raw_content:
Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

IDENTIFICATION NUMBER:

MHLO001-149

A. BUILDING:

1710 SYKES STREET
BURLINGTON, NC 27215

JUST IN TIME YOUTH SERVICES

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 05/29/2024

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

R-C
05/17/2024

(x4) ID
PREFIX
TAG

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

ID
PREFIX
TAG

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

DEFICIENCY)

(xs)
COMPLETE
DATE

V 000!

V 366|

INITIAL COMMENTS

Acomplaint and follow-up survey was completed
on May 17, 2024. The complaint (intake
#NC00216574, #NC00216390 and
#NC00216982) were unsubstantiated.
Deficiencies were cited.

This facility is licensed for the following service
category: 10A NCAC 27G. 1700

Residential Treatment Staff Secure for Children
or Adolescents

The facility is licensed for 4 and currently has a
census of 4.

The survey sample consisted of audits of 3
current clients.

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 |, Il or Ill incidents. The policies
shall require the provider to respond by:

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

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

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

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

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

(6) adhering to confidentiality requirements
set forth in G.S. 75, Article 2A, 10A NCAC 26B,

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

STATE FORM

V 000

V 366

6899

BWC511

TITLE

(X6) DATE

If continuation sheet 1 of 8

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHLO001-149

A. BUILDING:

1710 SYKES STREET
BURLINGTON, NC 27215

JUST IN TIME YOUTH SERVICES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/29/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R-C
05/17/2024

42 CFR Parts 2 and 3 and 45 CFR Parts 160 and
164; and

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

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

by:

(1) immediately securing the client record
by:

(A) obtaining the client record;

(B) making a photocopy;

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

(2) convening a meeting of an internal

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

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

(B) gather other information needed;

(C) issue written preliminary findings of fact

Division of Health Service Regulation
STATE FORM

6809

BWC511

(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 1 V 366

If continuation sheet 2 of 8

Division of Health Service Regulation

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

MHLO001-149

NAME OF PROVIDER OR SUPPLIER

A. BUILDING:

1710 SYKES STREET
BURLINGTON, NC 27215

JUST IN TIME YOUTH SERVICES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/29/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

R-C
05/17/2024

(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 2 V 366

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;

(D) the Department;

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

(F) any other authorities required by law.

Division of Health Service Regulation
STATE FORM

6809

BWC511

If continuation sheet 3 of 8

Division of Health Service Regulation

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

MHLO001-149

NAME OF PROVIDER OR SUPPLIER

A. BUILDING:

1710 SYKES STREET
BURLINGTON, NC 27215

JUST IN TIME YOUTH SERVICES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/29/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R-C
05/17/2024

(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 3 V 366

This Rule is not met as evidenced by:

Based on record reviews and interviews, the
facility failed to implement a policy governing their
response to Level Ill incidents as required. The
findings are:

Review on 5/6/24 of Client #2's record revealed:
-He was 17 years old.

-Admission date of 9/30/23.

-Diagnoses of Oppositional Defiant Disorder,
Unspecified Mood Disorder, Mild Intellectual
Developmental Disability, Post Traumatic Stress
Disorder, Intermittent Explosive Disorder,
Conduct Disorder and Other Specified Trauma
and Stressor Related Disorder.

Review on 5/6/24 of the facility's level | incident
report revealed:

-Client #2 eloped from the facility the evening of
5/1/24.

-Client #2 left the facility without permisson with
no shoes, socks and shirt.

-Police was called, located client #2 and
transported back to the facility.

-Client #2 refused to return to enter the facility
and the police escorted him to the hospital.

Review on 5/6/24 of the North Carolina Incident
Response Improvement System (IRIS) revealed:
-There was no incident documented in the system
as of 9:00 a.m.

Interview on 5/6/24 with the Program Director
revealed:

-Client #2 eloped from the facility on 5/1/24.
-The police was called and returned client #2
about 12:00 a.m. on 5/2/24.

-The police took client #2 to the hospital due to
client refusing to enter the facility.

Division of Health Service Regulation
STATE FORM

6809

BWC511

If continuation sheet 4 of 8

Division of Health Service Regulation

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

MHLO001-149

NAME OF PROVIDER OR SUPPLIER

A. BUILDING:

1710 SYKES STREET
BURLINGTON, NC 27215

JUST IN TIME YOUTH SERVICES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/29/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R-C
05/17/2024

(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 366] Continued From page 4

-The IRIS report was not completed.

-He was responsible for completing the IRIS
report.

-He would designate staff to train to complete the
IRIS report in case he was out.

-He reported the CEO generally would complete
the IRIS report as a backup.

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

V 367] 27G .0604 Incident Reporting Requirements

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

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

Division of Health Service Regulation
STATE FORM

V 366

V 367

6809

BWC511

If continuation sheet 5 of 8

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHLO001-149

A. BUILDING:

1710 SYKES STREET
BURLINGTON, NC 27215

JUST IN TIME YOUTH SERVICES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/29/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R-C
05/17/2024

or responding.

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

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

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

(1) hospital records including confidential
information;

(2) reports by other authorities; and

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

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

Division of Health Service Regulation
STATE FORM

6809

BWC511

(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 5 V 367

If continuation sheet 6 of 8

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHLO001-149

A. BUILDING:

1710 SYKES STREET
BURLINGTON, NC 27215

JUST IN TIME YOUTH SERVICES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/29/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

R-C
05/17/2024

definition of a level II or level Ill incident;

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

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

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

(6) a statement indicating that there have

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

This Rule is not met as evidenced by:

Based on record review and interviews, the
facility failed to ensure an incident report was
submitted to the Local Management Entity
(LME)/Managed Care Organization (MCO) within
72 hours as required. The findings are:

Review on 5/6/24 of the North Carolina Incident
Response Improvement System (IRIS) reports
revealed:

- Client #2 eloped out of the facility through the
front door on 5/1/24 and local law enforcement
was notfied.

- No documentation the IRIS report was
submitted as required until 5/6/24 at 5:05 p.m.

Interview on 5/17/24 with the Program Director
revealed:

Division of Health Service Regulation
STATE FORM

6809

BWC511

(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 6 V 367

If continuation sheet 7 of 8

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

JUST IN TIME YOUTH SERVICES

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

MHLO001-149

1710 SYKES STREET

BURLINGTON, NC 27215

PRINTED: 05/29/2024

(X2) MULTIPLE CONSTRUCTION (x3)
A. BUILDING:

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

DATE SURVEY
COMPLETED

R-C
05/17/2024

PROVIDER'S PLAN OF CORRECTION

-He was responsible for completing the IRIS
report.

-He would designate staff to train to complete the
IRIS report in case he was out.

-He reported the CEO generally would complete
the reports as a backup.

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

Division of Health Service Regulation
STATE FORM

6809

BWC511

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 367] Continued From page 7 V 367

If continuation sheet 8 of 8


state: NC

facility_name: Just In Time Youth Services

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

raw_content:
PRINTED: 11/02/2023
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
MHL001-149 B. WING _____ 10/20/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES 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 000} INITIAL COMMENTS V 000

An annual, complaint and follow up survey was
completed on October 20, 2023. The complaint
was unsubstantiated (intake #NC00208407).
Deficiencies were cited.

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

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

V 109} 27G .0203 Privileging/Training Professionals Vv 109

10A NCAC 27G .0203 COMPETENCIES OF
QUALIFIED PROFESSIONALS AND
ASSOCIATE PROFESSIONALS
(a) There shall be no privileging requirements for
qualified professionals or associate professionals.
(b) Qualified professionals and associate
professionals shall demonstrate knowledge, skills
and abilities required by the population served.
(c) At such time as a competency-based
employment system is established by rulemaking,
then qualified professionals and associate
professionals shall demonstrate competence.
(d) Competence shall be demonstrated by
exhibiting core skills including:
(1) technical knowledge;

) cultural awareness;

) analytical skills;

) decision-making;
(5) interpersonal skills;

') communication skills; and

) clinical skills.
(e) Qualified professionals as specified in 10A
NCAC 27G .0104 (18)(a) are deemed to have

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

STATE FORM 6899 SXMD11 If continuation sheet 1 of 18

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL001-149 B. WING

NAME OF PROVIDER OR SUPPLIER
1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 11/02/2023
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
10/20/2023

met the requirements of the competency-based
employment system in the State Plan for
MH/DD/SAS.

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

This Rule is not met as evidenced by:

Based on record review and interviews, one of
one Associate Professional (the
Director/Associate Professional) failed to
demonstrate knowledge, skills and abilities to
meet the needs of clients. The findings are:

Review on 10/18/23 of the personnel record for
the Director/Associate Professional revealed:
-Date of hire was 2/24/07.

Review of 10/17/23 of a video taken by staff #1
on his personal cellphone revealed:

-The video was recorded on 10/8/23 and was 3
minutes and 49 seconds in duration.

-Staff #1 recorded client #1 while he was having a
behavior in his bedroom.

-Client #1 was crying, screaming and grunting.
-Client #1 tried to open the window and said "I'm
running away, | hate this place."

-Throughout the video client #1 could be heard
saying the following: "Leave me alone, I'm not
Division of Health Service Regulation

STATE FORM

809 SXMD11

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

DEFICIENCY)
V 109} Continued From page 1 Vv 109

If continuation sheet 2 of 18

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIER/CLIA

IDENTIFICATION NUMBER: A. BUILDING:

MHL001-149 B. WING

1710 SYKES STREET
BURLINGTON, NC 27215

JUST IN TIME YOUTH SERVICES

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 11/02/2023
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
10/20/2023

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 109} Continued From page 2 Vv 109

doing anything to you." "You never know when to
leave me alone, stop messing with me, now I'm in
rouble because you." "Then [the
Director/Associate Professional] going to be
ussing at me because you don't know how to
stop coming in my room." "Leave me alone, stop
coming in my room, stop, you in here messing
with me, please stop."

nterview on 10/18/23 with client #1 revealed:
-"Staff record them all the time with their
cellphones whenever they act up."

-"Staff send [the Director/Associate Professional]
he videos and they get in trouble."

nterview on 10/18/23 with client #2 revealed:
-Staff recorded them sometimes with their
cellphones if they are having behaviors at the
acility.

-He wasn't sure why staff were recording them.

nterview on 10/18/23 with client #3 revealed:
-Whenever they have behaviors staff will
sometimes record them with their cellphones.
-He thought staff were recording them to show
he Director/Associate Professional.

nterviews on 10/17/23 and 10/19/23 with staff #1
revealed:

-He started recording client #1 with his cellphone
during the incident on 10/8/23.

-The Director/Associate Professional told staff
"when something happens to record the clients,
because clients lie on staff."

-"| have been recording clients having behaviors
with my cellphone since | started at the facility last
year in April 2022."

Interview on 10/18/23 with staff #2 revealed:
-They sometimes record clients while they have

Division of Health Service Regulation

STATE FORM

809 SXMD11

If continuation sheet 3 of 18

Division of Health Service Regulation

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

(X2) MULTIPLE CONSTRUCTION

A. BUILDING:
MHL001-149 B. WING
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1710 SYKES STREET
JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

PRINTED: 11/02/2023
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
10/20/2023

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)

Vv 109 V 109

Continued From page 3

behaviors.

-"The [Director/Associate Professional] told them
to do that, because sometimes the clients lie
about incidents with staff."

Interviews on 10/18/23 and 10/19/23 with the
Director/Associate Professional revealed:

-"| have been encouraging staff to record
incidents the clients are having with their personal
phones."

-Staff record the incidents because the clients
“will lie and say staff hurt them."

-"There are too many incidents with the clients
and the clients are constantly lying and being
manipulative."

-"I'm trying to take precautions and protect my
staff."

-They have been recording incidents with the
clients on cell phones for about the last year.
-Staff send her the videos of the incidents.
-She also send the videos from the phones to
some of the parents, "so they can observe the
clients behaviors."

Vv 114 Vv 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.

Division of Health Service Regulation

STATE FORM 6899

SXMD11

If continuation sheet 4 of 18

PRINTED: 11/02/2023

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
MHL001-149 B. WING 10/20/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1710 SYKES STREET
JUST IN TIME YOUTH SERVICES
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 114| Continued From page 4 Vv 114

(d) Each facility shall have basic first aid supplies
accessible for use.

This Rule is not met as evidenced by:

Based on record review and interviews, the

acility failed to ensure fire and disaster drills were
completed quarterly on each shift. The findings
are:

Reviews on 10/17/23 and 10/18/23 of the facility's
ire and disaster drill logs dated 11/14/22 to
10/10/23 revealed:

-There was no fire drill conducted on 2nd shift for
he 3rd quarter (July, August, September) of
2023.

-There was no disaster drill conducted on 2nd
shift for the 4th quarter (October, November,
December) of 2022.

-There were no disaster drills conducted on ‘st or
2nd shift for the 3rd quarter (July, August,
September) of 2023.

nterview on 10/18/23 with Client #1 revealed:

-He was admitted to the facility in May 2023, and
completed one fire drill.
-The facility did not complete any disaster drills.

nterview on 10/18/23 with Client #2 revealed:
-The facility completed fire drills.
-The facility never completed disaster drills.

nterview on 10/18/23 with Client #3 revealed:
-He was admitted to the facility 4 months ago.
-Staff had not completed any disaster drills.

nterview on 10/20/23 with Client #4 revealed:

-The facility completed fire and disaster drills.

Division of Health Service Regulation

STATE FORM 6299

SXMD11 If continuation sheet 5 of 18

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL001-149 B. WING

NAME OF PROVIDER OR SUPPLIER
1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 11/02/2023
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
10/20/2023

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 114| Continued From page 5 Vv 114

Interview on 10/18/23 with Staff #2 revealed:
-He worked 1st shift at the facility.

- Staff completed fire and disaster drills monthly
with clients.

-The last fire and disaster drill was "about 2-3
weeks ago."

Interviews on 10/17/23 and 10/20/23 with the
Program Director revealed:

-The facility operated under two shifts.

-First shift was from 7:00am to 7:00pm.

-Second shift was from 7:00pm to 7:00pm.
-There may be some additional documentation of
fire and disaster drills in the storage unit.

-They moved older paperwork to a storage unit.

V 132} G.S. 131E-256(G) HCPR-Notification, V 132

Allegations, & Protection

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

(g) Health care facilities shall ensure that the
Department is notified of all allegations against
health care personnel, including injuries of
unknown source, which appear to be related to
any act listed in subdivision (a)(1) of this section.
(which includes:

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

c. Misappropriation of the property of a

Division of Health Service Regulation

STATE FORM 6899

SXMD11

If continuation sheet 6 of 18

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL001-149 B. WING

NAME OF PROVIDER OR SUPPLIER

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 11/02/2023
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
10/20/2023

healthcare facility.

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

e. Fraud against a health care facility or against
a patient or client for whom the employee is
providing services).

Facilities must have evidence that all alleged
acts are investigated and must make every effort
to protect residents from harm while the
investigation is in progress. The results of all
investigations must be reported to the
Department within five working days of the initial
notification to the Department.

This Rule is not met as evidenced by:

Based on record reviews and interviews, the
acility failed to ensure an allegation of abuse was
reported to Health Care Personnel Registry
(HCPR) within five working days. The findings
are:

Review on 10/18/23 of staff #1's personnel record
revealed:

-Date of hire was 4/15/22.

-He was hired as a Paraprofessional.

Review on 10/17/23 of client #1's record
Division of Health Service Regulation

STATE FORM 6899

SXMD11

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

DEFICIENCY)
V 132] Continued From page 6 V 132

If continuation sheet 7 of 18

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL001-149 B. WING

NAME OF PROVIDER OR SUPPLIER

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 11/02/2023
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
10/20/2023

revealed:

-Admission date of 5/9/23.

-Diagnoses of Disruptive Mood Dysregulation
Disorder, Oppositional Defiant Disorder, Attention
Deficit Hyperactivity Disorder and Reactive
Attachment Disorder.

-He was 12 years old.

-Psychological Evaluation completed
10/26/20-His behavioral issues include failure to
conform to rules, arguing with caregivers, lying
and easily aroused hostility. He is also
non-compliant with household rules. He had a
history of being argumentative, oppositional
behavior, truancy, dishonesty, runaway behavior,
use of inappropriate language, verbal aggression,
physical aggression, temper tantrums and
destruction of property.

Review on 10/18/23 of an In-house incident
report dated 10/8/23 for client #1 revealed:
-"[Client #1] was in trouble because he was fight
in morning and at 2:15 [client #1] asked staff to
take him out and he said no because and [client
#1] went to his room and he closed the door so
hard and staff told him to keep your door open
because | can see you don't hurt yourself, he
didn't listen and he start yelling and cursing the
staff and it take 4-5 minutes and then he start
destroying the property and staff did the child
standing hold for 3 minutes then he calm down."

Review on 10/16/23 of the North Carolina Incident
Response Improvement System (IRIS) revealed:
-There was no level III incident report submitted
by the facility for an allegation of abuse against
staff #1 related to him assaulting client #1 on
10/8/23.

Interview on 10/17/23 with the Program Director
revealed:

Division of Health Service Regulation

STATE FORM

809 SXMD11

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

DEFICIENCY)
V 132] Continued From page 7 V 132

If continuation sheet 8 of 18

PRINTED: 11/02/2023
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
MHL001-149 B. WING _____ 10/20/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES 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 132] Continued From page 8 V 132

-There was an incident with client #1 and staff #1
on 10/8/23.

-After the incident client #1 alleged staff #1
assaulted him.

-Client #1 alleged staff #1 "slammed him."

-He did not report the allegation of abuse with
staff #1 and client #1 to HCPR.

-"| have no reason for not reporting to HCPR,
other than trying to get all the facts together about
the incident."

-He confirmed the agency failed to report the
allegations of abuse to HCPR within five working
days.

Interview on 10/18/23 with the Director/Associate
Professional revealed:

-She was aware of the incident with client #1 and
staff # on 10/8/23.

-Client #1 alleged "[staff #1] picked him up and
slammed him on the floor."

-It was not reported to HCPR because they get
confused about when to report incidents."

-She confirmed the agency failed to report the
allegations of abuse to HCPR within five working
days.

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

V 366} 27G .0603 Incident Response Requirments V 366

10A NCAC 27G .0603 INCIDENT
RESPONSE REQUIREMENTS FOR
CATEGORY AAND B PROVIDERS

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

(1) attending to the health and safety needs

Division of Health Service Regulation
STATE FORM 6899 SXMD11 If continuation sheet 9 of 18

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

MHL001-149

JUST IN TIME YOUTH SERVICES

STREET ADDRESS, CITY, STATE, ZIP CODE
1710 SYKES STREET
BURLINGTON, NC 27215

PRINTED: 11/02/2023

FORM APPROVED
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
A. BUILDING: COMPLETED
R
B.WING 10/20/2023

(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 9 V 366

of individuals involved in the incident;

(2) determining the cause of the incident;
(3) developing and implementing corrective
measures according to provider specified
timeframes not to exceed 45 days;

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

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

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

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

(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

Division of Health Service Regulation
STATE FORM

6899 SXMD11 If continuation sheet 10 of 18

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL001-149 B. WING

NAME OF PROVIDER OR SUPPLIER
1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 11/02/2023
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
10/20/2023

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

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

(B) gather other information needed;

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

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

Division of Health Service Regulation

STATE FORM 6899

SXMD11

(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

If continuation sheet 11 of 18

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL001-149 B. WING

NAME OF PROVIDER OR SUPPLIER
1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 11/02/2023
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
10/20/2023

for maintaining and updating the client's
treatment plan, if different from the reporting
provider;

(D) the Department;

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

(F) any other authorities required by law.

This Rule is not met as evidenced by:

Based on record reviews and interviews, the
facility failed to implement a policy governing their
response to Level Ill incidents as required. The
findings are:

Review on 10/18/23 of staff #1's personnel record
revealed:
-Date of hire was 4/15/22.

-He was hired as a Paraprofessional.

Review on 10/17/23 of client #1's record
revealed:
Admission date of 5/9/23.

-Diagnoses of Disruptive Mood Dysregulation
Disorder, Oppositional Defiant Disorder, Attention
Deficit Hyperactivity Disorder and Reactive
Attachment Disorder.

-He was 12 years old.

-Psychological Evaluation completed
10/26/20-His behavioral issues include failure to
conform to rules, arguing with caregivers, lying
and easily aroused hostility. He is also
non-compliant with household rules. He had a
history of being argumentative, oppositional
behavior, truancy, dishonesty, runaway behavior,
Division of Health Service Regulation

STATE FORM

809 SXMD11

(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 11 V 366

If continuation sheet 12 of 18

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL001-149 B. WING

NAME OF PROVIDER OR SUPPLIER
1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 11/02/2023
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
10/20/2023

use of inappropriate language, verbal aggression,
physical aggression, temper tantrums and
destruction of property.

Review on 10/18/23 of an In-house incident
report dated 10/8/23 for client #1 revealed:
-"[Client #1] was in trouble because he was fight
in morning and at 2:15 [client #1] asked staff to
take him out and he said no because and [client
#1] went to his room and he closed the door so
hard and staff told him to keep your door open
because | can see you don't hurt yourself, he
didn't listen and he start yelling and cursing the
staff and it take 4-5 minutes and then he start
destroying the property and staff did the child
standing hold for 3 minutes then he calm down."

Review on 10/16/23 of the North Carolina Incident
Response Improvement System (IRIS) revealed:
-There was no level III incident report submitted
by the facility for an allegation of abuse against
staff #1 related to him assaulting client #1 on
10/8/23.

-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 10/17/23 with the Program Director
revealed:

-There was an incident with client #1 and staff #1
on 10/8/23.

-After the incident client #1 alleged staff #1
assaulted him.

-Client #1 alleged staff #1 "slammed him."
Division of Health Service Regulation

STATE FORM

809 SXMD11

(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

If continuation sheet 13 of 18

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL001-149 B. WING

NAME OF PROVIDER OR SUPPLIER
1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 11/02/2023
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
10/20/2023

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 366 | Continued From page 13 V 366

-"| didn't do a report in IRIS because there was no
restraint and [staff #1] didn't touch him."

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

Interview on 10/18/23 with the Director/Associate
Professional revealed

-She was aware of the incident with client #1 and
staff # on 10/8/23.

-Client #1 alleged "[staff #1] picked him up and
slammed him on the floor."

-"Most of the time [the Program Director] put
reports in IRIS, however he did not for that
incident."

-She didn't know why the Program Director failed
to put that incident into IRIS.

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

V 367| 27G .0604 Incident Reporting Requirements V 367
10A NCAC 27G .0604 INCIDENT
REPORTING REQUIREMENTS FOR
CATEGORY AAND B PROVIDERS

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

Division of Health Service Regulation

STATE FORM 6899

SXMD11

If continuation sheet 14 of 18

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL001-149 B. WING

NAME OF PROVIDER OR SUPPLIER
1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 11/02/2023
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
10/20/2023

means. The report shall include the following
information:

(1) reporting provider contact and
identification information;

(2) client identification information;

(3) type of incident;

(4) description of incident;

(5) status of the effort to determine the

cause of the incident; and

(6) other individuals or authorities notified
or responding.

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

(1) 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

Division of Health Service Regulation

STATE FORM 6899

SXMD11

(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 14 V 367

If continuation sheet 15 of 18

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL001-149 B. WING

NAME OF PROVIDER OR SUPPLIER
1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 11/02/2023
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
10/20/2023

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
the definition of a level II or level III incident;

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

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

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

This Rule is not met as evidenced by:

Based on record review and interviews, 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. The findings are:

Division of Health Service Regulation

STATE FORM 6899

SXMD11

(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 18

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

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL001-149 B. WING

NAME OF PROVIDER OR SUPPLIER
1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 11/02/2023
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
10/20/2023

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

ID
PREFIX
TAG

(X4) ID
PREFIX
TAG

CROSS-REFERENCED TO THE APPROPRIATE

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

(x5)
COMPLETE
DATE

DEFICIENCY)

V 367 | Continued From page 16 V 367

Refer to V-366 regarding implementing a policy
governing their response to Level III incidents.
-There was an allegation of physical abuse on
10/8/23 involving staff #1 and client #1.

-Review of the North Carolina Incident Reporting
Improvement System (IRIS) revealed the
Program Director and Program/Associate
Professional failed to report the above incidents
to the LME/MCO within 72 hours.

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

This Rule is not met as evidenced by:

Based on observation and interviews, the facility
and its grounds were not maintained in a safe,
clean, attractive and orderly manner. The findings
are:

Observation on 10/17/23 at approximately
10:15am revealed:

-Client #4's bedroom window had 3 missing
panes approximately 6 x 7 inches.

-The bathtub and shower had pea size brown
stains along the rim of the tub.

-The bathroom sink was clogged and had slow
drainage of water.

-4 broken slats on the window blinds in the dining
room area.

-3 broken slats on the window blinds in Client #2
and Client #3's bedroom.

-2 broken slats on the window blinds in the
bathroom.

Division of Health Service Regulation

STATE FORM 6899

SXMD11

If continuation sheet 17 of 18

Division of Health Service Regulation

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

(X2) MULTIPLE CONSTRUCTION

A. BUILDING:
MHL001-149 B. WING
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1710 SYKES STREET
JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

PRINTED: 11/02/2023
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
10/20/2023

-Microwave handle was missing.

-1 hole approximately 2 inches in diameter on the
wall in the staff sitting area.

-10 wooden panels were peeling away from the
kitchen walls.

- The front entrance storm door was misaligned
and scraped the concrete when door was
opened.

Interview on 10/20/23 with Client #4 revealed:
- "| broke it [bedroom window] about two weeks
ago, because | was mad."

Interviews on 10/17/23 and 10/20/23 with the
Program Director revealed:

-Client #4 broke his window about 2 weeks ago.
-"When everyone gets mad, they go for the
windows."

-He had not talked to the landlord regarding the
issues with the facility. The Director/Associate
Professional talked to landlord.

-They replaced the blinds "frequently," but the
clients broke them "often."

- "| do what | can."

Interview on 10/18/23 with the Director/Associate
Professional revealed:

-She was aware of maintenance issues with
facility.

-The Program Director and staff #2 were taking
care of some of those issues.

-She did not own the facility, she was renting it
from someone else.

-She talked to the landlord about the
maintenance issues, however he had not made
the repairs.

Division of Health Service Regulation

STATE FORM 6899

SXMD11

(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 17 V 736

If continuation sheet 18 of 18

inspection_type: MHLCS Annual, Complaint, and Follow-up

document_type: Statement of Deficiency


summary: Plan of Correction - MHLCS Complaint

inspection_type: MHLCS Complaint

document_type: Plan of Correction


summary: Statement of Deficiency - MHLCS Complaint

raw_content:
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHLO001-149

A. BUILDING:

1710 SYKES STREET
BURLINGTON, NC 27215

JUST IN TIME YOUTH SERVICES

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 05/19/2023

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

Cc
05/16/2023

(x4) ID
PREFIX
TAG

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

ID
PREFIX
TAG

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

DEFICIENCY)

(xs)
COMPLETE
DATE

V 000!

V 132|

INITIAL COMMENTS

Acomplaint survey was completed on May 16,
2023. The complaint (intake #NC00201409) and
(Intake #NC00201614) were unsubstantiated.
Deficiencies were cited.

This facility is licensed for the following service
category: 10A NCAC 27G. 1700

Residential Treatment Staff Secure for Children
or Adolescents

The facility is licensed for 4 and currently has a
census of 4.

The survey sample consisted of audits of 2
current clients, 1 former client.

G.S. 131E-256(G) HCPR-Notification,
Allegations, & Protection

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

(g) Health care facilities shall ensure that the
Department is notified of all allegations against
health care personnel, including injuries of
unknown source, which appear to be related to
any act listed in subdivision (a)(1) of this section.
(which includes:

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

c. Misappropriation of the property of a
healthcare facility.

d. Diversion of drugs belonging to a health care

Division of Health Service Regulation

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

STATE FORM

V 000

V 132

6899

GODC11

TITLE

(X6) DATE

If continuation sheet 1 of 6

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHLO001-149

PRINTED: 05/19/2023

1710 SYKES STREET
BURLINGTON, NC 27215

JUST IN TIME YOUTH SERVICES

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED
(X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
A. BUILDING: COMPLETED
Cc
05/16/2023

facility or to a patient or client.

e. Fraud against a health care facility or against
a patient or client for whom the employee is
providing services).

Facilities must have evidence that all alleged
acts are investigated and must make every effort
to protect residents from harm while the
investigation is in progress. The results of all
investigations must be reported to the
Department within five working days of the initial
notification to the Department.

This Rule is not met as evidenced by:

Based on record review and interview, the facility
failed to assure an allegation of abuse was
reported to the Health Care Personal Registry
(HCPR) nor did the facility initate a plan of
protection to protect clients while an investigation
was in progress. The finding is:

Record review and interviews on 5/2/23 - 5/16/23
revealed no allegations of abuse had been
reported to the HCPR.

Review on 5/2/23 of FC#1's record revealed:
-Age: 17.
-Admission date of 3/14/23.

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 132] Continued From page 1 V 132

Division of Health Service Regulation
STATE FORM

6809

GODC11

If continuation sheet 2 of 6

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHLO001-149

A. BUILDING:

1710 SYKES STREET
BURLINGTON, NC 27215

JUST IN TIME YOUTH SERVICES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/19/2023

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

Cc
05/16/2023

-Diagnoses of Conduct Disorder,
Childhood-Onset Type, Unspecified Trauma and
Stressor-related Disorder, Provisional Disruptive
Mood Dysregulation Disorder, High Risk Sexual
Behavior, Child Sexual Abuse, Suspected,
Subsequent Encounter and Parent-Child
Relational Problem.

-Involuntary Commitment 4/15/23.

-Discharged 4/15/23.

-FC#1 reported allegations to the Police on
4/22/23.

Review on 5/9/23 of the Police Report Narrative
dated 4/22/23 revealed:

-"On 4/22/23, at approximately 1933 (7:33 p.m.),
[Officer] responded to [County Hospital] for a
sexual assault case. [Officer] spoke with [FC#1]
who stated that he had been sexually and
physically assaulted at the Just in Time Youth
Services home. This interview took place at the
[County Hospital] behavioral health unit where
[FC#1] was committed. [FC#1] stated that a male
named [Staff #2] had approached [FC#1] when
he originally came to stay at the home. This
would have been around the end of March. [Staff
#2] came into [FC#1's] room to speak with him.
At the time, [FC#1] was in a room that had two
beds, but [FC#1] was the only staying in the
room. [FC#1] sat on the bed nearest to the back
of the room, toward a window. [Staff #2] sat on
the bed nearest to the bedroom door.

-[Staff #2] told [FC#1] a joke that he described as,
"inappropriate." [FC#1] stated that he did laugh
at the joke. [Staff #2] then bent over to tie his
shoe, stood up and sat down next to [FC#1] on
his bed. [Staff #2] then put his hand on [FC#1's]
thigh and asked [FC#1] if he was gay. [FC#1]
stated that he was bisexual but had not publicly
announced that information and did not feel
comfortable discussing it with [Staff #2]. [Staff

Division of Health Service Regulation

STATE FORM

6809

GODC11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 132] Continued From page 2 V 132

If continuation sheet 3 of 6

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHLO001-149

A. BUILDING:

1710 SYKES STREET
BURLINGTON, NC 27215

JUST IN TIME YOUTH SERVICES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/19/2023

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

Cc
05/16/2023

#2] told [FC#1] that he was gay. [FC#1] stated
that he froze, but eventually told [Staff #2] to stop.
-A couple of days after the incident, [Staff #2]
approached [FC#1] again in his room. [Staff #2]
began to take his hand and feel [FC#1's] thigh.
[FC#1] stated that he was wearing pants that had
a button on them, but that it did not actually
button. [Staff #2] tried unbuttoning his pants,
realized he did not need to, then slipped his hand
down [FC#1's] pants. [Staff #2] then began to
fondle [FC#1's] penis.

-[FC#1] could not give much detail about what
exactly had occurred. Whenever [FC#1] would
begin to discuss what happened, he would hide
his face and cry. [FC#1] stated that he had not
reported the incident to anyone because he did
not want to cause problems. [FC#1] stated that
he froze due to being previously raped.

-While disclosing this information to [Officer],
[FC#1] began to discuss a separate incident in
which another employee [Staff #1] had physically
assaulted him. [FC#1] stated the incident
happened a day before he had been committed
to the hospital 4/14/23. [Staff #1] told [FC#1] that
he was going to search his room for something.
[Staff #1] then grabbed [FC#1] while he was on
his bed and put his forearm on [FC#1's] neck.
[Staff #1] then picked [FC#1] up and threw him
onto the ground. [FC#1] stated that he hit part of
the bed so hard that the wood broke. [FC#1]
grabbed a nearby desk leg and was going to pick
it up and use it against [Staff #1] but [Staff #1]
grabbed [FC#1] and punched him in the eye. At
one point, [Staff #1] punched [FC#1] in the arm.
[Staff #1] told [FC#1] that he hit him because
[FC#1] was going to hit him first. [FC#1] stated
that this incident led [FC#1] to run away and that
he had seen, [FC#1] assault other kids as well.
[FC#!] could not recall the name of the other
victim. [FC#1] was able to provide much more

Division of Health Service Regulation

STATE FORM

6809

GODC11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 132] Continued From page 3 V 132

If continuation sheet 4 of 6

Division of Health Service Regulation

PRINTED: 05/19/2023

FORM APPROVED

detail about this assault than he was about the
sexual assault.

-[FC#1] stated that he had been punched in the
right eye. [Officer] could not see any obvious
injuries to [FC#1's] eye. [FC#1] also had bruises
to his left arm. One bruise was closer to his
shoulder and other closer to his bicep. [FC#1]
stated that he had frequently reported physical
abuse to his mother but had only just told her
today about the sexual abuse.

-[Officer] checked with medical personnel to see
if [FC#1] had entered the hospital with injuries.
None of [FC#1's] records noted any obvious
injuries upon his arrival. [FC#1] did have a history
of self-harm."

"Interview with [FC#1's] mother:

-[Officer] spoke with [FC#1's] mother, over the
phone. [FC#1's] mother stated that [FC#1] had
called her approximately 20 times that day.
[FC#1's] mother suspected that [FC#1] was upset
because it was [FC#1's] grandmother's birthday
and she was getting a lot of attention. [FC#1's]
mother stated that [FC#1] would make up stories
to make himself the center of attention. The final
time [FC#1] called [FC#1's] mother, [FC#1]
disclosed that he had been sexually assaulted.
-[FC#1's] mother stated that [FC#1] had
described the suspect that had sexually assaulted
him as an 18-year-old boy who lived in the group
home. [FC#1] stated that this suspect was not an
employee, but also not a patient. [FC#1] had
given [FC#1's] mother a name of the suspect, but
she could not remember it.

-[FC#1's] mother stated that she was not sure
whether the sexual assault allegations were true,
but she thought that the physical assault
allegations were. [FC#1] had run away from the
group home and stated that, the reason why
[FC#1] had, was because of the physical abuse.

Division of Health Service Regulation

STATE FORM

809 GODC11

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL001-149 05/16/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1710 SYKES STREET
JUST IN TIME YOUTH SERVICES
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 132] Continued From page 4 V 132

If continuation sheet 5 of 6

Division of Health Service Regulation

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

MHLO001-149

NAME OF PROVIDER OR SUPPLIER

A. BUILDING:

1710 SYKES STREET
BURLINGTON, NC 27215

JUST IN TIME YOUTH SERVICES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/19/2023

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

Cc
05/16/2023

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 132] Continued From page 5 V 132

[FC#1's] mother stated that [FC#1] wanted to be
able to live with her at home but due to [FC#1's]
mental health issues and past homicidal
attempts, [FC#1] was not allowed to.

-[Officer] explained to [FC#1's] mother that there
would be an investigation into [FC#1's] allegation.
[FC#1's] mother had not seen [FC#1] since
[FC#1] had been taken to the hospital, so she
could not say whether [FC#1] had arrived with
injuries.

- ...[Officers] responded to [County Hospital] to
take pictures of [FC#1's] injuries. [Officer]
contact CPS and made a report about the
incident."

Interview on 5/2/23 with the Director/Associate
Professional and Program Director revealed:
-They learned of the allegation on 4/16/23 when
the county social worker arrived at the home.
-The social worker did not provide details of the
allegations.

-They also learned FC#1 reported an allegation
while at the hospital.

-In the future they would conduct an internal
investigation and report all allegations of abuse to
HCPR.

-They would submit a report to HCPR and/or call
about this allegation.

Division of Health Service Regulation
STATE FORM

6809

GODC11

If continuation sheet 6 of 6


raw_content:
PRINTED: 01/27/2023

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
Cc
MHL001-149 B. WING 01/26/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES 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 000} INITIAL COMMENTS V 000

Acomplaint survey was completed on January
26, 2023. The complaint was substantiated
(intake #NC0019626). No deficiencies were cited.

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

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

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

STATE FORM 6899 PFIT11 If continuation sheet 1 of 1


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

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 11/04/2022
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
R
MHLO001-149 10/13/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1710 SYKES STREET
JUST IN TIME YOUTH SERVICES
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 000) INITIAL COMMENTS Vv 000

An annual and follow-up survey was completed
on October 13, 2022. No deficiencies were cited.

This facility is licensed for the following service
category: 10A NCAC 27G. 1700

Residential Treatment Staff Secure for Children
or Adolescents

The facility is licensed for 4 and currently has a
census of 4.

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

P39411

TITLE (X6) DATE

If continuation sheet 1 of 1

inspection_type: MHLCS Annual and Follow-up


summary: Plan of Correction - MHLCS Follow-up

raw_content:
Division of Health Service Regulation

PRINTED: 05/02/2022
FORM APPROVED

STATEMENT OF DEFICIENCIES AND

PLAN OF CORRECTION IDENTIFICATION NUMBER:

MHL001-149
NAME OF PROVIDER OR SUPPLIER

JUST IN TIME YOUTH SERVICES

(X1) PROVIDER/SUPPLIER/CLIA} (X2) MULTIPLE CONSTRUCTION
A. BUILDING:

STREET ADDRESS, CITY, STATE, ZIP CODE
1710 SYKES STREET

BURLINGTON, NC 27215

(X3) DATE SURVEY
COMPLETED

R
03/04/2022

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID

PROVIDER'S PLAN OF CORRECTION (x5)

INITIAL COMMENTS

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) V 000

A follow up survey was completed on the March
4, 2022. Deficiencies were cited.

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

The facility is licensed for 4 beds and currently
has a census of 3. The survey sample consisted
of audits of 2 current clients.

V 293 V 293

27G .1701 Residential Tx. Child/Adol - Scope

10A NCAC 27G .1701 SCOPE

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

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

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

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

(2) treatment in a staff secure setting.(e)
Services shall be designed to:

RECEIVED

By

cvhicks at 3:45 pm, May 25, 2022

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

TITLE (X6) DATE

Division of Health Service Regulation

PRINTED: 05/02/2022

FORM

APPROVED

STATE FORM 6899 J9BU11 If continuation sheet 1 of 3
STATEMENT OF DEFICIENCIES AND | (x1) PROVIDER/SUPPLIERICLIA | (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
R
MHL001-149 B. WING 03/04/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES

BURLINGTON, NC 27215

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

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

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

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

This Rule is not met as evidenced by: Based
on record review and interviews, the facility
failed to coordinate care with other
individuals and agencies within the client's
system of care, affecting 2 of 3 audited
clients (Client # and Client #3). The findings
are:

Review on 3/4/22 of Client #1 record revealed:
-Admission date of 1/19/21.

-Diagnosis of Disruptive Mood Dysregulation
Disorder, Mild Intellectual Disability Disorder,
Autism Spectrum Disorder, Attention Deficit

Hyperactivity Disorder- Combined Type and Post

Group Home meet with therapist to
establish a time schedule for therapy that
will allow the group home to hold clients
therapy sessions within the home to
eliminate the agency intermixing of clients
from different levels of care during therapy
sessions.

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 293) Continued From page 1 V 293

PRINTED: 05/02/2022
FORM APPROVED
Division of Health Service Regulation
Division of Health Service Regulation
STATE FORM 6899 J9BU11 If continuation sheet 2 of 3

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

R
03/04/2022

MHL001-149

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1710 SYKES STREET

JUST IN TIME YOUTH SERVICES

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 293) Continued From page 2 V 293
Traumatic Stress Disorder- With Deployed
Expression.

Review on 3/4/22 of Client #2 record revealed:
-Admission date of 11-18/21.

-Diagnosis of Generalized Anxiety Disorder,
Attention Deficit Hyperactivity Disorder-
Combined Presentation and Intermittent
Explosive Disorder.

Interview on 3/4/22 with the Home Manager
revealed:

-Client #1 and Client#2 received weekly therapy
services virtually.

-Therapy sessions were held at another group
home location.

-The sessions were held in a confidential location
to allow privacy for clients.

Interview on 2/25/22 with the Director revealed: -
The therapy sessions were held virtually on the
computer.

-Clients had therapy sessions at the home
weekly.

-Since the homes engage in social activities
together, thought it was OK they had therapy
sessions at same home as long as staff was
present with clients.

-Confirmed that facility failed to coordinate care
within the client's system of care.

inspection_type: MHLCS Follow-up


summary: Statement of Deficiency - MHLCS Follow-up

raw_content:
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

MHL001-149

A. BUILDING:

B. WING

STREET ADDRESS, CITY, STATE, ZIP CODE

1710 SYKES STREET

JUST IN TIME YOUTH SERVICES BURLINGTON, NC 27215

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/02/2022
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

R
03/04/2022

(X4) ID
PREFIX
TAG

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

ID
PREFIX
TAG

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

(x5)
COMPLETE
DATE

V 000

V 293

INITIAL COMMENTS

A follow up survey was completed on the March
4, 2022. Deficiencies were cited.

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

The facility is licensed for 4 beds and currently
has a census of 3. The survey sample consisted
of audits of 2 current clients.

27G .1701 Residential Tx. Child/Adol - Scope

10A NCAC 27G .1701 SCOPE

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

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

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

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

(2) treatment in a staff secure setting.

(e) Services shall be designed to:

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

STATE FORM

V 000

V 293

6899

J9BU11

TITLE (X6) DATE

If continuation sheet 1 of 3

PRINTED: 05/02/2022

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
MHL001-149 B. WING 03/04/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1710 SYKES STREET
JUST IN TIME YOUTH SERVICES
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 293] Continued From page 1 V 293

(1) include individualized supervision and

structure of daily living;

(2) minimize the occurrence of behaviors

related to functional deficits;

(3) ensure safety and deescalate out of

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

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

This Rule is not met as evidenced by:

Based on record review and interviews, the
facility failed to coordinate care with other
individuals and agencies within the client's
system of care, affecting 2 of 3 audited clients
(Client # and Client #3). The findings are:

Review on 3/4/22 of Client #1 record revealed:
-Admission date of 1/19/21.

-Diagnosis of Disruptive Mood Dysregulation
Disorder, Mild Intellectual Disability Disorder,
Autism Spectrum Disorder, Attention Deficit
Hyperactivity Disorder- Combined Type and Post
Division of Health Service Regulation

STATE FORM 6899 J9BU11 If continuation sheet 2 of 3

PRINTED: 05/02/2022

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
MHL001-149 B. WING 03/04/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1710 SYKES STREET
JUST IN TIME YOUTH SERVICES
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 293] Continued From page 2 V 293

Traumatic Stress Disorder- With Deployed
Expression.

Review on 3/4/22 of Client #2 record revealed:
-Admission date of 11-18/21.

-Diagnosis of Generalized Anxiety Disorder,
Attention Deficit Hyperactivity Disorder-
Combined Presentation and Intermittent
Explosive Disorder.

Interview on 3/4/22 with the Home Manager
revealed:

-Client #1 and Client#2 received weekly therapy
services virtually.

-Therapy sessions were held at another group
home location.

-The sessions were held in a confidential location
to allow privacy for clients.

Interview on 2/25/22 with the Director revealed:
-The therapy sessions were held virtually on the
computer.

-Clients had therapy sessions at the home
weekly.

-Since the homes engage in social activities
together, thought it was OK they had therapy
sessions at same home as long as staff was
present with clients.

-Confirmed that facility failed to coordinate care
within the client's system of care.

Division of Health Service Regulation
STATE FORM 6899 J9BU11 If continuation sheet 3 of 3