facility_name: Happiness Within

raw_content:
PRINTED: 07/02/2025

FORM APPROVED.
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (Xt) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X8) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER COMPLETED

A. BUILDING

B. WING

06/26/2025

MHL013-235

STREET ADDRESS, CITY, STATE, ZIP CODE
711 SYLVAN STREET SW
CONCORD, NC 28025

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (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)

NAME OF PROVIDER OR SUPPLIER

HAPPINESS WITHIN

V 000 INITIAL COMMENTS v 000

An annual and complaint survey was completed
on 6/26/25. The complaint was substantiated |
(intake #NC00231060). 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 has a current
census of 3. The survey sample consisted of
audits of 2 current clients and 1 former clients.

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

10A NCAC 27G .0209 MEDICATION

REQUIREMENTS

(c) Medication administration:

(1) Prescription or non-prescription drugs shall

only be administered to 2 client on the written

order of a person authorized by law to prescribe

drugs. |

(2) Medications shall be self-administered by |

clients only when authorized in writing by the

client's physician |

(3) Medications, including injections, shall be

administered only by licensed persons, or by

unlicensed persons trained by a registered nurse,

pharmacist or other legally qualified person and

privileged to prepare and administer medications.

(4) A Medication Administration Record (MAR) of

all drugs administered to each client must be kept | RECEIVED
current. Medications administered shall be =

recorded immediately after administration. The

MAR is to include the following: Jur § 2025
(A) client's name;

(B) name, strength, and quantity of the drug; DHSR.444 Licensure Sect
(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 TITLE (X6) DATE

STATE FORM 6888 5CM511 Ifcontinuaton sheet 1 of 15

Tu a

Division of Health Service R

‘STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

HAPPINESS WITHIN

equiation
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER

MHLO013-235

(X2) MULTIPLE CONSTRUCTION

ABULDING

PRINTED: 07/02/2025
FORM APPROVED

STREET ADDRESS, CITY, STATE, ZIP CODE

711 SYLVAN STREET SW

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

V 418 Continued From page 1

(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 observations, record review and
interviews, the facility failed to ensure the MAR
was kept current affecting 1 of 2 current clients
(client #2). The findings are

Review on 0/24/25 and 6/26/25 of Client #2's
record revealed:

- Admission date 6/17/24;

- Diagnoses Disruptive Mood Dysregulation
Disorder, Bipolar Affective Disorder,

Intermittent Explosive Disorder;

- Physician's order dated 6/1 0/25 Cetirizine
(Zyrtec) 10 milligram (mg), Take 1 tablet daily:

- Discontinued Physician order dated 6/10/25 for
Cetirizine 10mg.

Observations on 6/23/25 of Client 2's medication
revealed:
- Cetirizine 10mg was unavailable.

Review on 6/23/25 of Client #2's MAR from April
1, 2025-June 23, 2025 revealed:

- Cetirizine 10mg not listed on the MAR from May

44, 2025-June 23, 2025.

Interview on 6/26/25 with Client #2 revealed

Division of Health Service Regulation

CONCORD, NC 28025

5CM511

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

‘Rule 10A NCAC 27G .0209 MEDICATION
|REQUIREMENTS (V118)

Corrective Action:

|

All MARs were immediately reviewed for
completeness and accuracy Missing entries
were corrected based on verified physician
orders and pharmacy records

‘The physician was contacted and issued a
‘discontinuation order for cetirizine to ensure
|clarity in documentation moving forward.
|All staff responsible for medication
\administration have completed retraining on
'PRN documentation, transcribing physician
orders, and MAR updates by August 10th,
2025

Preventive Measures:

Anew medication verification checklist must
now be completed within 24 hours of receiving
‘a new prescription to ensure timely entry into
the MAR.

‘The Executive Director must verify all MAR
‘entries match physician orders during weekly
audits. Direct care staff will receive monthly
‘refresher training on medication
documentation standards.

|Monitoring

|The Executive Director will conduct weekly
MAR audits and review all new prescriptions
received.

A medication tracking log will be maintained to
ensure all medications administered are also
reflected on the MAR.

(x3) DATE SURVEY
COMPLETED

06/26/2025

If continuation sheet 2 of 15

PRINTED: 07/02/2025
FORM APPROVED

Division of Health Service Regulation

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

(X2] MULTIPLE CONSTRUCTION
A BUILDING

(X3) DATE SURVEY
COMPLETED

B WING

MHL013-235 06/26/2025

STREET ADDRESS, CITY, STATE, ZIP CODE
741 SYLVAN STREET SW
CONCORD, NC 28025

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (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)

NAME OF PROVIDER OR SUPPLIER

HAPPINESS WITHIN

V118 Continued From page 2 Frequency:

|MAR audits: Weekly
- Was administered medications daily; Training refreshers: Monthly
- Remembered going to the doctor due to a flare | Verification of new medications: Within 24
up with allergies and receiving medications but hours of physician order
did not remember any details about the
medication. Responsible Party.

Qualified Professional, Executive Director

Interview on 6/26/25 with Staff #1 revealed

- Had no recollection of taking Client #2 to the
doctor, administering the cetirizine 10mg, and
writing iton the PRN Medication/Medication Flow
Sheet on 5/10/25.

Interview on 6/25/25 with the Executive Director
revealed: |
- Was responsible for the MARs, along with the

Qualified Professional and Program Director;

- Was unable to provide details about Client #2's |
Physician order dated 5/10/25 for cetirizine 10mg;
- There was no explanation for why the cetirizine
was not listed on the MAR.

V 293 27G .1701 Residential Tx. Child/Adol - Scope V 293

10A NCAC 27G .1701 SCOPE

(a) Aresidential treatment staff secure facility for

children or adolescents is one that is a

free-standing residential facility that provides |
intensive, active therapeutic treatment and |
interventions within a system of care approach. It
shall not be the primary residence of an individual
who is not a client of the facility.

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

(c) The population served shall be children or
adolescents who have a primary diagnosis of
mental illness, emotional disturbance or
substance-related disorders; and may also have

Division of Health Service Regulation
STATE FORM fee 5CM511 If continuation sheet 3 of 15

PRINTED: 07/02/2025
FORM APPROVED

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (%1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER COMPLETED
A. BUILDING:
MHL043-235 8. WING 06/26/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

711 SYLVAN STREET SW

PINE: WIT
HAPPINESS WITHIN CONCORD, NC 28025

(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 3 Vv 293 |

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 toa
community-based residential setting in order to
facilitate treatment; and

(2) treatment in a staff secure setting.

(e) Services shall be designed to:

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

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

(3) ensure safety and deescalate out of

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 reviews and interviews the

Division of Health Service Regulation
STATE FORM 6539 5CM511 If continuation sheet 4 of 15

PRINTED: 07/02/2025
FORM APPROVED

Division of Health Service Regulation

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

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A BUILDING

BEING, 06/26/2025

MHL013-235

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

711 SYLVAN STREET SW

f}
HAPPINESS: WITHIN CONCORD, NC 28025

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION
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 283 Continued From page 4 Vv 293 Deficiency #2: 10A NCAC 27G .1701 — Scope
(V293)
family failed to provide the necessary level of ( )
supervision affecting 1 current client (Client #1) Corrective Action
and 1 Former Client (FC) (FC #3). The findings
are: | Immediate staff retraining has been implemented

to emphasize active supervision techniques,

| especially during community outings and in
unsupervised or semi-private settings like jacuzzis
or locker rooms.

Review on 6/24/25 of Client #1's record revealed:
- Admission date 7/19/24;

- Age 17: 7 | All involved staff (Staff #1, Staff #2, QP) will

~ Diagnoses Post traumatic Stress Disorder, complete training on trauma-informed observation,

Major Depressive Disorder, Recurrent Episode, | peer dynamic risk assessment, and YMCA-

Oppositional Defiant Disorder, Conduct Disorder, | specific supervision procedures by August 10th,

Generalized Anxiety Disorder, Personal History of | 2025

Neglect in Childhood, Personal History, Past A post-outing debriefing protocol is now

History in Physical Abuse on Childhood, Personal | mandatory alow Senta aoe
iscomfort, or peer-related incidents.

History of Self. Harm Staff have been reminded and retrained on the

policy that requires constant visual supervision

Review on 6/24/25 of Former Client #3's record | when clients are in water or other enclosed group

revealed settings.
- Admission date 4/4/25; Preventive Measures:
- Age 16;

Peer interaction risk assessments will be

- Diagnoses Major Depressive Disorder, Single
incorporated into daily shift planning and outing

Episode, Severe Without Psychotic Features.

approvals
. “ Increased staffing ratios will be required for
Review: on Gf24/26 of the facility's Internal | outings involving potential high-risk pairings or
Investigation Report revealed locations with limited visibility
- Incident Summary- "On May 27, 2025, Client | Outing request forms must now include a risk level
[Client #1] disclosed to staff that she was sexually | indicator and an identified lead supervisor for
assaulted by a peer, Client [FC #3], during a behavioral monitoring.

Clinical staff will provide ongoing support plans for
Client #1 and conduct weekly check-ins for at
least 60 days post-incident.

Monitoring:

supervised group outing to the YMCA on May 23,
2025. The incident allegedly occurred in the
jacuzzi where the accused client digitally
penetrated [Client #1] without her consent. The
disclosure was made four days after the incident

The Program Director will conduct monthly audits

due to the victim's fear and confusion." of community outing logs, staffing rosters, and
- Disclosure and Response- "On May 27, 2025, debriefing forms.

[Client #1] pulled a staff member aside and | Supervisors will conduct random shadowing
reported the incident. She stated she was afraid during outings to ensure proper supervision is

to disclose the assault sooner due to fear of the being implemented.

other client and uncertainty about what to do. She
described the situation as initially appearing

Division of Health Service Regulation
STATE FORM oe 5CMS511 if continuation sheet 5 of 15

Division of Health Service Regulation

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

MHL013-235

(X2) MULTIPLE CONSTRUCTION
A BUILDING

B. WING

PRINTED: 07/02/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

06/26/2025

NAME OF PROVIDER OR SUPPLIER

HAPPINESS WITHIN

V 293 Continued From page 5 V 293

playful to others, which added to her hesitation to
speak up. She noted that the accused stopped
the act when blood was observed. The group
home took immediate action to ensure [Client
#1)'s safety, including arranging medical care and
notifying her DSS (Department of Social
Services) guardian."

- Staff Actions and Supervision Review- "Staff
(Staff #1, Staff #2, Qualified Professional) on duty
during the outing reported no visible signs of
distress from either party at the time of the
incident. Clients were observed interacting in
what appeared to be a playful manner.
Supervision protocols were followed based on
Current policy, though closer attention to peer
dynamics is now being emphasized as part of
corrective action."

- Corrective and Preventive Measures-
“Reinforcement of supervision strategies during
outings, including closer observation of peer
interactions. Staff retraining on identifying subtle
signs of distress and how to initiate check-ins.
Mandatory post-outing debriefing with clients to
encourage open communication
Trauma-informed care practices reinforced
among all staff. Review of outing approval
protocols and staffing ratios for high-risk
environments. Continued clinical support and
safety planning for [Client #1].

Collaboration with DSS and law enforcement to
ensure due process and accountability.”

Interview on 6/26/25 with Client #1 revealed:

- Was dating FC #3;

- Was physically assaulted by FC #3 while in the
hot tub at the local YMCA;

- Denied

- Staff was unable to see "but not that good" what
was going on in the hot tub due to a chair and the
bubbles in the hot tub.

(xa) 10 SUMMARY STATEMENT OF DEFICIENCIES io
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG

STREET ADDRESS, CITY, STATE, ZIP CODE
711 SYLVAN STREET SW
CONCORD, NC 28025

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

DEFICIENCY)

Frequency

Staff retraining: Completed and reviewed
quarterly

Outing audits: Monthly

Client-specific supervision plans: Reviewed
weekly

Peer risk assessments: Conducted per outing
Responsible Party:

Program Director, Qualified Professional, and
Clinical Supervisor

a

Division of Health Service Regulation
STATE FORM 6038

5CM511 If continuation sheet 6 of 18

Division of Health Service Regulation

STATEMENT O}
AND PLAN OF

NAME OF PROVIDER OR SUPPLIER

HAPPINESS WITHIN

PRINTED: 07/02/2025
FORM APPROVED

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER

MHLO013-235

(X2) MULTIPLE CONSTRUCTION ({X3) DATE SURVEY
A BUILDING COMPLETED
B WING ££ 06/26/2025

(x4) ID
PREFIX
TAG

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

V 293

Continued From page 6

Interview on 6/23/25 with FC #3 revealed:

- Was in an on and off relationship with Client #1;
- Fought Client #1 two times;

- Client #1 touched her thigh

Interview on 6/23/25 with the Legal Guardian/
Department of Social Services Social Worker for
FC #3 revealed:

- FC #3 and Client #1 were dating;

- Was told by FC #3 that Client #1 “wanted her to
do it (penetrate her)" while in the hot tub:

- FC #3 confessed that she did "penetrate" Client
#1

Interview on 6/25/25 with Staff #1 revealed

- Was at the local YMCA with the clients the first
half of the visit and Staff #2 relieved me when
shift was over;

- Was not in the water while supervising the
clients in the jacuzzi;

- No knowledge of Client #1 and FC #3 being in a
relationship;

- No knowledge of sexualized behaviors for Client
#1 and FC #2.

Interview on 6/25/25 with Staff #2 revealed:

- Gave Client #1 and FC #3 a high five while in
the jacuzzi at the start of shift on 5/23/25;

- Denied seeing Client #1 and FC #3 touching
each other while in the jacuzzi;

- No knowledge of Client #1 and FC #3 being in a
relationship;

- Unaware of any sexualized behaviors for Client
#1 and FC #3

Interview on 6/26/25 with the Qualified
Professional revealed:

- Client #1 and FC #3 was asked by the guard at
the YMCA to come around from the slide to be in

STREET ADDRESS, CITY, STATE, ZIP CODE
711 SYLVAN STREET SW
CONCORD, NC 28025

Division of Health Service Regulation

STATE FORM

iD PROVIDER'S PLAN OF CORRECTION ox)
PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 293
|
ae 5CM511 If continuation sheet 7 of 15

(X4) 1D
PREFIX
TAG

V 293

V 294

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

HAPPINESS WITHIN

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER

A BUILDING

B. WING

MHL013-235

711 SYLVAN STREET SW
CONCORD, NC 28025
SUMMARY STATEMENT OF DEFICIENCIES ID

(EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX
REGULATORY OR LSC IDENTIFYING INFORMATION) TAG

Continued From page 7

line of sight;

- Client #1 and FC #3 then went to sit in the
jacuzzi and turned on the bubbles for the jacuzzi;
- Talked with Client #1 at times while she was in
the jacuzzi;

- There was no change in Client #1's demeanor
or mood;

- Don't get in the water with the clients;

- "We have put a pause on going to the pool."

- Clients now have secret gestures to show staff
they need help |

Interview on 6/26/25 with the Executive Director

revealed

- Learned of the incident between Client #1 and

FC #3 on 5/27/25 after FC #3 was no longer in |
the facility;

- Completed an internal investigation of the

allegations that FC #3 penetrated Client #1;

- Retrained staff on the protocol on supervision of

clients while on outings.

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 07/02/2025
FORM APPROVED.

(X3) DATE SURVEY
COMPLETED

06/26/2025

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

8)
COMPLETE
DATE

Division of Health Service Regulation

STATE FORM

27G .1702 Residential Tx. Child/Adol -Reg. for Q V 294
P
10A NCAC 27G .1702 REQUIREMENTS OF
QUALIFIED PROFESSIONALS
(a) Each facility shall utilize at least one direct
care staff who meets the requirements of a |
qualified professional as set forth in 10A NCAC
27G .0104(18). In addition, this qualified
professional shall have two years of direct client
care experience.
(b) For each facility of five or less beds:
(1) the qualified professional specified in
Paragraph (a) of this Rule shall perform clinical
and administrative responsibilities a minimum of
10 hours each week; and
(2) 70% of the time shall occur when
809

5CM511

If continuation sheet 8 of 15

PRINTED: 07/02/2025
FORM APPROVED

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER 72 BOLBING COMPLETED

MHL013-235 B. WING _£________. 06/26/2025

STREET ADDRESS, CITY, STATE, ZIP CODE
711 SYLVAN STREET SW
CONCORD, NC 28025

NAME OF PROVIDER OR SUPPLIER

HAPPINESS WITHIN

(Xa) 10 SUMMARY STATEMENT OF DEFICIENCIES iD PROVIDER'S PLAN OF CORRECTION (x8)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

V 294 Continued From page 8 Vv 294

children or adolescents are awake and present in
the facility.

(c) For each facility of six or more beds

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

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

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

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

(2) oversight of emergencies;

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

(4) participation in treatment planning
meetings;

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

(6) provision of basic case management |
functions.

This Rule is not met as evidenced by

Based on interview and record review the person
identified as the facility's Qualified Professional
(QP) failed to meet the requirements of a
Qualified Professional. The findings are

Division of Health Service Regulation
STATE FORM oe 5CM511 feontinuation sheet 9 of 15

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDE R/SUPPLIERICLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER

A. BUILDING

MHL013-235 Bs MING

HAPPINESS WITHIN CONCORD, NC 28025

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

(X2) MULTIPLE CONSTRUCTION

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

711 SYLVAN STREET SW

PRINTED: 07/02/2025
FORM APPROVED

(X3] DATE SURVEY
COMPLETED

06/26/2025

PROVIDER'S PLAN OF CORRECTION (xs)

(EACH CORRECTIVE ACTION SHOULD BE COMPLETE
CROSS-REFERENCED TO THE APPROPRIATE DaTE
DEFICIENCY)

V 294 Continued From page 9 Vv 294

Review on 6/24/25 of the Qualified Professional's
personne! record revealed:

- Hire date 11/15/23;

- Job title Qualified Professional

- Bachelor's Degree in Food Management 2013;
- Resume documented experience in food
services, no experience with the Mental
Health/Developmental Disability/Substance
Abuse (MH/DD/SA) population.

Interview on 6/24/25 and 6/26/25 with the
Qualified Professional revealed:

- No prior experience in human services before
employment;

- Duties included the day to day schedule for the
clients, checked the MARs (Medication
Administration Record), checked progress notes,
held group sessions with clients;

- Trained by the Executive Director and Program
Director.

Interview on 6/24/25 and 6/26/25 with the
Executive Director revealed:
- Unaware the QP did not meet the requirements

to be a QP;
- "She (QP) does everything so well and is on top
of it."
V 285 27G .1703 Residential Tx. Child/Adol - Req. forA Vv 295
Pp

10A NCAC 27G .1703 REQUIREMENTS FOR
ASSOCIATE PROFESSIONALS

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

Division of Health Service Regulation
STATE FORM —

a

| Deficiency #3: 10A NCAC 27G .1702 -
Requirements of Qualified Professionals
(v294)

Corrective Action:
The unqualified QP has been removed from

| their position. A qualified QP will be hired and
verified with documentation on file by August
10th, 2025. HR will implement a credential
tracking system for all roles
Preventive Measures:
The credential tracking system will be
reviewed monthly to ensure ali professional
staff meet state standards
Monitoring:
Program Director or HR Manager will review

| credentials during onboarding and maintain
monthly compliance checks.

| Frequency:

| Credential reviews at hire and monthly
thereafter.

| Responsible Party:Executive Directorn and

| Human Resources

5CM511 if continuation sheet 10 of 15

PRINTED: 07/02/2025
FORM APPROVED.

Division of Health Service Regulation

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

(3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A BUILDING:

B. WING

06/26/2025

MHL013-235

STREET ADDRESS, CITY, STATE, ZIP CODE
741 SYLVAN STREET SW
CONCORD, NC 28025

NAME OF PROVIDER OR SUPPLIER

HAPPINESS WITHIN

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x8)
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)

Deficiency #4: 10A NCAC 27G .1703 -—
Requirements for Associate Professionals
(b) The governing body responsible for each |(V295)

facility shall develop and implement written Corrective Action:

policies that specify the responsibilities of its
associate professional(s). Ata minimum these
policies shall address the following:

Vv 295 Continued From page 10 V 295

The Associate Professional who was not
\consistently available has been formally

(1) management of the day to day | 4
day-to-day operations of the facility; separated from employment due to failure to
(2) supervision of paraprofessionals meet full-time work expectations. A recruitment

\process was initiated immediately following the
\citation, and a fully qualified Associate
|Professional will be hired by August 10th,

regarding responsibilities related to the
implementation of each child or adolescent's

treatment plan; and
2025, meeting the definition under 10A NCAC
(3) fl participation in service planning |27G .0104(1). Documentation of qualifications
meetings and full-time employment commitment is on
file.

|Preventive Measures

|All APs will now sign an agreement
acknowledging the requirement to work full-

This Rule is not met as evidenced by: time and maintain consistent attendance.
Based on record review and interviews, the Transportation stability and work availability will
facility failed to employ an Associate Professional be verified during the interview process. The
(AP) who provided services to the group home on hiring checklist has been updated to ensure all
a full time basis. The findings are: 'staffing requirements under 10A NCAC

27G 1703 are confirmed before employment
Review on 6/24/25 of the Associate Professional's |Monitoring:
personnel record revealed:
- Hire date 11/10/23; [The Program Director and HR Manager will
- Job title Associate Professional; jointly review AP attendance on a bi-weekly
- Bachelor's Degree in Psychology 2017 and basis.

Staff rosters will be audited monthly to ensure
at least one qualified Associate Professional is
actively working full-time.

Any AP absences longer than five consecutive
|days will be reviewed and documented with a

plan of coverage

Frequency:

Master's Degree in Psychology 2019

Interview on 6/26/25 with the Associate
Professional revealed:

- Had not worked at the facility since March due
to transportation issues.
Bi-weekly review of staffing schedules and AP

attendance
Monthly compliance audits of staffing
require fal

Interview on 6/26/25 with the Executive Director
*eABdiad: not worked in the facility in months;

~ AP completed some work assignments that did
Division of Health Service Regulation

STATE FORM - 5CM511 if continuation sheet 11 of 15

PRINTED: 07/02/2025
FORM APPROVED

Division of Health Service Regulation

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

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A BUILDING

B. WING

MHL013-235 06/26/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
711 SYLVAN STREET SW
CONCORD, NC 28025

HAPPINESS WITHIN

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES fr) 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)

Responsible Party:
Executive Directorn and Human

Resources Manager
|

295 Continued From page 11

not require her to be in the facility

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 II
incidents and level Il 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 shail include the following

information:

(1) reporting provider contact and |
identification information;

(2) client identification information;

(3) type of incident;

(4) description of incident;

(5) status of the effort to determine the

cause of the incident; and

(6) other individuals or authorities notified

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

(1) the provider has reason to believe that
information provided in the report may be
erroneous, misleading or otherwise unreliable; or

Division of Health Service Regulation
STATE. FORM = 5CM511 It continuation sheet 12 of 15

PRINTED: 07/02/2025
FORM APPROVED
Division of Health Service Regulation

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

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A BUILDING

B. WING

06/26/2025

MHL013-235

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
711 SYLVAN STREET SW
CONCORD, NC 28025

HAPPINESS WITHIN

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES. 1D 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 bare

DEFICIENCY)

V 367 Continued From page 12

(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 Ill 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 II
incidents involving a client death to the Division of
Health Service Regulation within 72 hours of
becoming aware of the incident. In cases of
client death within seven days of use of seclusion
or restraint, the provider shall report the death
immediately, as required by 10A NCAC 26C
-0300 and 10A NCAC 27E .0104(e)(18). |
(e) Category A and B providers shall send a

report quarterly to the LME responsible for the |
catchment area where services are provided

The report shall be submitted on a form provided

by the Secretary via electronic means and shall

include summary information as follows:

(1) medication errors that do not meet the

definition of a level Il or level III incident;

(2) restrictive interventions that do not meet

the definition of a level |! or level Ill 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 Ill

incidents that occurred; and
(6) a statement indicating that there have

Division of Health Service Regulation
STATE. FORM Laid 5SCM511 If continuation sheet 13 of 15

PRINTED: 07/02/2025
FORM APPROVED

Division of Health Service Regulation

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

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A BUILDING

NG 06/26/2025

MHL013-235

STREET ADDRESS, CITY, STATE, ZIP CODE
711 SYLVAN STREET SW
CONCORD, NC 28025

NAME OF PROVIDER OR SUPPLIER

HAPPINESS WITHIN

V 367

STATE FORM

Continued From page 13

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 Rute 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 that incident reports were
submitted to the Local Management Entity
(LME)/Managed Care Organization (MCO)
responsible for the catchment areas where
services were provided within 72 hours of
becoming aware of the incident affecting 1 of 1
Former Client (FC) (FC #3). The findings are

Review on 6/24/25 of Former Client #3's record

Vv 367

(x4) 1D 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)

Deficiency #5: 10A NCAC 27G .0604 —
Incident Reporting Requirements (V367)
Corrective Action:
The facility will conduct a full review of its
incident reporting procedures and has identify
gaps in timely submission to the LME/MCO. All
staff responsible for incident documentation
and reporting will be retrained on the IRIS
reporting requirements, including the 72-hour
submission deadline for Category A and B
incidents. The training will completed by
August 10th, 2025.
Preventive Measures:
A revised Incident Reporting Protocol has
| been implemented, which includes a 24-hour
internal reporting window to supervisors and a
48-hour deadline for entry into IRIS to allow
sufficient time for review and accuracy. A
checklist is now used to track the date and
time an incident occurred, when it was
| discovered, and when it was submitted to IRIS.
Monitoring:
The QP or designee will maintain a monthly
incident log audit to ensure all incidents have
| been reported timely. Any late submissions will
be documented and reviewed during staff

revealed | supervision.
- Admission date 4/4/25;
- Age 16: Frequency:

- Diagnoses Major Depressive Disorder, Single
Episode, Severe Without Psychotic Features.

Review on 6/24/25 of the North Carolina Incident
Response Improvement System (IRIS) from April
1, 2025- June 23, 2025 revealed the following
incidents were not reported within the required
time:

- FC #3 went AWOL and made suicidal ideations
FC #3 was involuntary committed into the local
hospital on 5/12/25. The provider did not submit
report until 5/16/25 into IRIS.

- FC #3 broke a whiteboard and used it to inflict a

Division of Health Service Regulation

Internal incident review: Within 24 hours of
occurrence

IRIS submission: Within 48 hours of
| awareness
Audit of incident log: Monthly
Review in staff meetings: Monthly
Responsible Party:
Qualified Professional (QP) and Executive
Director

S5CM511

lf continuation sheet 14 of 15

PRINTED: 07/02/2025
FORM APPROVED

Division of Health Service Regulation

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

(X3) DATE SURVEY

(X2) MULTIPLE CONSTRUCTION
COMPLETED

A. BUILDING:

8. WING

MHLO13-235 06/26/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
711 SYLVAN STREET SW
CONCORD, NC 28025

(x4) 1D 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)

HAPPINESS WITHIN

Vv 367 Continued From page 14

laceration on herself and unintentionally injured

two staff members during their attempt to safely

disarm her.

FC #3 used profane language and made verbal

threats to access a locked

Cabinet to retrieve a knife and harm others in the

home. The client then exited

the home without permission and attempted to

retrieve the broken object

from the outdoor trash can, The provider did not

submit report until 5/18/25 into IRIS.

- FC #3 had self harm to previous wound along

with continuous suicidal ideations. FC #3 was |
transported to local hospital for evaluation on

6/13/25. The provider did not submit report until i
5/18/25 into IRIS.

- On 5/27/25, the provider learned FC #3

allegedly penetrated Client #1 while on an outing

at the local YMCA on 5/23/25. The provider did

not submit report until 6/1/25 into IRIS

Interview on 6/24/25 with the Executive Director
revealed:

- Completed incident reports in IRIS: |
- Aware the incident reports were being reported

after 72 hours of becoming aware of the incident

- Planned to start getting the incident reported

within the timeframe.

- Completed incident reports once learned of the

incident.

Division of Health Service Regulation
STATE FORM cave SCMS11 if continuation sheet 15 of 1


state: NC

summary: Statement of Deficiency - MHLCS Annual and Complaint

raw_content:
Division of Health Service Regulation

PRINTED: 07/02/2025
FORM APPROVED

10A NCAC 27G .0209 MEDICATION
REQUIREMENTS

(c) Medication administration:

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

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

(3) Medications, including injections, shall be
administered only by licensed persons, or by
unlicensed persons trained by a registered nurse,
pharmacist or other legally qualified person and
privileged to prepare and administer medications.
(4) A Medication Administration Record (MAR) of
all drugs administered to each client must be kept
current. Medications administered shall be
recorded immediately after administration. The
MAR is to include the following:

(A) client's name;

(B) name, strength, and quantity of the drug;
(C) instructions for administering the drug;

(D) date and time the drug is administered; and

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

STATE FORM

6808 5CM511

TITLE

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHLO013-235 06/26/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
711 SYLVAN STREET SW
HAPPINESS WITHIN
CONCORD, NC 28025
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000} INITIAL COMMENTS V 000
An annual and complaint survey was completed
on 6/26/25. The complaint was substantiated
(intake #NC00231060). 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 has a current
census of 3. The survey sample consisted of
audits of 2 current clients and 1 former clients.
V 118| 27G .0209 (C) Medication Requirements Vv 118

(X6) DATE

If continuation sheet 1 of 15

Division of Health Service Regulation

PRINTED: 07/02/2025

FORM APPROVED

(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 observations, record review and
interviews, the facility failed to ensure the MAR
was kept current affecting 1 of 2 current clients
(client #2). The findings are:

Review on 6/24/25 and 6/26/25 of Client #2's
record revealed:

- Admission date 6/17/24;

- Diagnoses Disruptive Mood Dysregulation
Disorder, Bipolar Affective Disorder,

Intermittent Explosive Disorder;

- Physician's order dated 5/10/25 Cetirizine
(Zyrtec) 10 milligram (mg), Take 1 tablet daily;

- Discontinued Physician order dated 6/10/25 for
Cetirizine 10mg.

Observations on 6/23/25 of Client 2's medication
revealed:
- Cetirizine 10mg was unavailable.

Review on 6/23/25 of Client #2's MAR from April
1, 2025-June 23, 2025 revealed:

- Cetirizine 10mg not listed on the MAR from May
11, 2025-June 23, 2025.

Interview on 6/26/25 with Client #2 revealed:

Division of Health Service Regulation
STATE FORM

6809

5CM511

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHLO013-235 06/26/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
711 SYLVAN STREET SW
HAPPINESS WITHIN
CONCORD, NC 28025
(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 1 Vv 118

If continuation sheet 2 of 15

Division of Health Service Regulation

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

MHLO013-235

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 07/02/2025

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

711 SYLVAN STREET SW
CONCORD,

HAPPINESS WITHIN

NC 28025

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

06/26/2025

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

ID
PREFIX
TAG

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

(xs)
COMPLETE
DATE

V 118] Continued From page 2

- Was administered medications daily;

- Remembered going to the doctor due to a flare
up with allergies and receiving medications but
did not remember any details about the
medication.

Interview on 6/26/25 with Staff #1 revealed:

- Had no recollection of taking Client #2 to the
doctor, administering the cetirizine 10mg, and
writing it on the PRN Medication/Medication Flow
Sheet on 5/10/25.

Interview on 6/25/25 with the Executive Director
revealed:

- Was responsible for the MARs, along with the
Qualified Professional and Program Director;

- Was unable to provide details about Client #2's
physician order dated 5/10/25 for cetirizine 10mg;
- There was no explanation for why the cetirizine
was not listed on the MAR.

V 293] 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

Division of Health Service Regulation
STATE FORM

V 118

V 293

6809

If continuation sheet 3 of 15

PRINTED: 07/02/2025

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
MHLO013-235 06/26/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
711 SYLVAN STREET SW
HAPPINESS WITHIN
CONCORD, NC 28025
(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

of care.

Division of Health Service Regulation
STATE FORM

V 293] Continued From page 3 V 293

co-occurring disorders including developmental
disabilities. These children or adolescents shall
not meet criteria for inpatient psychiatric services.
(d) The children or adolescents served shall
require the following:

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

(2) treatment in a staff secure setting.

(e) Services shall be designed to:

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

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

(3) ensure safety and deescalate out of

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

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

6808 5CM511

If continuation sheet 4 of 15

Division of Health Service Regulation

PRINTED: 07/02/2025
FORM APPROVED

family failed to provide the necessary level of
supervision affecting 1 current client (Client #1)
and 1 Former Client (FC) (FC #3). The findings
are:

Review on 6/24/25 of Client #1's record revealed:
- Admission date 7/19/24;

- Age 17;

- Diagnoses Post traumatic Stress Disorder,
Major Depressive Disorder, Recurrent Episode,
Oppositional Defiant Disorder, Conduct Disorder,
Generalized Anxiety Disorder, Personal History of
Neglect in Childhood, Personal History, Past
History in Physical Abuse on Childhood, Personal
History of Self Harm.

Review on 6/24/25 of Former Client #3's record
revealed:

- Admission date 4/4/25;

- Age 16;

- Diagnoses Major Depressive Disorder, Single
Episode, Severe Without Psychotic Features.

Review on 6/24/25 of the facility's Internal
Investigation Report revealed:

- Incident Summary- "On May 27, 2025, Client
[Client #1] disclosed to staff that she was sexually
assaulted by a peer, Client [FC #3], during a
supervised group outing to the YMCA on May 23,
2025. The incident allegedly occurred in the
jacuzzi where the accused client digitally
penetrated [Client #1] without her consent. The
disclosure was made four days after the incident
due to the victim's fear and confusion."

- Disclosure and Response- "On May 27, 2025,
[Client #1] pulled a staff member aside and
reported the incident. She stated she was afraid
to disclose the assault sooner due to fear of the
other client and uncertainty about what to do. She
described the situation as initially appearing

Division of Health Service Regulation

STATE FORM

6808 5CM511

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHLO013-235 06/26/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
711 SYLVAN STREET SW
HAPPINESS WITHIN
CONCORD, NC 28025
(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 4 V 293

If continuation sheet 5 of 15

Division of Health Service Regulation

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

MHLO013-235

NAME OF PROVIDER OR SUPPLIER

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

711 SYLVAN STREET SW

HAPPINESS WITHIN

PRINTED: 07/02/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

06/26/2025

CONCORD, NC 28025
(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 5 V 293

playful to others, which added to her hesitation to
speak up. She noted that the accused stopped
the act when blood was observed. The group
home took immediate action to ensure [Client
#1]'s safety, including arranging medical care and
notifying her DSS (Department of Social
Services) guardian."

- Staff Actions and Supervision Review- "Staff
(Staff #1, Staff #2, Qualified Professional) on duty
during the outing reported no visible signs of
distress from either party at the time of the
incident. Clients were observed interacting in
what appeared to be a playful manner.
Supervision protocols were followed based on
current policy, though closer attention to peer
dynamics is now being emphasized as part of
corrective action."

- Corrective and Preventive Measures-
"Reinforcement of supervision strategies during
outings, including closer observation of peer
interactions. Staff retraining on identifying subtle
signs of distress and how to initiate check-ins.
Mandatory post-outing debriefing with clients to
encourage open communication.
Trauma-informed care practices reinforced
among all staff. Review of outing approval
protocols and staffing ratios for high-risk
environments. Continued clinical support and
safety planning for [Client #1].

Collaboration with DSS and law enforcement to
ensure due process and accountability."

Interview on 6/26/25 with Client #1 revealed:

- Was dating FC #3;

- Was physically assaulted by FC #3 while in the
hot tub at the local YMCA;

- Denied

- Staff was unable to see "but not that good" what
was going on in the hot tub due to a chair and the
bubbles in the hot tub.

Division of Health Service Regulation
STATE FORM

6809

5CM511

If continuation sheet 6 of 15

Division of Health Service Regulation

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

NAME OF PROVIDER OR SUPPLIER

HAPPINESS WITHIN

MHLO013-235

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 07/02/2025

STREET ADDRESS, CITY, STATE, ZIP CODE
711 SYLVAN STREET SW

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

06/26/2025

Interview on 6/23/25 with FC #3 revealed:

- Was in an on and off relationship with Client #1;
- Fought Client #1 two times;

- Client #1 touched her thigh

Interview on 6/23/25 with the Legal Guardian/
Department of Social Services Social Worker for
FC #3 revealed:

- FC #3 and Client #1 were dating;

- Was told by FC #3 that Client #1 "wanted her to
do it (penetrate her)" while in the hot tub;

- FC #3 confessed that she did "penetrate" Client
#1.

Interview on 6/25/25 with Staff #1 revealed:

- Was at the local YMCA with the clients the first
half of the visit and Staff #2 relieved me when
shift was over;

- Was not in the water while supervising the
clients in the jacuzzi;

- No knowledge of Client #1 and FC #3 being ina
relationship;

- No knowledge of sexualized behaviors for Client
#1 and FC #2.

Interview on 6/25/25 with Staff #2 revealed:

- Gave Client #1 and FC #3 a high five while in
the jacuzzi at the start of shift on 5/23/25;

- Denied seeing Client #1 and FC #3 touching
each other while in the jacuzzi;

- No knowledge of Client #1 and FC #3 being ina
relationship;

- Unaware of any sexualized behaviors for Client
#1 and FC #3.

Interview on 6/26/25 with the Qualified
Professional revealed:
- Client #1 and FC #3 was asked by the guard at

the YMCA to come around from the slide to be in

Division of Health Service Regulation
STATE FORM

6809

CONCORD, NC 28025
(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 6 V 293

If

continuation sheet 7 of 15

Division of Health Service Regulation

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

MHLO013-235

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 07/02/2025

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

711 SYLVAN STREET SW
CONCORD,

HAPPINESS WITHIN

NC 28025

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

06/26/2025

(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 293] Continued From page 7

line of sight;

- Client #1 and FC #3 then went to sit in the
jacuzzi and turned on the bubbles for the jacuzzi;
- Talked with Client #1 at times while she was in
the jacuzzi;

- There was no change in Client #1's demeanor
or mood;

- Don't get in the water with the clients;

- "We have put a pause on going to the pool."

- Clients now have secret gestures to show staff
they need help.

Interview on 6/26/25 with the Executive Director
revealed:

- Learned of the incident between Client #1 and
FC #3 on 5/27/25 after FC #3 was no longer in
the facility;

- Completed an internal investigation of the
allegations that FC #3 penetrated Client #1;

- Retrained staff on the protocol on supervision of
clients while on outings.

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

10A NCAC 27G .1702 REQUIREMENTS OF
QUALIFIED PROFESSIONALS

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

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

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

(2) 70% of the time shall occur when

Division of Health Service Regulation
STATE FORM

V 293

V 294

6809

If continuation sheet 8 of 15

Division of Health Service Regulation

HAPPINESS WITHIN

NAME OF PROVIDER OR SUPPLIER

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

A. BUILDING:

MHLO013-235

711 SYLVAN STREET SW
CONCORD, NC 28025

PRINTED: 07/02/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

06/26/2025

(1)

(2)

(1)
Section;
(2)
(3)
(4)
(5)

(6)

children or adolescents are awake and present in
the facility.
(c) For each facility of six or more beds:

Paragraph (a) of this Rule shall perform clinical
and administrative responsibilities a minimum of
32 hours each week; and

children or adolescents are awake and present in
the facility.

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

professional(s) as set forth in Rule .1703 of this

services to children or adolescents;
meetings;
adolescent's treatment plan; and

functions.

This Rule is not met as evidenced by:

Based on interview and record review the person
identified as the facility's Qualified Professional
(QP) failed to meet the requirements of a
Qualified Professional. The findings are:

the qualified professional specified in

70% of the time shall occur when

supervision of its associate
oversight of emergencies;

provision of direct psychoeducational
participation in treatment planning
coordination of each child or

provision of basic case management

Division of Health Service Regulation
STATE FORM

6808 5CM511

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 294] Continued From page 8 V 294

If continuation sheet 9 of 15

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHLO013-235

HAPPINESS WITHIN

CONCORD,

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

NC 28025

PRINTED: 07/02/2025

STREET ADDRESS, CITY, STATE, ZIP CODE
711 SYLVAN STREET SW

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

06/26/2025

(x4) ID
PREFIX
TAG

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

ID
PREFIX
TAG

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

(xs)
COMPLETE
DATE

Vv 294

V 295]

Continued From page 9

Review on 6/24/25 of the Qualified Professional's
personnel record revealed:

- Hire date 11/15/23;

- Job title Qualified Professional

- Bachelor's Degree in Food Management 2013;
- Resume documented experience in food
services, no experience with the Mental
Health/Developmental Disability/Substance
Abuse (MH/DD/SA) population.

Interview on 6/24/25 and 6/26/25 with the
Qualified Professional revealed:

- No prior experience in human services before
employment;

- Duties included the day to day schedule for the
clients, checked the MARs (Medication
Administration Record), checked progress notes,
held group sessions with clients;

- Trained by the Executive Director and Program
Director.

Interview on 6/24/25 and 6/26/25 with the
Executive Director revealed:

- Unaware the QP did not meet the requirements
to be a QP;

- "She (QP) does everything so well and is on top
of it."

27G .1703 Residential Tx. Child/Adol - Req. for A
Pp

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

(a) In addition to the qualified professional
specified in Rule .1702 of this Section, each
facility shall have at least one full-time direct care
staff who meets or exceeds the requirements of

an associate professional as set forth in 10A
NCAC 27G .0104(1).

Division of Health Service Regulation
STATE FORM

V 294

V 295

6809

If continuation sheet 10 of 15

Division of Health Service Regulation

PRINTED: 07/02/2025
FORM APPROVED

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

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

regarding responsibilities related to the
implementation of each child or adolescent's
treatment plan; and

(3) participation in service planning
meetings.

This Rule is not met as evidenced by:

Based on record review and interviews, the
facility failed to employ an Associate Professional
(AP) who provided services to the group home on
a full time basis. The findings are:

Review on 6/24/25 of the Associate Professional's
personnel record revealed:

- Hire date 11/10/23;

- Job title Associate Professional;

- Bachelor's Degree in Psychology 2017 and
Master's Degree in Psychology 2019.

Interview on 6/26/25 with the Associate
Professional revealed:

- Had not worked at the facility since March due
to transportation issues.

Interview on 6/26/25 with the Executive Director
revealed:

- AP had not worked in the facility in months;

- AP completed some work assignments that did

Division of Health Service Regulation

STATE FORM

6808 5CM511

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHLO013-235 06/26/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
711 SYLVAN STREET SW
HAPPINESS WITHIN
CONCORD, NC 28025
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 295] Continued From page 10 V 295

If continuation sheet 11 of 15

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

STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

PRINTED: 07/02/2025
FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHLO013-235 06/26/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
711 SYLVAN STREET SW
HAPPINESS WITHIN
CONCORD, NC 28025
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 295] Continued From page 11 V 295
not require her to be in the facility.
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
means. The report shall include the following

information:

(1) reporting provider contact and
identification information;

(2) client identification information;

(3) type of incident;

(4) description of incident;

(5) status of the effort to determine the
cause of the incident; and

(6) other individuals or authorities notified

or responding.

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

(1) the provider has reason to believe that
information provided in the report may be
erroneous, misleading or otherwise unreliable; or

Division of Health Service Regulation
STATE FORM

6809

5CM511

If continuation sheet 12 of 15

Division of Health Service Regulation

HAPPINESS WITHIN

NAME OF PROVIDER OR SUPPLIER

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

A. BUILDING:

MHLO013-235

711 SYLVAN STREET SW
CONCORD, NC 28025

PRINTED: 07/02/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

06/26/2025

(2)

(1)

(2)
(3)

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:

information;

the provider obtains information

hospital records including confidential

reports by other authorities; and
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
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

(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 12 V 367

Division of Health Service Regulation
STATE FORM

6809

If continuation sheet 13 of 15

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHLO013-235

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

711 SYLVAN STREET SW
CONCORD, NC 28025

HAPPINESS WITHIN

PRINTED: 07/02/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

06/26/2025

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 that incident reports were
submitted to the Local Management Entity
(LME)/Managed Care Organization (MCO)
responsible for the catchment areas where
services were provided within 72 hours of
becoming aware of the incident affecting 1 of 1
Former Client (FC) (FC #3). The findings are:

Review on 6/24/25 of Former Client #3's record
revealed:

- Admission date 4/4/25;

- Age 16;

- Diagnoses Major Depressive Disorder, Single
Episode, Severe Without Psychotic Features.

Review on 6/24/25 of the North Carolina Incident
Response Improvement System (IRIS) from April
1, 2025- June 23, 2025 revealed the following
incidents were not reported within the required
time:

- FC #3 went AWOL and made suicidal ideations.
FC #3 was involuntary committed into the local
hospital on 5/12/25. The provider did not submit
report until 5/16/25 into IRIS.

- FC #3 broke a whiteboard and used it to inflict a

(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 13 V 367

Division of Health Service Regulation
STATE FORM

6809

5CM511

If continuation sheet 14 of 15

Division of Health Service Regulation

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

MHLO013-235

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 07/02/2025

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

711 SYLVAN STREET SW

HAPPINESS WITHIN

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

06/26/2025

CONCORD, NC 28025
(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

laceration on herself and unintentionally injured
two staff members during their attempt to safely
disarm her.

FC #3 used profane language and made verbal
threats to access a locked

cabinet to retrieve a knife and harm others in the
home. The client then exited

the home without permission and attempted to
retrieve the broken object

from the outdoor trash can. The provider did not
submit report until 5/18/25 into IRIS.

- FC #3 had self harm to previous wound along
with continuous suicidal ideations. FC #3 was
transported to local hospital for evaluation on
5/13/25. The provider did not submit report until
5/18/25 into IRIS.

- On 5/27/25, the provider learned FC #3
allegedly penetrated Client #1 while on an outing
at the local YMCA on 5/23/25. The provider did
not submit report until 6/1/25 into IRIS.

Interview on 6/24/25 with the Executive Director
revealed:

- Completed incident reports in IRIS;

- Aware the incident reports were being reported
after 72 hours of becoming aware of the incident;
- Planned to start getting the incident reported
within the timeframe.

- Completed incident reports once learned of the
incident.

Division of Health Service Regulation
STATE FORM

6809

If continuation sheet 15 of 15

inspection_type: MHLCS Annual and Complaint

document_type: Statement of Deficiency


facility_name: Transcending Heights  LLC

summary: Statement of Deficiency - MHLCS Follow-up

raw_content:
Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL013-240

TRANSCENDING HEIGHTS, LLC

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 02/09/2026

STREET ADDRESS, CITY, STATE, ZIP CODE
550 ARCHDALE DRIVE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

R
01/30/2026

A follow up survey was completed on 1/30/26. 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 6 and has a current
census of 4.

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

STATE FORM

6899

CONCORD, NC 28027
(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 Follow-up


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

raw_content:
Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL013-240

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

STREET ADDRESS, CITY, STATE, ZIP CODE

550 ARCHDALE DRIVE

TRANSCENDING HEIGHTS, LLC

CONCORD,

NC 28027

PRINTED: 10/29/2025

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R-C
10/09/2025

(x4) ID
PREFIX
TAG

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

ID PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH CORRECTIVE ACTION SHOULD BE
TAG CROSS-REFERENCED TO THE APPROPRIATE

DEFICIENCY)

(xs)
COMPLETE
DATE

V 000!

V 118)

INITIAL COMMENTS

A complaint and follow up survey was completed
on 10/9/25. The complaint was unsubstantiated
(Intake #NC00233095). A deficiency was cited.

The 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 6 and has a current
census of 3. The survey sample consisted of
audits of 3 current clients.

27G .0209 (C) Medication Requirements

10A NCAC 27G .0209 MEDICATION
REQUIREMENTS

(c) Medication administration:

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

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

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

STATE FORM

V 000

V 118

6808 CRTN11

TITLE

(X6) DATE

If continuation sheet 1 of 7

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL013-240

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

STREET ADDRESS, CITY, STATE, ZIP CODE

550 ARCHDALE DRIVE

TRANSCENDING HEIGHTS, LLC

PRINTED: 10/29/2025

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R-C
10/09/2025

(E) name or initials of person administering the
drug.

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

This Rule is not met as evidenced by:

Based on record reviews and interviews, the
facility failed to ensure medications were
administered only by licensed persons, or by
unlicensed persons trained in medication
administration by a registered nurse, pharmacist
or other legally qualified person affecting 2 of 2
audited paraprofessional staff (Staff #1 and #2).
The findings are:

Review on 10/2/25 of Staff #1's personnel record
revealed:

- Date of hire 11/25/24;

- Medication administration training certification
signed by the Registered Nurse (RN) and dated
8/13/25.

Review on 10/2/25 of Staff #2's personnel record
revealed:

- Date of hire 5/27/25;

- Medication administration training certification
signed by the RN and dated 8/13/25.

Review on 10/3/25 of the North Carolina Board of
Nursing website revealed:

- The Registered Nurse's North Carolina
permanent license expired as of 11/30/23.

Division of Health Service Regulation

STATE FORM

6808 CRTN11

CONCORD, NC 28027
(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 1 Vv 118

If continuation sheet 2 of 7

Division of Health Service Regulation

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

NAME OF PROVIDER OR SUPPLIER

TRANSCENDING HEIGHTS, LLC

MHL013-240

CONCORD,

NC 28027

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 10/29/2025

STREET ADDRESS, CITY, STATE, ZIP CODE
550 ARCHDALE DRIVE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

R-C
10/09/2025

Review on 10/3/25 of the Georgia Board of
Nursing website revealed:

- The Registered Nurse had Registered
Professional Nurse-eNLC (enhanced Nurse
Licensure Compact) license with an expiration
date of 1/31/26.

Review on 10/8/25 of the Nurse Licensure
Compact NLC website revealed:

- "New NLC rules include one requiring nurses
moving from one compact state to another
compact state to apply for licensure in their new
Primary State of Residence (PSOR) within 60
days."

Interview on 10/7/25 with Staff #1 revealed:

- Completed a virtual medication administration
training on 8/13/25;

- Completed a 10 question test after the virtual
training;

- "[House Manager (HM)/Associate Professional
(AP)] observed me do a pass (administer
medications to clients) and went over the
medication packet (overview of what was taught
in virtual training) with me;"

- Administered medications to clients while on
shift.

Interview on 10/7/25 with Staff #2 revealed:

- Attended medication training virtually on a zoom
call "sometime in August (2025);"

- "We had a nurse (RN) on there (zoom call) to
help us with anything we had questions with;"

- "There was a test afterwards with about 10
questions;"

- "The House Manager (HM/AP) made sure we
understood everything after the training;"

- Administered medications to clients while on

shift.

Division of Health Service Regulation
STATE FORM

6809

CRTN11

(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 Vv 118

If continuation sheet 3 of 7

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

STATEMENT OF DEFICIENCIES

PRINTED: 10/29/2025

(X2) MULTIPLE CONSTRUCTION

FORM APPROVED

(X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL013-240 10/09/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
550 ARCHDALE DRIVE
TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027
(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

Interview on 10/2/25 and 10/7/25 with the
Registered Nurse revealed:

- Moved to North Carolina in January 2025;

- Completed the paperwork for nursing license to
practice nursing in North Carolina;

- Completed first medication administration
training virtually on 8/13/25 for the facility;

- "The demonstration (medication pass) was not
part of the training (medication administration)
because there are no injections, it's just pills that
they give (administer) clients or watch the clients
take themselves;"

- The training "consisted of safety, how to check
and double check for patient identification, the
awareness of drugs they are giving, the side
effects and different things like that;"

- Staff were required to pass the medication
administration training with a test score of at least
80%;

- Ensured staff competency by answering
questions of staff during the training and staff was
given a test at the end of the training.

Interview on 10/2/25 with the HM/AP revealed:
- Staff #1 and Staff #2 completed medication
administration virtually with a nurse (RN) on
8/13/25;

- Staff #1 and Staff #2 had to take a test after the
virtual training;

- There was no in person part of the medication
administration training for staff to demonstrate
competency in medication administration;

- The nurse demonstrated how to complete
medication administration virtually;

Interviews on 10/2/25 and 10/7/25 with the
Qualified Professional (QP) revealed:

- "Medication training was completed in August
(2025):"

Division of Health Service Regulation
STATE FORM

6808 CRTN11

If continuation sheet 4 of 7

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL013-240

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

STREET ADDRESS, CITY, STATE, ZIP CODE

550 ARCHDALE DRIVE

TRANSCENDING HEIGHTS, LLC

PRINTED: 10/29/2025

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R-C
10/09/2025

- "The training was completed virtually with all the
staff by a nurse (RN);"

- "The nurse (RN) demonstrated how to do a med
(medication) pass;"

- "We ensure staff competency when staff take
the test and make sure there are no mistakes on
the MARs, when me and [HM/AP] review the
MARs and then our pharmacist comes and do
medication reviews."

Interview on 10/8/25 with the Human
Resources/Compliance Consultant revealed:

- Was responsible for setting up the medication
administration training with the RN;

- "The other individual we have to do our
medication training was not available;"

- "| wasn't aware that they had to have every staff
member do a medication pass, my understanding
that was for nursing homes and not residential
facilities;"

- "| know the staff had to take a test after they
completed the training."

Review on 10/8/25 of the facility's Plan of
Protection dated 10/8/25 and completed by the
Licensee revealed:

- "What immediate action will the facility take to
ensure the safety of the consumers in your care?
Transcending Heights LLC will ensure medication
requirements are followed per the rule 10A NCAC.
27G .0209.

All staff will be trained per the rule, 'by a
registered nurse, pharmacist, or a legally qualified
person and privileged to prepare and administer
medications’.

In the context of healthcare, legally qualified
persons privileged to prepare and administer
medications generally include licensed medical
professionals, such as:

Physicians (MDs (Doctor of Medicine) and DOs

Division of Health Service Regulation

STATE FORM

6808 CRTN11

CONCORD, NC 28027
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118] Continued From page 4 Vv 118

If continuation sheet 5 of 7

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL013-240

TRANSCENDING HEIGHTS, LLC

CONCORD,

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

NC 28027

PRINTED: 10/29/2025

STREET ADDRESS, CITY, STATE, ZIP CODE
550 ARCHDALE DRIVE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

R-C
10/09/2025

(Doctor of Osteopathic Medicine)): They have the
broadest prescriptive authority and can
administer a wide range of medications.
Registered Nurses (RNs): They are typically
responsible for administering medications
prescribed by a healthcare provider and often
oversee the administration by other personnel.
Licensed Practical Nurses (LPNs): They can also
administer medications under the supervision of a
registered nurse or doctor.

Physician Assistants (PAs): They can administer
medications in accordance with their approved
practice, under physician supervision.
Pharmacists: They verify prescriptions, dispense
medications, and may administer certain
medications like vaccines, depending on state
laws and collaborative practice agreements.
Advanced Practice Registered Nurses (APRNs):
This includes Nurse Practitioners (NPs), who
have advanced education and can prescribe and
administer medications. Only staff having current
and up-to-date medication certificates will
administer medications. MAR's will be checked
daily for accuracy and to ensure that the
appropriately trained person has signed.

- Describe your plans to make sure the above
happens.

New and current staff will be trained and/or
retrained to ensure medications are administered
correctly to residents in care. MAR's will be
checked daily to ensure medication has been
administered, and staff have signed/initialed and
documented properly per the medication orders
or discontinue orders. Medication training to
include observation will be scheduled with a
qualified person privileged to prepare and
administer medications by October 17, 2025.
Medications will only be administered by staff
possessing a medication administration certificate
on file."

Division of Health Service Regulation
STATE FORM

6809

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118] Continued From page 5 Vv 118

If continuation sheet 6 of 7

Division of Health Service Regulation

PRINTED: 10/29/2025

FORM APPROVED

The facility served children ranging in age 13-17
with diagnoses that include Oppositional Defiant
Disorder, Attention Deficit Hyperactivity Disorder,
Post Traumatic Stress Disorder, Major
Depression, Generalized Anxiety Disorder and
Conduct Disorder. On August 13, 2025, the Staff
#1 and Staff #2 received medication
administration training by a RN who was not
licensed by the North Carolina Board of Nursing.
The staff were not assessed for their competency
to administer medication upon completion of the
classroom portion of the medication
administration training. Staff #1 and Staff #2
administered medications to the clients while not
being fully trained with the longest serving staff
having commenced employement in November
2024.

This deficiency constitutes a Continuing Type B
rule violation which is detrimental to the health,
safety and welfare of the clients for failure to
correct within 45 days.

Division of Health Service Regulation
STATE FORM

6809

CRTN11

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R-C
MHL013-240 10/09/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
550 ARCHDALE DRIVE
TRANSCENDING HEIGHTS, LLC
CONCORD, NC 28027
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 118] Continued From page 6 Vv 118

If continuation sheet 7 of 7

inspection_type: MHLCS Complaint and Follow-up