for the
months of June and July of 2024 revealed:
-Check Blood Pressure Weekly:

-June = There were no recordings fram 6/2-
6/30.

-July = There were no recordings from 7/1-
7/30.

Observation on 7/30/24 at about 12:00 pm of the
facility's medication room revealed:
-There was a blood pressure monitor on site.

Interview on 7/30/24 with the Vice President of
Operations revealed:

-He was not aware that the blood pressure
checks for clients #1 and #3 had not been
completed accordingly to instructions on their
FL2.

-The Qualified Professional (QP) recently
resigned from the agency.

-The QP was supposed to check to make sure
the blood pressure checks were being completed.
-That was one of the reasons he resigned. He
found out that he was not able to complete all the
duties the position entailed.

-A new Program Specialist had been hired. New
staff among with nurses and new QP would be
monitoring to make sure client's blood pressures
would be checked.

-He acknowledged that staff had not recorded the
high blood pressure check readings accordingly
to instructions from their FL2 for clients #1 and #3
Division of Health Service Regulation

STATE FORM Goes OTEF1

if continuation sheet 8 of 9

PRINTED: 07/31/2024
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: 7 COMPLETED
A BUILDING: _
R-C
MHL001-086 B. WING —____________W_. 07/30/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2150 HAW RIVER-HOPEDALE ROAD
HAW RIVER, NC 27258

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x8)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

HAW RIVER GROUP HOME

V 291 Continued From page 8
in their MAR.

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

Division of Health Service Regulation
STATE FORM 669 OTEFII If continuation sheet 9 of 9


state: NC

facility_name: Haw River Group Home

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

raw_content:
PRINTED: 07/31/2024

Division of Health Service Regulation

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

MHL001-086 B. WING

STREET ADDRESS, CITY, STATE, ZIP CODE

2150 HAW RIVER-HOPEDALE ROAD
HAW RIVER, NC 27258

NAME OF PROVIDER OR SUPPLIER

HAW RIVER GROUP HOME

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

R-C
07/30/2024

SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION
(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

ID
PREFIX
TAG

(X4) ID
PREFIX

TAG
DEFICIENCY)

(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE

(x5)
COMPLETE
DATE

V 000) INITIAL COMMENTS V 000
Acomplaint and follow up survey was completed

on July 30, 2024. The complaint was

substantiated (intake #NC00219675).

Deficiencies were cited.

This facility is licensed for the following service
category: 10A NCAC 27G .5600C Supervised
Living for Adults with Developmental Disabilities.

The facility is licensed for 6 and currently has a
census of 6. The survey sample consisted of
audits of 4 current clients.

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 shal
clients only when au
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

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

be self-administered by
horized in writing by the

TITLE

(X6) DATE

809

STATE FORM OTEF M1

If continuation sheet 1 of 9

Division of Health Service Regulation

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

MHL001-086 B. WING

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2150 HAW RIVER-HOPEDALE ROAD

HAW RIVER GROUP HOME HAW RIVER, NC 27258

PRINTED: 07/31/2024
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R-C
07/30/2024

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 1 V 118

(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 review, and
interview, the facility failed to ensure medications
were administered on the written order of a
physician affecting 1 of 4 clients (Client #1) and
that MARs were kept current affecting 1 of 4
clients (Client #2). The findings are:

Review on 7/30/24 of Client #1's record revealed:
-Admission date of 11/15/13.

-Diagnoses of Autism Spectrum Disorder;
Generalized Anxiety Disorder; Depression;
Intellectual and Developmental Disabilities,
Moderate; Epilepsy, Unspecified, Not Intractable,
Without Status Epilepticus; Hyperlipidemia;
Hypertension; Allergic Rhinitis; Hemorrhoids;
Migraines.

-Discharge information from the local emergency
department:

-"[Client #1] is a 52 year old male with a
history of autism, anxiety, depression,
hypertension, hyperlipidemia, seizure disorder
and migraine who presents after he was
accidentally given another patient's medication
around 6 am today. He received the following
medication:

-2 carbamazepine.
Division of Health Service Regulation
STATE FORM 6299

OTEF11

If continuation sheet 2 of 9

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

(X2) MULTIPLE CONSTRUCTION

PRINTED: 07/31/2024
FORM APPROVED

(X3) DATE SURVEY

STATE FORM 6899

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHLO001-086 B. WING 07/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2150 HAW RIVER-HOPEDALE ROAD
HAW RIVER GROUP HOME
HAW RIVER, NC 27258
(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 2 V 118

-1 clonidine 0.1 milligram (mg).
-1 fenofibrate.

-1 fiber-lax.

-1 levetiracetam 750 mg.

-1 lorazepam 1 mg.

-1 sodium chloride 1 gram.

-1 vitamin B12 mg.

-The patient also is on a clonidine patch for
his high blood pressure control. This was
removed once it was realized that he had gotten
the other medication. The patient himself denies
any symptoms currently. He states he does not
feel dizzy or lightheaded, denies any acute pain,
difficulty breathing, palpitations, weakness or
nausea."

Review on 7/30/24 of a Medication Error report
dated 6/26/24 revealed:

-Report completed by the Qualified Professional
and Staff #5.

-Type of Error: Wrong Medication.

-Describe what happened-include medication
names and doses: "Staff administered [Client
#3}'s medication to [Client #1]. 2 carbamazepine
400 mg, 1 clonidine 0.1 mg, 1 fenofibrate 145 mg,
1 fiber-lax, 1 levetiracetam 750 mg, 1 lorazepam
1 mg, 1 sodium chloride 1 gram, 1 vitamin B12
mg.

-Notifications: Pharmacist.

-Level Determination: Level 1. Error does not
threaten person's health or safety.

-Staff Committing Error: [Staff #5].

-Further Action Needed: "Individual was taken to
the ER for further results of medication error. No
further action needed. Staff was told to be sure to
follow proper protocol they learned in med pass
to prevent further errors. Staff was also told that
during med training that they should focus in
giving meds and to do one individual at a time to
prevent errors. Staff was also to make sure that
Division of Health Service Regulation

OTEF11

If continuation sheet 3 of 9

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL001-086 B. WING

NAME OF PROVIDER OR SUPPLIER

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE
2150 HAW RIVER-HOPEDALE ROAD

PRINTED: 07/31/2024
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R-C
07/30/2024

only one individual should be in the med room at
a time and that should be the one to whom you
are giving meds to. Nurse was also contacted
about med error and staff will be retrained on
administering meds."

-Note from the Nurse: "RN has developed a
remedial class to be implemented. Additional
training will take place 7/16/- 17/2024 to assist in
med admin and monitoring."

Review on 7/30/24 of Client #2's record revealed:
-Admission date of 8/17/17.
-Diagnoses of Autism Spectrum Disorder,
Obsessive Compulsive Disorder, Attention Deficit
Hyperactive Disorder and Asthma.
-Physician orders dated 11/14/23.

-Amantadine 100 mg- Take two capsules
twice daily.

-Clonidine 0.1 mg- Take two tablets twice
daily.

-Olanzapine 15 mg- Take one tablet twice
daily.

-Divalproex 250 mg- Take one tablet daily at
night.

Observation on 7/30/24 at about 12:05 pm of
Client #2's medications revealed:
-All medications aforementioned were available.

Review on 7/30/24 of Client #2's MARs for June
2024 through July 2024 revealed:
-July:

-Amantadine 100 mg- Was not initialed as
given by staff on 7/26 (evening) and 7/29
(evening).

-Clonidine 0.1 mg- Was not initialed as given
by staff on 7/29 (evening).

-Olanzapine 15 mg- Was not initialed as
given by staff on 7/29 (evening).

-Divalproex 250 mg- Was not initialed as
Division of Health Service Regulation
STATE FORM

809 OTEF11

HAW RIVER GROUP HOME
HAW RIVER, NC 27258
(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 9

Division of Health Service Regulation

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

MHL001-086 B. WING

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2150 HAW RIVER-HOPEDALE ROAD

HAW RIVER GROUP HOME HAW RIVER, NC 27258

PRINTED: 07/31/2024
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R-C
07/30/2024

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)

Vv 118 V 118

Continued From page 4

given by staff on 7/29 (evening).

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

Interview on 7/30/24 with Staff #5 revealed:
-Regarding medication error: "On 6/26/24, | came
and pulled the wrong client's medications out the
box. | felt in a hurry. | felt like | was running late. |
was working by myself. | was trying to get in the
schedule to get the guys ready and out of the
home to their program."

-When she realized her error, she contacted her
supervisor and the nurse.

-She was informed to contact emergency
services.

-Client #1 went to the local emergency
department to be checked.

-Client #1 was checked, did not have any
problems and was returned home that same day.
-An incident medication error report was made.
-She was also retrained by the Nurse regarding
"Medication Pass."

Interview on 7/30/24 with the Vice President of
Operations revealed:

-He knew why the state had received a complaint.
-One individual had received another client's
medications in error.

-When the medication error occurred, [Staff #5]
noticed the error right away.

-Staff #5 notified her supervisor, pharmacist was
contacted, emergency personnel was contacted
and attended the home, Client #1 went to the
emergency department to be checked. He was
fine and returned to the facility later that same
day.

-An incident report was made. Staff #5 and others
Division of Health Service Regulation

STATE FORM 6299

OTEF11

If continuation sheet 5 of 9

Division of Health Service Regulation

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

MHL001-086 B. WING

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

2150 HAW RIVER-HOPEDALE ROAD

HAW RIVER GROUP HOME HAW RIVER, NC 27258

PRINTED: 07/31/2024
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R-C
07/30/2024

(X4) ID
PREFIX
TAG

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

in the agency were retrained.

-Regarding some medications not being initialed
by staff on the MAR: He was not aware of
missing initials.

-He acknowledged Client #1 received another
client's medications which he did not have
physician's orders for and the MAR was not being
kept current.

V 291} 27G .5603 Supervised Living - Operations Vv 291
10A NCAC 27G .5603 OPERATIONS,

(a) Capacity. A facility shall serve no more than
six clients when the clients have mental illness or
developmental disabilities. Any facility licensed
on June 15, 2001, and providing services to more
han six clients at that time, may continue to
provide services at no more than the facility's
icensed capacity.

(b) Service Coordination. Coordination shall be
maintained between the facility operator and the
qualified professionals who are responsible for
reatment/habilitation or case management.

(c) Participation of the Family or Legally
Responsible Person. Each client shall be
provided the opportunity to maintain an ongoing
relationship with her or his family through such
means as visits to the facility and visits outside
he facility. Reports shall be submitted at least
annually to the parent of a minor resident, or the
legally responsible person of an adult resident.
Reports may be in writing or take the form of a
conference and shall focus on the client's
progress toward meeting individual goals.

(d) Program Activities. Each client shall have
activity opportunities based on her/his choices,
needs and the treatment/habilitation plan.
Activities shall be designed to foster community
inclusion. Choices may be limited when the court

Division of Health Service Regulation

STATE FORM 6899 OTEF11

If continuation sheet 6 of 9

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL001-086 B. WING

NAME OF PROVIDER OR SUPPLIER

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE
2150 HAW RIVER-HOPEDALE ROAD

PRINTED: 07/31/2024
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R-C
07/30/2024

or legal system is involved or when health or
safety issues become a primary concern.

This Rule is not met as evidenced by:

Based on record reviews and interviews the
acility failed to coordinate with other qualified
professionals who are responsible for the
reatment/habilitation for 4 of 4 audited clients (#1
and #3). The findings are:

Review on 7/30/24 of client #1's record revealed:
-Admisison date of 11/15/13.

-Diagnoses of Autism Spectrum Disorder;
Generalized Anxiety Disorder; Depression;
ntellectual and Developmental Disabilities,
Moderate; Epilepsy, Unspecified, Not Intractable,
Without Status Epilepticus; Hyperlipidemia;
Hypertension; Allergic Rhinitis; Hemorrhoids;
Migraines.
-FL2 dated 2/8/24: check blood pressure weekly.

Review on 7/30/24 of client #1's Medication
Administration Record (MAR) for the months of
June and July of 2024 revealed:
-Check Blood Pressure:

-June =There were no recordings from 6/2-
6/30.

-July = Hand written instructions to check
them daily. There were no recordings from 7/1-
7/10; 7/19-7/23, 7/26-7/31.

Observation on 7/30/24 at about 12:00 pm of the
facility's medication room revealed:
-There was a blood pressure monitor on site.

Review on 7/30/24 of client #3's record revealed:
-Admisison date of 4/13/91. .

Division of Health Service Regulation

STATE FORM

809 OTEF11

HAW RIVER GROUP HOME
HAW RIVER, NC 27258
(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 291} Continued From page 6 V 291

If continuation sheet 7 of 9

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL001-086 B. WING

NAME OF PROVIDER OR SUPPLIER

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE
2150 HAW RIVER-HOPEDALE ROAD

PRINTED: 07/31/2024
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R-C
07/30/2024

-Diagnoses of Moderate Intellectual and
Developmental Disabilities; Benign Essential
Hypertension; Seizures; Anxiety; B12 Deficiency;
Other Hyperlipidemia; Urethra Stricture; Anemia;
Psoriasis, Unspecified Allergies.

-FL2 dated 8/13/24: check blood pressure
weekly.

Review on 7/30/24 of client #3's MAR for the
months of June and July of 2024 revealed:
-Check Blood Pressure Weekly:

-June = There were no recordings from 6/2-
6/30.

-July = There were no recordings from 7/1-
7/30.

Observation on 7/30/24 at about 12:00 pm of the
facility's medication room revealed:
-There was a blood pressure monitor on site.

Interview on 7/30/24 with the Vice President of
Operations revealed:

-He was not aware that the blood pressure
checks for clients #1 and #3 had not been
completed accordingly to instructions on their
FL2.

-The Qualified Professional (QP) recently
resigned from the agency.

-The QP was supposed to check to make sure
the blood pressure checks were being completed.
-That was one of the reasons he resigned. He
found out that he was not able to complete all the
duties the position entailed.

-A new Program Specialist had been hired. New
staff among with nurses and new QP would be
monitoring to make sure client's blood pressures
would be checked.

-He acknowledged that staff had not recorded the
high blood pressure check readings accordingly
to instructions from their FL2 for clients #1 and #3
Division of Health Service Regulation

STATE FORM

809 OTEF11

HAW RIVER GROUP HOME
HAW RIVER, NC 27258
(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 291} Continued From page 7 V 291

If continuation sheet 8 of 9

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION

PRINTED: 07/31/2024
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHLO001-086 B. WING 07/30/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2150 HAW RIVER-HOPEDALE ROAD
HAW RIVER GROUP HOME
HAW RIVER, NC 27258
(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 291} Continued From page 8 V 291
in their MAR.
This deficiency constitutes a re-cited deficiency
and must be corrected within 30 days.
Division of Health Service Regulation
STATE FORM 6899 QTEF11 If continuation sheet 9 of 9

inspection_type: MHLCS Complaint and Follow-up

document_type: Statement of Deficiency


summary: Plan of Correction - MHLCS Annual

raw_content:
Division of Health Service Requlation

PRINTED: 04/24/2024
FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
MHL001-086 04/23/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2150 HAW RIVER-HOPEDALE ROAD
HAW RIVER GROUP HOME
HAW RIVER, NC 27258
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE | COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE

V.000) INITIAL COMMENTS

An annual survey was completed on April 23,
| 2024. Deficiencies were cited.

This facility is licensed for the following service
category: 10A NCAC 27G .5600C Supervised
Living for Adults with Developmental Disabilities.

This facility is licensed for 6 and currently has a
census of 6. The survey sample consisted of
audits of 3 current clients.

V 108 27G .0202 (F-I) Personnel Requirements

10A NCAC 27G .0202 PERSONNEL

REQUIREMENTS

(f) Continuing education shall be documented.

(g) Employee training programs shall be

provided and, at a minimum, shall consist of the

following:

(1) general organizational orientation;

(2) training on client rights and confidentiality as

delineated in 10A NCAC 27C, 27D, 27E, 27F and

10A NCAC 26B;

(3) training to meet the mh/dd/sa needs of the

client as specified in the treatment/habilitation

plan; and

(4) training in infectious diseases and

| bloodborne pathogens.
(h) Except as permitted under 10a NCAC 27G
-5602(b) of this Subchapter, at least one staff
member shall be available in the facility at all
times when a client is present. That staff
member shall be trained in basic first aid
including seizure management, currently trained

to provide cardiopulmonary resuscitation and
trained in the Heimlich maneuver or other first aid

| techniques such as those provided by Red Cross,

the American Heart Association or their

| equivalence for relieving airway obstruction.

Supervisor will ensure that the
staff will have her CPR/First Aid
training class complete by May
10th, 2024. Supervisor will also
ensure that staff is informed in
advance when annual training

is scheduled. Staff will also get
a printed schedule reminder of
annual/on going training classes
set in the future.

RECEIVED

OHSR-MH Licensure Sect

Division of Health Service Regulation

i at

LABORATORY DIRECTOR'S OR ee ene Al SIGNATURE
A

STATE FORM

(X6) DATE

all eye

if continudtion sheet 1 of 5

Division of Health Service Regulation

PRINTED: 04/24/2024
FORM APPROVED

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

MHL001-086 B, WING

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY

COMPLETED

04/23/2024

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

2150 HAW RIVER-HOPEDALE ROAD

HAW RIVER GROUP HOME

HAW RIVER, NC 27258

T

SUMMARY STATEMENT OF DEFICIENCIES 1D
(EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX
REGULATORY OR LSC IDENTIFYING INFORMATION) TAG

(xa) 10 |
PREFIX

TAG

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

(XS)
COMPLETE
DATE

V 108 Continued From page 1 Vv 108

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

| clients.

This Rule is not met as evidenced by:

Based on record reviews and interviews, the
facility failed to ensure 1 of 3 staff (Staff #5) was
trained in First Aid. The findings are:

Review on 4/23/24 of Staff #5's personnel record
revealed:

-Date of Hire: 2/9/24.

-She was hired as a Group Home Co-Manager.
-There was no evidence she had completed
training in First Aid.

Interview on 4/23/24 with the Human Resources
Director revealed:

-She thought Staff #5 had completed her training
in first aid.

-She would be immediately registering Staff #5 to
attend first aid training.

-Staff #5 had completed the training on
Cardiovascular Resuscitation (CPR) and filing
staff may had gotten confused and thought the
certificate was for First Aid and CPR.

Interview on 4/23/24 with the Vice President of
Operations revealed:

-He did not know that Staff #3's training on first
aid was missing.

| -He acknowledged that Staff #3 did not have in
her records a first aid training.

Division of Health Service Regulation
STATE FORM 6899

6JMW11

if continuation sheet 2 of 5

PRINTED: 04/24/2024

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
MHL001-086 8. WING ___________. 04/23/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2150 HAW RIVER-HOPEDALE ROAD
HAW RIVER GROUP HOME HAW RIVER, NG 27258
(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) |
Vv 204 27G .5603 Supervised Living - Operations V 291 Supervisor will ensure service |
coordination is maintained by re-
1 foe he = s plein th training the staff on how to properly
Bit Cheais ven tv oherus has mann Wass oh GoouME hor the Medion
2 Wi ave me Administration Record (MAR) for

developmental disabilities. Any facility licensed
on June 15, 2001, and providing services to more
than six clients at that time, may continue to

rovide services at no more than the facility's ‘
feensed capacity. y mentation then eventually fade to

(b) Service Coordination. Coordination shall be | monthly,etc. to be certain all docu-
maintained between the facility operator and the | mentation is recorded correctly in a
qualified professionals who are responsible for timely manner according the FL2.
treatment/habilitation or case management.

(c) Participation of the Family or Legally
Responsible Person. Each client shall be
provided the opportunity to maintain an ongoing

| relationship with her or his family through such
means as visits to the facility and visits outside
the facility. Reports shall be submitted at least
annually to the parent of a minor resident, or the
legally responsible person of an adult resident.
Reports may be in writing or take the form of a
conference and shall focus on the client's
progress toward meeting individual goals.

(d) Program Activities. Each client shall have
activity opportunities based on her/his choices,
needs and the treatment/habilitation plan.
Activities shall be designed to foster community

| inclusion. Choices may be limited when the court
or legal system is involved or when health or
safety issues become a primary concern.

every individual served in the faci-
lity. Supervisor will check MAR on
a bi-weekly basis for correct docu-

This Rule is not met as evidenced by:

Based on record reviews and interviews the
facility failed to coordinate with other qualified
professionals who are responsible for the

Division of Health Service Regulation
STATE FORM 8899 6JMW11 If continuation sheet 3 of 5

PRINTED: 04/24/2024

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
MHL001-086 BL WING 04/23/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2150 HAW RIVER-HOP! E ROAI
HAW RIVER GROUP HOME OPEDAL D
HAW RIVER, NC 27258
(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)
Vv 291 Continued From page 3 Vv 291

treatment/habilitation for 2 of 3 audited clients (#4
& #2). The findings are:

Review on 4/23/24 of client #1's record revealed:
-Admisison date of 12/1/92.
-Diagnoses of Moderate Intellectual and
Developmental Disabilities; Essential
Hypertension; Pre-Diabetes; Vitamin D
| Deficiency; Dyslipidemia; Sleep Apnea; Seasonal
Allergies.
-FL2 dated 4/15/24: check blood pressure
weekly.

Review on 4/23/24 of client #1's Medication
Administration Record (MAR) for the months of
February, March and April of 2024 revealed:
-There were no recordings for blood pressure
checks for the months of February, March or
April.

| Review on 4/23/24 of client #2's record revealed:
-Admisison date of 11/15/13.
-Diagnoses of Autism Spectrum Disorder;
Generalized Anxiety Disorder; Depression;
Intellectual and Developmental Disabilities,
Moderate; Epilepsy, Unspecified, Not Intractable,
Without Status Epilepticus; Hyperlipidemia;

| Hypertension; Allergic Rhinitis; Hemorrhoids;

Migraines.

-FL2 dated 2/8/24: check blood pressure weekly.

Review on 4/23/24 of client #2's MAR for the
months of February, March and April of 2024
revealed:
-There were no recordings for blood pressure
checks for the following:
-March = No recordings on 3/18 and 3/25.
-April = There were no recordings for the
month.

Division of Health Service Regulation
STATE FORM

6899

6JMW11 If continuation sheet 4 of 5

Division of Health Service Regulation

PRINTED: 04/24/2024
FORM APPROVED

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

MHLO001-086

02

B. WING

) MULTIPLE CONSTRUCTION,
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

04/23/2024

NAME OF PROVIDER OR SUPPLIER

HAW RIVER GROUP HOME

STREET ADDRESS, CITY, STATE, ZIP CODE

2150 HAW RIVER-HOPEDALE ROAD
HAW RIVER, NC 27258

SUMMARY STATEMENT OF DEFICIENCIES,

| PROVIDER'S PLAN OF CORRECTION | (x5)

(X4) 1D | 1D
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)
v29o1 Continued From page 4 v291

Observation on 4/23/24 at about 12:00 pm of the
facility's medication room revealed:
-There was a blood pressure monitor on site.

Interview on 4/23/24 with the Vice President of
Operations revealed:
-He was under the impression that facility staff
had been recording the client's high blood
| pressure checks.
-Staff were supposed to log on the back of the
MAR the blood pressure checks for the clients.
| -He was not aware that there were no high blood
| pressure checks for cilents #1 and #2.
-He acknowledged that staff had not recorded the
high blood pressure check readings for clients #1
and #2 in their MAR.

Division of Health Service Regulation
STATE FORM

6899

6JMW11 If continuation sheet 5 of 5

inspection_type: MHLCS Annual

document_type: Plan of Correction


summary: Statement of Deficiency - MHLCS Annual

raw_content:
PRINTED: 04/24/2024
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:
MHL001-086 B. WING _____ 04/23/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

2150 HAW RIVER-HOPEDALE ROAD

HAW RIVER, NC 27258
(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)

HAW RIVER GROUP HOME

V 000} INITIAL COMMENTS Vv 000

An annual survey was completed on April 23,
2024. Deficiencies were cited.

This facility is licensed for the following service
category: 10A NCAC 27G .5600C Supervised
Living for Adults with Developmental Disabilities.

This facility is licensed for 6 and currently has a
census of 6. The survey sample consisted of
audits of 3 current clients.

V 108] 27G .0202 (F-I) Personnel Requirements V 108

10A NCAC 27G .0202 PERSONNEL
REQUIREMENTS

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

(1) general organizational orientation;

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

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

(4) training in infectious diseases and
bloodborne pathogens.

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

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

STATE FORM 6899 6JMW11 If continuation sheet 1 of 5

Division of Health Service Regulation

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

MHL001-086 B. WING

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2150 HAW RIVER-HOPEDALE ROAD

HAW RIVER GROUP HOME HAW RIVER, NC 27258

PRINTED: 04/24/2024
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

04/23/2024

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 108 V 108

Continued From page 1

(i) The governing body shall develop and
implement policies and procedures for identifying,
reporting, investigating and controlling infectious
and communicable diseases of personnel and
clients.

This Rule is not met as evidenced by:

Based on record reviews and interviews, the
acility failed to ensure 1 of 3 staff (Staff #5) was
rained in First Aid. The findings are:

Review on 4/23/24 of Staff #5's personnel record
revealed:

-Date of Hire: 2/9/24.

-She was hired as a Group Home Co-Manager.
-There was no evidence she had completed
raining in First Aid.

nterview on 4/23/24 with the Human Resources
Director revealed:

-She thought Staff #5 had completed her training
in first aid.

-She would be immediately registering Staff #5 to
attend first aid training.

-Staff #5 had completed the training on
Cardiovascular Resuscitation (CPR) and filing
staff may had gotten confused and thought the
certificate was for First Aid and CPR.

Interview on 4/23/24 with the Vice President of
Operations revealed:

-He did not know that Staff #3's training on first

aid was missing.

-He acknowledged that Staff #3 did not have in

her records a first aid training.

Division of Health Service Regulation

STATE FORM 6299

6JMW11

If continuation sheet 2 of 5

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION

PRINTED: 04/24/2024
FORM APPROVED

(X3) DATE SURVEY

10A NCAC 27G .5603 OPERATIONS,

(a) Capacity. A facility shall serve no more than
six clients when the clients have mental illness or
developmental disabilities. Any facility licensed
on June 15, 2001, and providing services to more
han six clients at that time, may continue to
provide services at no more than the facility's
icensed capacity.

(b) Service Coordination. Coordination shall be
maintained between the facility operator and the
qualified professionals who are responsible for
reatment/habilitation or case management.

(c) Participation of the Family or Legally
Responsible Person. Each client shall be
provided the opportunity to maintain an ongoing
relationship with her or his family through such
means as visits to the facility and visits outside
he facility. Reports shall be submitted at least
annually to the parent of a minor resident, or the
legally responsible person of an adult resident.
Reports may be in writing or take the form of a
conference and shall focus on the client's
progress toward meeting individual goals.

(d) Program Activities. Each client shall have
activity opportunities based on her/his choices,
needs and the treatment/habilitation plan.
Activities shall be designed to foster community
inclusion. Choices may be limited when the court
or legal system is involved or when health or
safety issues become a primary concern.

This Rule is not met as evidenced by:

Based on record reviews and interviews the
facility failed to coordinate with other qualified
professionals who are responsible for the

Division of Health Service Regulation

STATE FORM 6899 6JMW11

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHLO001-086 B. WING 04/23/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2150 HAW RIVER-HOPEDALE ROAD
HAW RIVER GROUP HOME
HAW RIVER, NC 27258
(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 291} 27G .5603 Supervised Living - Operations Vv 291

If continuation sheet 3 of 5

PRINTED: 04/24/2024

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
MHL001-086 B. WING 04/23/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

2150 HAW RIVER-HOPEDALE ROAD
HAW RIVER, NC 27258

HAW RIVER GROUP HOME

(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 291} Continued From page 3 Vv 291

reatment/habilitation for 2 of 3 audited clients (#1
& #2). The findings are:

Review on 4/23/24 of client #1's record revealed:
-Admisison date of 12/1/92.

-Diagnoses of Moderate Intellectual and
Developmental Disabilities; Essential
Hypertension; Pre-Diabetes; Vitamin D
Deficiency; Dyslipidemia; Sleep Apnea; Seasonal
Allergies.

-FL2 dated 4/15/24: check blood pressure
weekly.

Review on 4/23/24 of client #1's Medication
Administration Record (MAR) for the months of
February, March and April of 2024 revealed:
-There were no recordings for blood pressure
checks for the months of February, March or
April.

Review on 4/23/24 of client #2's record revealed:
-Admisison date of 11/15/13.

-Diagnoses of Autism Spectrum Disorder;
Generalized Anxiety Disorder; Depression;
ntellectual and Developmental Disabilities,
Moderate; Epilepsy, Unspecified, Not Intractable,
Without Status Epilepticus; Hyperlipidemia;
Hypertension; Allergic Rhinitis; Hemorrhoids;
Migraines.
-FL2 dated 2/8/24: check blood pressure weekly.

Review on 4/23/24 of client #2's MAR for the
months of February, March and April of 2024
revealed:
-There were no recordings for blood pressure
checks for the following:
-March = No recordings on 3/18 and 3/25.
-April = There were no recordings for the
month.

Division of Health Service Regulation

STATE FORM 6899 6JMW11 If continuation sheet 4 of 5

Division of Health Service Regulation

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

MHL001-086 B. WING

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2150 HAW RIVER-HOPEDALE ROAD

HAW RIVER GROUP HOME HAW RIVER, NC 27258

PRINTED: 04/24/2024
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

04/23/2024

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 291} Continued From page 4 V 291

Observation on 4/23/24 at about 12:00 pm of the
facility's medication room revealed:
-There was a blood pressure monitor on site.

Interview on 4/23/24 with the Vice President of
Operations revealed:

-He was under the impression that facility staff
had been recording the client's high blood
pressure checks.

-Staff were supposed to log on the back of the
MAR the blood pressure checks for the clients.
-He was not aware that there were no high blood
pressure checks for cilents #1 and #2.

-He acknowledged that staff had not recorded the
high blood pressure check readings for clients #1
and #2 in their MAR.

Division of Health Service Regulation

STATE FORM 6899 6JMW11

If continuation sheet 5 of 5


summary: Statement of Deficiency - MHLCS Annual

raw_content:
Division of Health Service Re

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

NAME OF PROVIDER OR SUPPLIER

MHLO001-086

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 06/19/2023

STREET ADDRESS, CITY, STATE, ZIP CODE

2150 HAW RIVER-HOPEDALE ROAD

HAW RIVER GROUP HOME
HAW RIVER, NC 27258

FORM APPROVED

(X3) DATE SURVEY
COMPLETED

06/14/2023

An annual survey was completed on June 14,
2023. No deficiencies were cited.

This facility is licensed for the following service
category: 10A NCAC 27G. 5600C

Supervised Living for Adults with Developmental
Disabilities

The facility is licensed for and currently has a
census of 6.

The survey sample consisted of audits of 3
current clients.

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

STATE FORM

6899

TITLE

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000) INITIAL COMMENTS Vv 000

(X6) DATE

If continuation sheet 1 of 1


summary: Statement of Deficiency - MHLCS Annual

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

MHL001-086

NAME OF PROVIDER OR SUPPLIER

HAW RIVER GROUP HOME

PRINTED: 04/11/2022

FORM APPROVED
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

A. BUILDING: COMPLETED
B.WING 04/08/2022

STREET ADDRESS, CITY, STATE, ZIP CODE

2150 HAW RIVER-HOPEDALE ROAD
HAW RIVER, NC 27258

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 000} INITIAL COMMENTS

An annual survey was completed on April 8,
2022. No deficiencies were cited.

This facility is licensed for the following service
category: 10A NCAC 27G .5600C Supervised
Living for Adults with Developmental Disabilities.

This faciity is licensed for 6 and currently has a
census of 4 clients. The survey sample consisted
of audits of 2 current clients and 1 deceased
client.

Division of Health Service Regulation

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

V 000

TITLE (X6) DATE

STATE FORM

809

BRBZ11 If continuation sheet 1 of 1


summary: Statement of Deficiency - MHLCS Annual and Complaint

raw_content:
Division of Health Service Re

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

NAME OF PROVIDER OR SUPPLIER

MHLO001-086

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 11/01/2019

STREET ADDRESS, CITY, STATE, ZIP CODE

2150 HAW RIVER-HOPEDALE ROAD

HAW RIVER GROUP HOME
HAW RIVER, NC 27258

(X3) DATE SURVEY
COMPLETED

FORM APPROVED

10/25/2019

An annual and complaint survey was completed
on October 25, 2019. The complaint was
unsubstantiated (Intake #NC00156593). There
were no deficiencies cited.

This facility is licensed for the following service
category: 10A NCAC 27G. 5600C Supervised

Living for Adults with Developmental Disabilities .

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

STATE FORM

6899

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000) INITIAL COMMENTS Vv 000

TITLE

(X6) DATE

If continuation sheet 1 of 1

inspection_type: MHLCS Annual and Complaint


summary: Statement of Deficiency - MHLCS Annual

raw_content:
PRINTED: 10/08/2018

FORM APPROVED
Division of Health Service Re
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHLO001-086 10/04/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
2150 HAW RIVER-HOPEDALE ROAD
HAW RIVER GROUP HOME
HAW RIVER, NC 27258
(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 survey was completed on October 4,
2018. No deficiencies were cited.

This facility is licensed for the following service
category: 10A NCAC 27G. 5600C Supervised

Living for Adults with Developmental Disabilities .

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

STATE FORM

6899

TITLE (X6) DATE

If continuation sheet 1 of 1