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

raw_content:
Division of Health Service Reg

STATEMENT OF DEFICIENCIES:
AND PLAN OF CORRECTION

(X4) 1D
PREFIX
TAG

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

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

INITIAL COMMENTS.

An annual, complaint and follow up survey was
completed on 10/21/25. The complaint was
unsubstantiated (Intake #NC00233789).
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 3. The survey sample consisted of
audits of 3 current clients.

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

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

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

(d) The plan shall include:

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

(2) strategies;

(3) staff responsible;

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

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

(6) written consent or agreement by the client or
responsible party, or a written statement by the
provider stating why such conse

Division of Health Service Regulation 3
LABORATORY DIRECTOR'S OR PROWDER/SUPPLIE

PRINTED: 11/12/2025
FORM APPROVED.

(X2) MULTIPLE CONSTRUCTION
A BUILOING:

(X3) DATE SURVEY
COMPLETED

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

Vv 112

Tuming Point Homes Quality Management
Director retrained the QP on PCP's and goal
wriling. This training took place

11/12/2025.

RECEIVED
NOV 26 2025
DHSR-MH Licensure Sect

If continuation sheet 1 of 30

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIER/CLIA. (X2) MULTIPLE CONSTRUCTION

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING:

(x4) ID
PREFIX
TAG

MHL013-226 8. WING,

PRINTED: 11/12/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

519 UNION STREET SOUTH
CONCORD, NC 28025

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

Continued From page 1
obtained.

This Rule is not met as evidenced by:
Based on record review and interviews, the
facility failed to develop and implement goals and

strategies in the treatment/habilitation plan to
address the client's needs for 1 of 3 clients (#2).
The findings are:

Review on 10/9/25 of Client #2's record revealed:
- Admission date 8/20/25;

- Age 17 years old;

- Diagnoses Oppositional Defiant Disorder,
Intermittent Explosive Disorder, Post Traumatic
Stress Disorder, Cannabis Use Disorder;

- Comprehensive Clinical Assessment (CCA)
addendum dated 6/20/25-" ... This level of care
will provide a safe and stable environment to
address the client's behavioral, emotional, and
substance use needs while promoting skill
development and accountability;"

- Person Centered Plan (PCP/treatment plan
dated on 10/16/24 and updated on 8/20/25 with
no goals or strategies related to substance use.

Interview on 10/10/25 with the Qualified
Professional revealed:

~ Reviewed Client #2's CCA addendum dated
6/20/25 prior to admission on 8/20/25;

- Was responsible for completing and updating
treatment plans; f

HMFH11

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

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

R
10/21/2025

If continuation sheet 2 of 30

Division of Health Service Regulation

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

MHL013-226

NAME OF PROVIDER OR SUPPLIER

PRINTED: 11/12/2025
FORM APPROVED

(X%2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY.
COMPLETED

R
BeWING —________4_ 10/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

519 UNION STREET SOUTH
CONCORD, NC 28025

UNION POINT

(X4) 1D SUMMARY STATEMENT OF DEFICIENCIES
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL
TAG REGULATORY OR LSC IDENTIFYING INFORMATION)

Continued From page 2

- The goals in the treatment plan were decided by
Client #2 and his legal guardian

- "| have tried talking to him (Client #2)
concerning the PCP but he knows it all."

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

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

Division of Health Service Regulation
STATE FORM

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

Plan for V118 and V123 10/21/2025

and ongoing
- Our Medical provider Dacre PA-C review
retrained our QP, AP, house team ers,

program Director on Medication Administration
on 10/21/2025 at 11:30 am.

-QM director will maintain oversight of the AP
and QP to ensure compliance with medication
and MARS.

-The AP and QP will review MARS daily

-The AP and QP will submit a checklist to the
Quality Management Director Weekly to report
Medication changes.

This checklist will highlight the following areas:
-Staff will sign and initial off on the MAR

-Staff will document Medication errors on the
MAR as applicable

-Staff will observe, monitor and document
medication side effects

-Staff will attach the Med order to the MAR
ETc.

-The Quality Management Director will meet
with the QP, AP and Team leader each month
until MAR compliance is brought back into
standard.

eons HMFH11 Hf continuation sheet 3 of 30

PRINTED: 11/12/2025
FORM APPROVED
Division of Health Service Ri

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

R
MHLO013-226 & be 10/21/2025

NAME OF PROVIDER OR SUPPLIER
§19 UNION $
CONCORD,

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE

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

UNION POINT

Continued From page 3

This Rule is not met as evidenced by:

Based on record reviews, interviews and
observation, the facility failed to ensure
medications were administered on the written
order of a physician and ensure that the MARs
was kept current affecting 3 of 3 of clients (client
#1, #2 and #3). The findings are:

Cross Reference: 10A NCAC 27G .0209
Medication Requirements (V123). Based on
record reviews and interviews the facility failed to
ensure all medications errors were reported
immediately to a pharmacy or physician affecting
3 of 3 clients (client #1, #2 and #3).

Review on 10/6/25 of Client #1's MARs from
7/1/25 to 10/6/25 revealed the following
medications were administered without a
physicians’ order on site:

- Erythromycin ointment 3500grams (pink eye),
initialed as administered at 8am and 8pm from
7/24/25 to 7/28/25, 8am on 7/29/25 and 7/30/25;
- Cyproheptadine 4mg (milligram) (appetite),
initialed as administered at 8am from 8/27/25
through 9/10/25, 9/12/25 through 9/23/25 and
10/4/25 and 10/5/25;

- Melatonin (sleep aid), initialed as administered
on 8/3/25, 8/7/25, 9/14/25 through 9/18/25,
9/20/25 and 9/21/25 with no reason why the
medication was administered or effectiveness
documented;

- Dexmethylphenidate ER (extended release)
25mg (Attention Deficit Hyperactivity Disorder)
(ADHD), Take one capsule by mouth every
morning, No initials for documentation of
Division of Health Service Regulation

STATE FORM FH11 If continuation sheet 4 of 30

PRINTED: 11/12/2025
FORM APPROVED

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

R
MHL013-226 8. WING J _______ 40/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
519 UNION STREET SOUTH
CONCORD, NC 28025

(4) 1D ‘SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION 5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE

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

UNION POINT

V 118] Continued From page 4

administration on 9/30/25;

- Risperidone 0.25mg (anxiety), Take 1 tablet by
mouth every night, No initials for documentation
of administration on 9/30/25.

Review on 10/6/25 of Client #2's record revealed:
- No physicians’ order in Client #2's medical
record for Erythromycin ophthalmic ointment.

Review on 10/6/25 of Client #2's MARs for
8/20/25 to 10/6/25 revealed the following
medications were administered without a
physicians’ order on site:

- Emtricitabine 200-300mg (Human
Immunodeficiency Virus/HIV prevention), first
administration documented on 9/13/25;

- Levocetirizine 5mg (allergies), administration
time initialed as 8am and 8pm on the 8/25, 9/25
and 10/25 MARs. Initialed as administered twice
at 8am and 8pm on 9/2/25 to 9/4/25, 9/9/25,
9/15/25 to 9/17/25;

- Hydroxyzine 50mg (anxiety), initialed as
administered on 8/24/25;

- Cromolyn 10ml (milliliter) (dry eye), initialed as
administered on 8/27/25.

Observation on 10/6/25 at approximately 5:45pm
of Client #2's medication storage container
revealed:

- One opened tube of Erythromycin ophthalmic
ointment 0.5% (5mg/g) and one unopened tube
of Erythromycin ophthalmic ointment 0.5%
(5mg/g).

Further review on 10/6/25 of Client #2's MARs for
8/20/25 through 10/7/25 revealed:

- No documentation of Erythromycin ophthalmic
ointment being administered for the review
period.

Division of Health Service Regulation
STATE FORM wo HMFH11 I continuation sheet 5 of 30

PRINTED: 11/12/2025

FORM APPROVED

Division of Health Service Regulation

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

R
MHLO13-226 8. Win ___ 10/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
519 UNION STREET SOUTH
CONCORD, NC 28025

(x4) 1D ‘SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

UNION POINT

Continued From page 5

Review on 10/6/25 of Client #3's MARs for 7/9/25
through 10/6/25 revealed the following
medications were administered without a
physicians’ order on site:

~ Methylphenidate 54mg (ADHD), initialed as “O"
(other see note) for administration from 8/10/25
through 8/13/25 however, there was no
explanation noted on MAR;

- Methylphenidate 36mg, order dated 9/5/25 there
were no initials for administration until 9/48/25;

- Flonase 200mg (allergies), listed on the 9/25
MAR to be administered at 8am, however, there
were no initials for administration from 9/1/25 to
9/30/25. September MAR documented with 0's on
9/1/25 through 9/6/25. Notes in the comment
section for 9/1/25 - 9/5/25 “out of nasal spray"
9/16/25 waiting on refill. 9/717/25 refill will be
ready after 2pm. 9/29/25 refused all meds went to
BH (behavioral health);"

- Flonase 200mg no initials for administration on
the 10/2025 MAR.

- Initialed as administered on the back of the July
2025 MAR as “non-prescription medication
given:"

- 7/24/25 5:30pm Aspirin 81mg (pain relief);

~ 7/26/25 through 7/28/25 (8pm) Melatonin 10mg;
- There were no administration instructions
documented on the MARs, no documentation as
to why the medication was administered or
effectiveness of the medication.

- Initialed as administered on the back of the
August 2025 MAR as “non-prescription
medication given:"
- 8/3/25 8:55pm melatonin;
- 8/6/25 8pm melatonin;
- 8/7/25 8pm melatonin;
- 8/12/25 "8" melatonin;
- There were no administration instructions
Division of Health Service Regulation
STATE FORM — HMFH11 continuation sheet 6 of 30

PRINTED: 11/12/2025
FORM APPROVED

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

R
MHL013-226 8. WING £_______ 10/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
519 UNION STREET SOUTH
CONCORD, NC 28025

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

DEFICIENCY)

UNION POINT

V 118] Continued From page 6

documented on the MARs, no documentation as
to why the medication was administered or
effectiveness of the medication.

- Initialed as administered on the back of the
September 2025 MAR as "non-prescription
medication given:”

- 8/7/25 8pm melatonin;

~ 9/14/25 through 9/21/25 8pm melatonin;

~ 9/23/25 8pm melatonin;

- 9/25/25 through 9/27/25 8pm melatonin;

- 9/30/25 8pm melatonin;

~- There were no administration instructions
documented on the MARs, no documentation as
to why the medications were administered or
effectiveness of the medication.

- Initialed as administered on the back of the
October 2025 MAR as "non-prescription
medication given:"

- 10/1/25 8pm melatonin;

- 10/3/25 8pm melatonin;

- There were no administration instructions
documented on the MARs, no documentation as
to why the medications were administered or
effectiveness of the medication.

Interview on 10/6/25 with Client #1 revealed:
~ Received medications daily;

- "Was out of medication one time when came
back from therapeutic leave but received the
medication,"

Interview on 10/6/25 with Client #2 revealed:
-"Most medications are PRN (as needed), so |
take as needed.”

Interview on 10/6/25 with Client #3 revealed:
- Received medications.

Division of Health Service Regulation
STATE FORM e800 HMFH11 I continuation sheet 7 of 30

PRINTED: 11/12/2025
FORM APPROVED
Division of Health Service Regulation

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

R
MHL013-226 8. WING HH 10/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADORESS, CITY, STATE, ZIP CODE
519 UNION STREET SOUTH
CONCORD, NC 28025

(X4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE

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

UNION POINT

Continued From page 7

Interview on 10/6/25 with Staff #1 revealed:
- Only lead staff administered medications.

Interview on 10/6/25 with Staff #2 revealed:
- She administered medications;
- Denied clients “run out" of medications.

Interview on 10/9/25 and 10/15/25 with the
Associate Professional (AP) revealed:

- Qualified Professional (QP) monitors the MARs
and ensures physicians’ orders and medications
are in the facility.

-"[QP] is responsible for the MARs, medications
and physician orders",

- He was unaware that the medication information
leaflets were not physicians' orders;

- "When we get a med (medication) from the
Pharmacy, we take the order that comes with the
prescription (information leaflet), and we put it
with the MAR. That's what we use as the doctor's
order, we thought that was the order;"

- "The MARs are being monitored weekly by me
and [QP]. | know | look over them to make sure
there are no holes on the MARs and make sure
all the staff have signed off on the MARs and
things like that. | usually do my checks (MAR) on
Mondays after the weekend. I'm not sure when
she (QP) does hers (monitors the MARs). Not
sure exactly what she checks;"

- He was unaware that the administration
instructions for Client #2's Levocetirizine were
incorrect on the MARs for August, September
and October 2025 MARs and that Client #2 had
received double doses of his Levocetirizine on
9/2/25 to 9/4/25, 9/9/25, 9/15/25 to 9/17/25;

- Did not know why staff had not documented
PRNs correctly or why there was no.
documentation of why medications were not
being administered to Client #1
(Dexmethylphenidate ER 9/30/25 and

Division of Health Service Regulation
STATE FORM ooo HMFH41 Hf continuation sheet 8 of 30

Division of Health Service Regulation

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

NAME OF PROVIDER OR SUPPLIER

MHL013-226

(X2) MULTIPLE CONSTRUCTION

A BUILDING:

B. WING

519 UNION STREET SOUTH

UNION POINT

(x4) 1D
PREFIX
TAG

Vv 118

CONCORD, NC 28025

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

Continued From page 8

Risperidone .25mg 9/30/25) and Client #3
(Methylphenidate 54mg from 8/10/25 through
8/13/25) was missing;

- "Yeah, yeah, all of that should have been
caught. | don't know how we would have missed
all of that."

Interview on 10/10/25 and 10/15/25 with the QP
revealed:

-"l review MARs twice a month;"

- Ensured the MARs were documented and that
staff initialed MARs correctly;

- Ensured that each medication had a physicians’
order,

- "We (staff) just found out that we needed signed
orders (physicians orders). We are working to
make sure that all the clients have the signed
orders in the facility;”

- "We had physicians’ orders for meds, last month
when we had management meeting;”

- Was unaware that the administration
instructions for Client #2's Levocetirizine were
incorrect on the MARs for August, September
and October 2025 MARs and that Client #2 had
received double doses of his Levocetirizine on
9/2/25 to 9/4/25, 9/9/25, 9/15/25 to 9/17/25;

- Did not know why staff had not documented
PRNs correctly or why there was no
documentation of why medications were not
being administered to Client #1
(Dexmethylphenidate ER 9/30/25 and
Risperidone .25mg 9/30/25) and Client #3
(Methylphenidate 54 mg from 8/10/25 through
8/13/25) was missing;

- Not sure what clients are taking their
medications for. "I'm not a medical provider.
There's no reason | should know what their meds
(medications) are for;"

- "lam not working right now, I'm not in my office
and I don't have my laptop. | can pull up all that

Division of Health Service Regulation

STATE FORM

HMFH11

PRINTED: 11/12/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

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

CROSS-REFERENCED TO THE APPROPRIATE

DEFICIENCY)

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R
10/21/2025

Mf continuation sheet 9 of 30

PRINTED: 11/12/2025
FORM APPROVED
Division of Health Service Regulation

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

R
MHL013-226 8 wing —______ 10/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
519 UNION STREET SOUTH
CONCORD, NC 28025

(x4) 1D ‘SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE

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

UNION POINT

Continued From page 9

information (physicians' orders/documentation of
medical visits/guardian information) on my laptop
once | get to my office and look at what you are
asking. | can give you a call back when | get to
my laptop and call you back.”

- The QP had not returned call prior to survey
exit.

Due to the failure to accurately document
medications administration, it could not be
determined if clients received their medications
as ordered by the physician.

Review on 10-17-25 of the facility's Plan of
Protection dated 10-17-25 and signed by the
Quality Management (QM) Director revealed:
-"What immediate action will the facility take to
ensure the safety of the consumers in your care?

- On 10/10/2025 the Quality Management
Director met with the house QP, AP and shift
team lead to retrain and review all medication
policies and procedures.
0 This training included:
“How to accurately document medications on
the MAR
"How to document medication errors, and who
needs to be notified in the event of a med
(medication) error.
"requirements of obtaining E-scripts Med
(medication) orders from the pharmacy
"review of how to communicate medication
changes to the team
"processes on how to document those
medication changes on the MAR.
"what qualifies an incident report as it pertains
to the MAR
"the requirement of needing a script for any
medication including over the counter meds

Division of Health Service Regulation

STATE FORM od HMFH11 continuation sheet 10 of 30

PRINTED: 11/12/2025
FORM APPROVED

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

R
MHL013-226 B WING _______ 10/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
519 UNION STREET SOUTH
CONCORD, NC 28025

(X4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE

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

UNION POINT

Continued From page 10

(medications).
- On 10/10/2025 the team lead communicated
e-script needs with the pharmacy. The pharmacy
agreed to release the script they receive from the
medical provider in addition to the medication
packet on the front of the med (medication)
pack.
- Turning Point Homes (Licensee) has
scheduled a all-staff meeting on 10/17/2025 to
address medication compliance.
0 QM director will create a MAR/Medication
admin (administration) check list as a resource
for staff administering medication starting
10/17/2025. This check list will be utilized by all
staff administering medication.
o Review when Incident reports are required as
it pertains to the MAR.
0 Program director will review Medication
policies and procedures with all staff.
- Turning Point Homes will require all clients to
go to [Local pharmacy] in order to acquire the
Med order that the prescribing physician sends
directly to the pharmacy.
© The QP andAP will check MAR daily to
ensure adherence to Medication Administration
Rules.
Describe your plans to make sure the above
happens.
+ The AP and QP will review MARS daily.
- The AP and QP will submit a checklist to the
Quality Management Director Weekly to report
Medication changes.
- The Quality Management Director will meet
with the QP, AP and Team leader each month
until MAR compliance is

brought back into standard.”

Review on 10-20-25 of the facility's amended plan
of protection dated 10-20-25 and signed by the
Quality Management Director revealed:

Division of Health Service Regulation

STATE FORM con HMFH11 W continuation sheet 11 of 30

PRINTED: 11/12/2025

FORM APPROVED

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (K3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A BUILDING: COMPLETED

R
MHLO13-226 8. WING ______HHH4HHH 10/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
519 UNION STREET SOUTH
CONCORD, NC 28025

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

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

UNION POINT

Continued From page 11

o “Our Medical provider [Local Provider], PA-C.
(Physician Assistant-Certified) will train our QP,
AP, house team leaders, program Director on
Medication Administration on 10/21/2025 at 11:30
am.

Describe your plans to make sure the above
happens.

- QM director will maintain oversight of the AP
and QP to ensure compliance with medication
and MARS.

- The AP and QP will review MARS daily

- The AP and QP will submit a checklist to the
Quality Management Director Weekly to report
Medication changes. This checklist will highlight
the following areas:

o — Staff will sign and initial off on the MAR

© — Staff will document Medication errors on the
MAR as applicable

0 — Staff will observe, monitor and document
medication side effects

o — Staff will attach the Med (medication) order to
the MAR

o ETC (et cetera).

- The Quality Management Director will meet
with the QP, AP and Team leader each month
until MAR compliance is brought back into
standard."

The facility served clients ranging from 12-17
years diagnosed with Post Traumatic Stress
Disorder, Impulse Control, Conduct Disorder and
Attention Deficit Hyperactivity Disorder. Between
July 2025- October 2025, facility staff
administered Client #1, #2, #3 medications
approximately 56 times in total without a written
physician. Client #2 received double doses of an
allergy medication on five separate occasions.
Client #2's medication storage container
contained an opened and unopened tube of an

Division of Health Service Regulation

STATE FORM Ld HMFH44 {f continuation sheet 12 of 30

PRINTED: 11/12/2025
FORM APPROVED

Division of Health Service Regulation
‘STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ABULLDING COMPLETED

R
MHLO013-226 B WING ______. 10/21/2025

NAME OF PROVIDER OR SUPPLIER, STREET ADDRESS, CITY, STATE, ZIP CODE
519 UNION STREET SOUTH
CONCORD, NC 28025

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

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

UNION POINT

Continued From page 12

eye cream but there was no physician order or
documentation of the eye cream. The facility also
failed to notify a pharmacist of physician about
medication errors, missed does, and client
refusals for Client #1, #2 and #3.

This deficiency constitutes a Type A1 rule
violation for serious neglect and must be
corrected within 23 days.

27G .0209 (H) Medication Requirements

10A NCAC 27G .0209 MEDICATION
REQUIREMENTS

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

This Rule is not met as evidenced by:

Based on record reviews and interviews, the
facility failed to ensure all medication errors were
immediately reported to a physician or pharmacist
affecting 3 of 3 clients (client #1, #2 and #3). The
findings are:

Review on 10/9/25 of Client #1's record revealed:
- Date of admission: 5/19/25;

- Age: 16 years;

- Diagnoses: Post Traumatic Stress Disorder

Division of Health Service Regulation
STATE FORM ~~ HMFH11 W continuation sheet 13 of 30

PRINTED: 11/12/2025
FORM APPROVED

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

R
MHL013-226 8. WING HHH 10/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
519 UNION STREET SOUTH
CONCORD, NC 28025

(x4) 1D ‘SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE

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

UNION POINT

Continued From page 13

(PTSD); Other Specified Disruptive Disorder;
Impulse Control and Conduct Disorder;
- Physicians’ orders for the following:

- 5/20/25 Dexmethylphenidate ER (extended
release) 25mg (milligram) (Attention Deficit
Hyperactivity Disorder/ADHD), take one capsule
by mouth every morning;

- 5/20/25 Risperidone 0.25mg (anxiety), take 1
tablet by mouth every night;

- There were no physicians’ orders for the
following:

- Erythromycin ointment 3.500grams (pink eye),
Apply 0.5 inches in the right eye twice daily for 7

days;

- Cyproheptadine 4mg (appetite), Take one
tablet by mouth every morning.

Review on 10/6/25 of Client #1's MARs for July
2025 revealed:
- Erythromycin ointment 3.500grams initialed as
"R" (refused) on 7/29/25 and 7/30/25;
- There was no documentation reported to Client
#1's physician or pharmacist for Client #1's
refusal of

Erythromycin ointment on 7/29/25 and 7/30/25.

Review on 10/6/25 of Client #1's MARs for August
2025 revealed:
- Dexmethylphenidate Extended Release 25mg
initialed as “R" (refused) from 8/13/25 to 8/26/25;
- Risperidone 0.25mg initialed as "R" on 8/23/25;
- Risperidone 0.25mg initialed as "R" on 8/24/25;
- There was no documentation reported to Client
#1's physician or pharmacist for Client #1's
refusal of

Dexmethylphenidate from 8/13/25 to 8/26/25
and Risperidone on 8/23/25 and 8/24/25.

Review on 10/6/25 of Client #1's MARs for
September 2025 revealed:

Division of Health Service Regulation

STATE FORM ~~ HMFH11 continuation sheet 14 of 30

PRINTED: 11/12/2025

FORM APPROVED

Division of Health Service Regulation

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

R
MHLO13-226 6 wing 10/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
519 UNION STREET SOUTH
CONCORD, NC 28025

(x4) 10 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE

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

UNION POINT

Continued From page 14

- Cyproheptadine 4mg initialed as "R" on 9/11/25;
- There was no documentation of administration
for Dexmethylphenidate ER and Risperidone on
9/30/25;
- There was no documentation reported to Client
#1's physician or pharmacist for Client #1's
refusal of

Cyproheptadine on 9/11/25 or for no initials for
documentation of Dexmethylphenidate or
Risperidone on 9/30/

25.

Review on 10/9/25 of Client #2's record revealed:
- Date of admission: 8/20/25;
- Age: 17 years;
- Diagnoses: PTSD; Intermittent Explosive
Disorder; Oppositional Defiant Disorder (ODD);
Cannabis Use Disorder;
- Physicians’ order for the following:
- 9/11/25 Emtricitabine 200-300mg (Human
Immunodeficiency Virus/HIV prevention), take
one tablet by mouth

daily.

Review on 10/6/25 of Client #2's September 2025
MARs revealed:
- Emtricitabine 200-300mg initialed as "R" on
9/19/25, 9/20/25, 9/21/25, 9/28/25, 9/29/25 and
9/30/25;
- There was no documentation reported to Client
#2's physician or pharmacist for Client #2's
refusal of

Emtricitabine on 9/19/25, 9/20/25, 9/21/25,
9/28/25, 9/29/25 and 9/30/25.

Review on 10/6/25 of Client #2's October 2025
MARSs revealed:

- Emtricitabine 200-300mg initialed as "R" on
10/1/25, 10/4/25;

- There was no documentation reported to Client
Division of Health Service Regulation

STATE FORM eae HMFH11 I continuation sheet 15 of 30

PRINTED: 11/12/2025
FORM APPROVED

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

R
MHL013-226 8 WING —__£____H!fHW—— 10/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
519 UNION STREET SOUTH
CONCORD, NC 28025

(X4) 10 ‘SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE

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

UNION POINT

Continued From page 15

#2's physician or pharmacist for Client #2's
refusal of
Emtricitabine on 10/1/25 or 10/4/25.

Review on 10/6/25 of Client #3's record revealed:
- Date of admission: 7/9/25;

- Age: 12 years;

- Diagnoses: ODD; ADHD, combined
presentation; Unspecified Trauma and Stressor
related Disorder;

- Physicians’ order for the following:

- 9/25/25-Methylphenidate 36mg (ADHD), take
one tablet by mouth every morning;

~ 10/9/25-Risperidone 0.5mg (anxiety), take 1
tablet by mouth two times a day;

- 8/7/25-Guanfacine 4mg (ADHD), take 1 tablet
by mouth at bedtime;

- 6/30/25-Hydroxyzine 50mg (anxiety), Take
one tablet by mouth two times a day as needed;
- No physicians’ orders for the following:

- Methylphenidate 54mg;

- Melatonin 10mg (sleep);

- Aspirin 81mg (pain relief);

- Flonase 200mg (allergies) administer 2 sprays
into each nostril every morning.

Review on 10/6/25 of Client #3's August 2025
MARSs revealed:
- Guanfacine 4mg initialed as “R" on 8/19/25;
- Methylphenidate 54mg initialed as "O" (other
see note) from 8/10/25 through 8/13/25 however
there was no

explanation noted on MAR;
- There was no documentation reported to Client
#3's physician or pharmacist for Client #3's
refusal of

Guanfacine on 8/19/25 or for no administration
of Methylphenidate from 8/10/25 through 8/13/25.

Review on 10/6/25 of Client #3's September 2025
Division of Health Service Regulation
STATE FORM cow HMFH11 W continuation sheet 16 of 30

PRINTED: 11/12/2025
FORM APPROVED

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

R
MHLO013-226 @ Wie. —~ —___ 10/21/2025
NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE
519 UNION STREET SOUTH
CONCORD, NC 28025

(X4) 10 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

UNION POINT

V 123} Continued From page 16

- October 2025 MARs revealed:
- Guanfacine 4mg initialed as "
- Risperidone 0.5mg initialed as "R" on 9/2/25;
- Methylphenidate 36 mg initialed as "R" on
9/2/25;
- Flonase 200mg was not initialed for
documentation on 9/1/25, 9/2/25, 9/3/25, 9/4/25,
and 9/5/25;
- Methylphenidate 36 mg: order dated 9/5/25 was
not initialed for documentation of administration
until 9/18/25;
- Flonase 200mg, listed on the 9/25 MAR to be
administered at 8am, however was not initialed
for documentation of administration from 9/1/25
to 9/30/25. 9/25 MAR initialed as 0's on 9/1/25
through 9/6/25. Notes in the comment section for
9/1/25 through 9/5/25 “out of nasal spray”
9/16/25 waiting on refill. 9/17/25 refill will be ready
after 2pm; 9/29/25 refused all meds went to BH
(behavioral health);"
- Flonase 200mg not documented on the 10/25
MAR;
- There was no documentation reported to Client
#3's physician or pharmacist for Client #3's
refusal of Guanfacine

on 9/29/25, Risperidone and Methylphenidate on
9/2/25.

Interview on 10/9/25 with the Associate
Professional (AP) revealed:

-"Most of the time, they (clients) don’t have any
problem taking their meds (medications). But they
are allowed to refuse meds (medications).
Refusals are documented on MARs."

-"Yes, someone should be calling the doctor (to
inform of medication refusals), | believe that
would be [Qualified Professional/QP]."

Interview on 10/10/25 and 10/15/25 with the QP
revealed:

Division of Health Service Regulation

STATE FORM one HMFH11 W continuation sheet 17 of 30

PRINTED: 11/12/2025
FORM APPROVED
Division of Health Service Reg
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

IDENTIFICATION NUMBER: A BUILDING: COMPLETED

R

MHL013-226 B. WING 10/21/2025

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

519 UNION STREET SOUTH

UNION POINT CONCORD, NC 28025

(X4) 1D
PREFIX
TAG

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

Continued From page 17

-Was not sure who was reporting medication
errors or refusals to the pharmacy. "I'm sure that
that is being done, I'm just not sure who exactly is
doing it. | believe it would be [AP's] responsibility."

This deficiency is cross referenced into 10A
NCAC 27G .0209 Medication Requirements
(V118) for a Type A1 rule violation and must be
corrected within 23 days.

27G .1704 Residential Tx. Child/Adol - Min.
Staffing

410A NCAC 27G .1704
REQUIREMENTS

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

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

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

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

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

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

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

MINIMUM STAFFING

Division of Health Service Regulation

STATE FORM

HMFH11

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

V 296

Client came home early from school and staff
were nol expecting him to be at the house.
Quality Management and Program Director
director met with AP, QP shift supervisor on
11/12/2025 and reviewed service expectations
and supervision/staffing requirements,

Quality Management Director and Program
Director reviewed the following with staff:

1- Make sure clients are aware of all staff
numbers and who to contact in case of a
emergency,

2- If staff have errands to run for the house
(such as grocery shopping) ensure that they
are doing these tasks during school hours
verses end of day when clients are coming
home from school. This will help eliminate any
staffing ratio concerns.

3- review of shift start times, and when to
arrive on shift.

4- Reviewed ratio requirements .

14/12/2025

Hf continuation sheet 18 of 30

PRINTED: 11/12/2025
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: A BUILDING: COMPLETED

R
MHL013-226 8. WING ________H 10/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
519 UNION STREET SOUTH
CONCORD, NC 28025

(X4) 1D ‘SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE

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

UNION POINT

Continued From page 18

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

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

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

This Rule is not met as evidenced by:

Based on record review and interviews the facility
failed to ensure the minimum staffing ratio of two
staff for up to four adolescents. The findings are:

Observation on 10/6/25 of the facility at
approximately 2:25pm-3:05pm revealed:

- Division Health Service Regulation surveyors
arrived at the facility at 2:25pm and rang the door
bell, no answer;

- Client #2 arrived at the facility walking alone at
2:40pm and preceded to walk to the back of the
facility and entered the facility;

- At 2:41pm surveyors walked to the back of the
facility and no one was there, the back door was
ajar;

Division of Health Service Regulation

STATE FORM one HMFH11 If continuation sheet 19 of 30

PRINTED: 14/12/2025
FORM APPROVED

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

R
MHL013-226 8. WING £____. 10/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
519 UNION STREET SOUTH
CONCORD, NC 28025

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

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

UNION POINT

Continued From page 19

- Staff #2 arrived at the facility at 3:00pm;
- Staff #1 arrived at the facility at 3:05pm.

Review on 10/9/25 of Client #2's record revealed:
- Admission date 8/20/25;

- Age 17 years old;

- Diagnoses: Oppositional Defiant Disorder,
Intermittent Explosive Disorder, Post Traumatic
Stress Disorder, Cannabis Use Disorder.

Interview on 10/6/25 with Client #2 revealed:

~- At 2:46pm came to the front door of the facility
and asked the Division Health Service Regulation
(DHSR) surveyors if they were at the facility for
the Shift Supervisor;

- At 2:49pm returned back to the front door and
informed DHSR surveyors that staff would be at
the facility in 5-10 minutes;

- Was not aware staff was not at the facility when
arrived to the facility from school;

- Today (10/6/25) was the first time any staff was
not at the facility when arrived from school;

- Rode the bus home from school;

- Walked to the facility from bus stop;

- Arrived to the facility each day from school
around 2:45-2:50pm.

Interview on 10/6/25 with Client #1 revealed:
- Two or three staff worked each shift;
- Never left alone in the facility.

Interview on 10/6/25 with Client #3 revealed:

- Never left alone in the facility;

- Refused to state how many staff worked each
shift.

Interview on 10/6/25 with Staff #1 revealed:

- Worked 2nd shift (3pm-11pm);

- Shift Supervisor worked until 7pm with 2nd shift
staff,

Division of Health Service Regulation
STATE FORM nd HMFH11 If continuation sheet 20 of 30

PRINTED: 11/12/2025
FORM APPROVED

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

R
MHL013-226 B wiNG HW 40/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
519 UNION STREET SOUTH
CONCORD, NC 28025

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE

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

UNION POINT

Continued From page 20

- Four staff worked each shift when 6 clients were
in the facility;

- 2 staff work each shift due to only 3 clients in
the facility;

- Client #2 arrived daily at the facility from school
before the start of his shift.

Interview on 10/6/25 with Staff #2 revealed:
- Two or three staff worked each shift;

- Client #2 arrived at the facility from school
before the start of her shift daily.

Interview on 10/6/25 with the Shift Supervisor
revealed:

- Left the facility with Client #1 and Client #3 to
purchase food on 10/6/25;

- Received a telephone call from Client #2, that
surveyors were at the facility;

- Client #2 was not due to be at the facility from
school until after 3pm;

~ Staff #1 and Staff #2 usually started shift
between 2:45pm-2:50pm;

- Two or three staff worked each shift.

Interview on 10/9/25 with the Associate
Professional revealed:

- "We (administrative staff) try to have 2-3 staff
work each shift depending on how many clients
are in the home (facility) at the time:"

-"| work all shifts, anytime someone (staff) calls
out. The last few months | have been working the
weekend shift.”

Interview on 10/10/25 with the Licensed
Professional/Program Director revealed:

- Two or three staff are on shift depending on the
ratio of clients in the home;

- "He (Client #2) will be turning 18 in a few days
he wants to come and go as he pleases and we
(staff) are dealing with those behaviors with him
Division of Health Service Regulation

STATE FORM oo HMFH11 continuation sheet 21 of 30

Division of Health Service Regulation

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

NAME OF PROVIDER OR SUPPLIER

MHL013-226

PRINTED: 11/12/2025
FORM APPROVED

(X2) MULTIPLE CONSTRUCTION (3) DATE SURVEY
A BUILDING: COMPLETED

R
B.WING 10/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

519 UNION STREET SOUTH

UNION POINT

(X4) ID
PREFIX
TAG

CONCORD, NC 28025

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

Continued From page 21

now.’

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,
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 Ill incident that occurs
while the provider is delivering a billable service

Division of Health Service Regulation

STATE FORM

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

V 366 11/12/2025

On 11/12/2025 Quality Management Director
retrained Facility QP, AP, Program Director
and shift supervisor on incident reporting
requirements. This training had a focus on
incident reporting as it pertains to med errors.

- HMFH11 Hfcontinuation sheet 22 of 30

PRINTED: 11/12/2025
FORM APPROVED

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

R
MHL013-226 8 WING ______H!4HH~— 10/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
519 UNION STREET SOUTH
CONCORD, NC 28025

(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE

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

UNION POINT

Continued From page 22

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;

(Cc) 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
LIME 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

Division of Health Service Regulation
STATE FORM oon HMFH11 W continuation sheet 23 of 30

PRINTED: 11/12/2025
FORM APPROVED

‘STATEMENT OF DEFICIENCIES (X%1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING: COMPLETED

R
MHL013-226 B. WING ———_______ 10/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
519 UNION STREET SOUTH
CONCORD, NC 28025

(X4) 10 ‘SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE

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

UNION POINT

Continued From page 23

minimizing the occurrence of future incidents. If
all documents needed for the report are not
available within three months of the incident, the
LME may give the provider an extension of up to
three months to submit the final report; and

(3) immediately notifying the following:

(A) the LME responsible for the catchment
area where the services are provided pursuant to
Rule .0604;

(B) the LME where the client resides, if
different;

(C) the provider agency with responsibility
for maintaining and updating the client's
treatment plan, if different from the reporting
provider;

(D) the Department;

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

(F) any other authorities required by law.

This Rule is not met as evidenced by:

Based on record reviews and interviews, the
facility failed to implement written policies
governing their responses to level Il incidents
affecting 3 of 3 clients (Client #1, #2, #3). The
findings are:

Review on 10/6/25 of the facility's incident reports
for Client #1 from July 1, 2025-October 6, 2025
revealed:

No incident reports or Risk/Cause/Analysis for:

- Client #1's refusal of Erythromycin ointment
3.500 grams two times in July ( 7/29, 7/30/25),

- Client #1's refusal of Risperidone 25 mg two
Division of Health Service Regulation

STATE FORM eos HMFH11 {continuation sheet 24 of 30

PRINTED: 11/12/2025
FORM APPROVED.
Division of Health Service Reg

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

R
MHL013-226 8. WING _______H4HH. 10/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
519 UNION STREET SOUTH
CONCORD, NC 28025

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

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

UNION POINT

Continued From page 24

times in August (8/23-8/24/25);

- Client #1's refusal of Dexmethylphenidate
Extended Release 25 mg (milligram) 14 times in
August (8/14-8/26/25) 8/13/25;

- Client #1 refused Dexmethylphenidate Extended
Release 25 mg on 9/11/25;

- Client #1 refused Cyproheptadine 4 mg on
9/11/25.

Review on 10/6/25 of the facility's incident reports
for Client #2 from July 1, 2025-October 6, 2025
revealed:

No incident reports or Risk/Cause/Analysis for:

- Client #2’s refusal of Emtricitabine 200-300mg
four times in September ( 9/19, 9/28-9/30/25);

+ Client #2's Emtricitabine 200-300mg was not
administered two times in September (9/20,
9/21/25);

- Client #2's refusal of Emtricitabine 200-300mg
two times in October (10/1-10/4/25).

Review on 10/6/25 of the facility's incident reports
for Client #3 from July 1, 2025-October 6, 2025
revealed:

No incident reports or Risk/Cause/Analysis for:

- Client #3 refused Guanfacine 4mg on 8/19/25;
- Client #3 refused Guanfacine 4mg on 9/29/25;
- Client #3 refused Risperidone 0.5mg on 8/2/25
- Client #3 refused Risperidone 0.5mg on 9/2/25;
- Client #3 refused Methylphenidate 36mg on
9/2/25;

- Client #3's Flonase 200mg was not
administered five times in September(9/1-9/5/25).

Interview on 10/6/25 with Staff #2 revealed:

- Completed incident reports when a client

refused medication on her shift;

- Was not aware incident reports were not being

completed when a client refused their

medications.

Division of Health Service Regulation

STATE FORM 000 HMFH11 continuation sheet 25 of 30

PRINTED: 11/12/2025
FORM APPROVED
Division of Health Service Regulation

‘STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X%3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILOING: COMPLETED

R
MHL013-226 8 wi ______W 40/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
519 UNION STREET SOUTH
CONCORD, NC 28025

(X4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDED 8Y FULL (EACH CORRECTIVE ACTION SHOULD BE

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

UNION POINT

Continued From page 25

Interview on 10/9/25 with the Associate
Professional revealed:

- Was responsible for making sure incident
reports were completed;

- Documented on the MARs, and in the client's
notes if the clients refused their medication but
did not complete an incident report;

- Planned to start documenting medication refusal
on incident reports.

Interview on 10/10/25 with the Qualified
Professional revealed:

- Learned in a meeting in September (2025), that
incident reports should be completed when a
client refused their medication.

1.Tuming Point Homes posted a sign with
27G .0304(b)(4) Hot Water Temperatures compliance rules for temperature range 10/10/2025

the water meter on 10/10/2025. ongoing
10A NCAC 27G .0304 FACILITY DESIGN AND aia palabra review

EQUIPMENT 2.Tuming Point Homes created a water
(b) Safety: Each facility shall be designed, temp fog to be filled out weekly by a staff
constructed and equipped in a manner that member. The temperature log was

+ i created on 10/7/2025
ensures the physical safety of clients, staff and and implemented in the week of

visitors. - : 10/13/2025.
(4) In areas of the facility where clients are

exposed to hot water, the temperature of the
water shall be maintained between 100-116
degrees Fahrenheit.

This Rule is not met as evidenced by:
Based on the interviews and observation the
facility failed to ensure that hot water was
maintained between 100 and 116 degrees
Fahrenheit. The findings are:

Observation on 10/6/25 at approximately
3:41-3:47pm of the facility's hot water

Division of Health Service Regulation
STATE FORM aan HMFH11 continuation sheet 26 of 30

PRINTED: 11/12/2025
FORM APPROVED

STATEMENT OF DEFICIENCIES (X41) PROVIDER/SUPPLIER/CLIA (X%2) MULTIPLE CONSTRUCTION (%3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A BUILDING: COMPLETED

R
MHL013-226 B. WING ____________ 10/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
519 UNION STREET SOUTH
CONCORD, NC 28025

(X4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE

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

UNION POINT

Continued From page 26

temperature revealed:

- Water temperature in the kitchen sink was
135 degrees Fahrenheit

~ Water temperature in Client #2's bathroom
sink was 135 degrees Fahrenheit

- Water temperature in Client #3's bathroom
sink was 135 degrees Fahrenheit

- Water temperature in the bathroom in the
hallway was 135 degrees Fahrenheit

Interview on 10/6/25 with Client #1 revealed:
- "I think it's too low, the water is cold;
- Had not been burned by the water.

Interview on 10/6/25 with Client #2 revealed:
- The water was not too hot;
~ Had not been burned by the water.

Interview on 10/6/25 with Client #3 revealed:
- The water was not too hot;
- Had not been burned by the water.

Interview on 10/6/25 with Staff #1 revealed:

~ There were three water temperature levels (A,
B, C) on the hot water heater;

- Turned the hot water heater back down to level
A from level B on 10/6/25 due to level B water
temperature being too hot;

- “Level Ais usually not hot enough;"

- Hot water temperature was turned up to level B
on 10/6/25 so the facility could be clean due to a
staff member being sick in the facility over the
weekend.

Interview on 10/6/25 with Staff #2 revealed:
- Clients nor facility staff were burned by the
water;
- "The water is normally never that hot (135
degrees Fahrenheit);
- "They (staff) must have just done that (turned
Division of Health Service Regulation
STATE FORM based HMFH11 If continuation sheet 27 of 30

PRINTED: 11/12/2025
FORM APPROVED

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

R
MHL013-226 8. WING _____.___. 10/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
519 UNION STREET SOUTH
CONCORD, NC 28025

(X4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

UNION POINT

V 752} Continued From page 27

the water temperature up) it's usually too cool."

Interview on 10/6/25 with the Shift Supervisor
revealed:

- Turned up the water temperature on 10/6/25 to
clean the facility after learning a staff member
had been sick in the facility over the weekend;

- Planned to turn back down the water before
leaving shift on 10/6/25.

Interview on 10/9/25 with the Associate
Professional (AP) revealed:

- "The water was turned up due to us (staff)
sterilizing in the home;"

- "We have never had concerns with the water,
it's always been 107;"

- "We (AP and maintenance) check the water
every month."

Interview on 10/6/25 with the Quality
Management Director revealed:

- Had staff to turn the water temperature down on
10/6/25 due to the water being too hot;

- Maintenance checked the water temperature
monthly;

- There was not a log of the water temperature
that was checked monthly.

Review on 10/6/25 of the Plan of Protection
written by the Quality Management Director and
dated 10/6/25 revealed:

“What immediate action will the facility take to
ensure the safety of the consumers in your care?
Once TPH (Turning Point Homes) (Licensee)
learned the water temperature was too high we
immediately acted and lowered the temperature
on site.

Describe your plans to make sure the above
happens.

TPH will post a sign with compliance rules for
Division of Health Service Regulation

STATE FORM Cd HMFH11 W continuation sheet 28 of 30

PRINTED: 11/12/2025
FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING: COMPLETED

R
MHL013-226 BWING 10/21/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
519 UNION STREET SOUTH
CONCORD, NC 28025

(X4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE

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

UNION POINT

Continued From page 28

temperature range on the water meter.
TPH will create a water temp log to be filled out
weekly by the AP."

Review on 10/6/25 of the amended Plan of
Protection written by the Quality Management
Director and dated 10/6/25 revealed:

"What immediate action will the facility take to
ensure the safety of the consumers in your care?
Once Turning Point Homes learned the water
temperature was too high in the kitchen and the
three bathrooms, we immediately acted by
lowering the water temperature on site.

Staff retested the water temperature in the
kitchen and 3 bathrooms; the newly tested
temperature was: 107' f (Fahrenheit).

Describe your plans to make sure the above
happens.

Turning Point Homes will post a sign with
compliance rules for temperature range on the
water meter by 10/10/2025.

Turning Point Homes will create a water temp log
to be filled out weekly by the AP. The temperature
log will be created on 10/7/2025 and implemented
in the week of 10/13/2025."

The facility served clients who were between 12
and 17 years old and diagnosed with Attention
Deficit Hyperactivity Disorder, Oppositional
Defiant Disorder, Intermittent Explosive Disorder,
Post Traumatic Stress Disorder, Cannabis Use
Disorder. On 10/16/25, the hot water temperature
in the facility was 135 degrees Fahrenheit in the
kitchen, the hallway bathroom, Client #2's
bathroom and Client #3's bathroom. The clients
were being exposed to hot water of 135 degrees
Fahrenheit which placed them at substantial risk
of harm.

This deficiency constitutes a Type A2 rule
violation for substantial risk of serious harm and
Division of Health Service Regulation

STATE FORM — HMFH11 H{ continuation sheet 29 of 30

PRINTED: 11/12/2025
FORM APPROVED

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

R
MHLO13-226 8. WING £____ 10/21/2025

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

519 UNION STREET SOUTH
CONCORD, NC 28025

(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

UNION POINT

V 752! Continued From page 29
must be corrected within 23 days.

Division of Health Service Regulation

STATE FORM Ld HMFH11 Hf continuation sheet 30 of 30
.

20

: Sie A ti~ L0 -Qoy6~

inspection_type: MHLCS Annual, Complaint, and Follow-up