summary: Statement of Deficiency - MHLCS Annual

raw_content:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G303
NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

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

(x4) ID
PREFIX
TAG

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

PRINTED: 10/30/2023

FORM APPROVED

OMB NO. 0938-0391

STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD
CHARLOTTE, NC 28212
ID PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH CORRECTIVE ACTION SHOULD BE

TAG CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

(X3) DATE SURVEY

COMPLETED

10/20/2023

(8)
COMPLETION
DATE

W 195 | ACTIVE TREATMENT SERVICES

CFR(s): 483.440

The facility must ensure that specific active
treatment services requirements are met.

This CONDITION is not met as evidenced by:
The team failed to: assure that each client
received a continuous active treatment program,
which includes aggressive, consistent
implementation of a program of specialized and
generic training and treatment directed towards
the acquisition of the behaviors necessary for the
client to function with as much self-determination
and independence as possible (W196); assure
the individual program plan included, for those
clients who lack them, training in personal skills
essential for privacy and independence
(including, but not limited to, toilet training,
personal hygiene, dental hygiene, self-feeding,
bathing, dressing, grooming, and communication
of basic needs), until it has been demonstrated
that the client is developmentally incapable of
acquiring them. (W242); assure data relative to
accomplishment of the criteria specified in client
individual program plan objectives must be
documented in measurable terms. (W252);
assure the individual program plan was reviewed
at least by the qualified intellectual disabilities
professional (QIDP) and revised as necessary,
including, but not limited to situations in which the
clients are failing to progress toward identified
objectives after reasonable efforts have been
made. (W257); and assure at least annually, that
the individual program plan was revised, as
appropriate. (W260).

The cumulative effect of these systemic practices

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

W 195

TITLE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that

other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14

days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued

program participation.

(X6) DATE

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:L3TL11

Facility ID: 924981

If continuation sheet Page 1 of 17

PRINTED: 10/30/2023
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

34G303 10/20/2023

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD

CHARLOTTE, NC 28212

MONROE ROAD

CFR(s): 483.440(a)(1)

Each client must receive a continuous active
treatment program, which includes aggressive,
consistent implementation of a program of
specialized and generic training, treatment, health
services and related services described in this
subpart, that is directed toward:

(i) The acquisition of the behaviors necessary for
the client to function with as much self
determination and independence as possible; and

(ii) The prevention or deceleration of regression
or loss of current optimal functional status.

This STANDARD is not met as evidenced by:
Based on observations and interview, verified by
review of record, the facility failed to assure that 6
of 6 clients in the group home (#1, #2, #3, #4, #5
and #6) received an aggressive and continuous
active treatment program directed towards
acquisition of skills identified in their person
centered plans (PCPs). The findings are:

A. Cross-reference W252. The facility failed to
assure that data was collected and documented
in sufficient frequency in the record to adequately
assess Client status towards the active treatment
goals in the PCPs for 6 of 6 clients in the group
home (#1, #2, #3, #4, #5 and #6).

B. Cross-reference W257. The facility failed to
assure that the qualified intellectual disabilities
professional (QIDP) reviewed and revised training
objectives included in their PCPs when necessary

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:L3TL11

Facility ID: 924981

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION %5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 195 | Continued From page 1 W 195
resulted in the team's failure to provide statutorily
mandated active treatment services to its clients.
W 196 | ACTIVE TREATMENT W 196

If continuation sheet Page 2 of 17

PRINTED: 10/30/2023
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION
IDENTIFICATION NUMBER:

(X3) DATE SURVEY

ABUILDING COMPLETED

34G303 10/20/2023

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD

CHARLOTTE, NC 28212

MONROE ROAD

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION %5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 196 | Continued From page 2 W 196
for 6 of 6 clients in the group home (#1, #2, #3,
#4, #5 and #6).

C. Cross-reference W242. The facility failed to
develop objectives to meet the basic skill needs
for inclusion in the PCPs for 4 of 6 clients in the
group home (#2, #4, #5 and #6).

D. Cross-reference W260. The facilily failed to
assure the PCPs for 2 of 6 clients (#4 and #5) in
the group home were revised, updated and
available on an annual basis as required.

W 242 | INDIVIDUAL PROGRAM PLAN W 242
CFR(s): 483.440(c)(6)(iii)

The individual program plan must include, for
those clients who lack them, training in personal
skills essential for privacy and independence
(including, but not limited to, toilet training,
personal hygiene, dental hygiene, self-feeding,
bathing, dressing, grooming, and communication
of basic needs), until it has been demonstrated
that the client is developmentally incapable of
acquiring them.

This STANDARD is not met as evidenced by:
The facility failed to assure the person centered
plans (PCPs) for 4 of 6 clients (#2, #4, #5 and #6)
included training in personal skills essential for
independence in toilet training, personal hygiene,
dental hygiene, self-feeding, bathing, dressing,
grooming and communication of basic needs as
evidenced by observations, interviews and record
verification. The findings are:

A. Review of client #4's most recent available
PCP dated 8/10/22 revealed the client to currently
have only 1 program to choose and participate in
an activity. This is noted to be the client's only

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:L3TL11 Facility ID: 924981 If continuation sheet Page 3 of 17

PRINTED: 10/30/2023
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

34G303 10/20/2023

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD

CHARLOTTE, NC 28212

MONROE ROAD

active treatment training objective as the client's
other 3 objectives are noted to be other service
goals (OSGs) for communication skills, gum
cleaning and exercise.

Further review of client #4's PCP revealed a
habilitation evaluation dated 9/20/23 which noted
recommendations for the client to have training
needs in bathroom use, meal preparation,
working on safety skills and further development
in the areas of self-help, independent living, and
community living skills. The habilitation
evaluation noted that self-help skills continues to
be a priority.

Continued review of the PCP also revealed an
adaptive behavior inventory (ABI) dated 9/26/23
which noted the client has deficits in dressing,
grooming, clothing care, meal preparation,
housekeeping and personal independence such
as picking up the mail. Observations of client #4
during the 10/19-20/23 survey revealed the client
to spend her time during afternoon observations
from 3:30 PM until 5:00 PM sitting on the couch in
the living room with peers except for 5 minutes at
4:35 PM when staff assisted the client to the
bathroom. Further observations revealed no
objective training was observed during this time.

Interviews to verify client programming were
difficult as the facility QIDP, home manager and
administrator are no longer employed or were
unavailable. Interview with the acting QIDP by
phone during the survey exit verified her review
noted a lack of active treatment programming and
program development to meet the client's needs.

B. Review of client #5's most recent available
PCP dated 8/5/22 revealed the client to currently

FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID:L3TL11

Facility ID: 924981

(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 COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 242 | Continued From page 3 W 242

If continuation sheet Page 4 of 17

PRINTED: 10/30/2023
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

34G303 10/20/2023

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD

CHARLOTTE, NC 28212

MONROE ROAD

have 3 objectives to follow a toileting schedule,
deliver friendship trays and complete a
social/leisure activity. Further review of the PCP.
revealed the client to also have 4 OSGs to
maintain learned skills of oral care, signing
bathroom, shampooing hair and exercise by
walking.

Continued review of the PCP revealed a
habilitation evaluation dated 9/20/23 which noted
recommendations for the client to have training
needs in wearing shoes/slipper in the home, self
medication administration skills, communication
skills and participating in an activity. The
habilitation evaluation again noted further
development for the client was needed in
self-help skills, communication, independent
living, self-direction and community living skills.

In addition, subsequent review of the PCP.
revealed an ABI dated 9/26/23 which noted client
#5 has needs bathing self thoroughly, drying self
and shampooing hair. The ABI also noted the
client is not independent in recreation/leisure or
housekeeping skills. Observations during the
10/19-20/23 survey, substantiated by review of
the client's PCP, revealed the client to be
non-verbal but have no training to increase
communication skills.

Interviews to verify client programming were
difficult as the facility QIDP, home manager and
administrator are no longer employed or were
unavailable. Interview with the acting QIDP by
phone during the survey exit verified her review
noted a lack of active treatment programming and
program development to meet the client's needs.

C. Review of client #6's PCP dated 1/10/23

FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID:L3TL11

Facility ID: 924981

(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 COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 242 | Continued From page 4 W 242

If continuation sheet Page 5 of 17

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G303
NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

PRINTED: 10/30/2023
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

10/20/2023
STREET ADDRESS, CITY, STATE, ZIP CODE

7621 MONROE ROAD
CHARLOTTE, NC 28212

revealed the client to currently have 3 goals to dry
her body after showering, exercise and deliver
friendship trays. Further review of the PCP
revealed the client to also have 3 OSGs to
maintain skills of washing hands, brushing teeth
and communication.

Continued review of the PCP revealed a
habilitation evaluation dated 1/27/22 which noted
recommendation for the client's next training to
include grooming skills, bathroom use, dining
skills, communication and participating in daily
activities. Subsequent review of the PCP also
revealed an ABI dated 9/26/23 which notes the
client to have no independence in signaling the
need to used the bathroom or washing her hands
after toileting. The ABI also noted client #6 needs
prompting at times while eating to slow down and
shows no independence in meal preparation or
housekeeping skills. Subsequent review of the
PCP revealed the client does not make choices in
daily activities or recreation/leisure items.

Interviews to verify client programming were
difficult as the facility QIDP, home manager and
administrator are no longer employed or were
unavailable. Interview with the acting QIDP by
phone during the survey exit verified her review
noted a lack of active treatment programming and
program development to meet the client's needs.

D. Review of client #2's PCP dated 10/02/23
revealed the client currently has 3 goals to select
an outfit, exercise, and work on single digit
addition. Further review of the PCP revealed the
client to also have 2 OSGs to grab a toothbrush
and apply lotion.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:L3TL11

(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 COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 242 | Continued From page 5 W 242

Facility ID: 924981 If continuation sheet Page 6 of 17

PRINTED: 10/30/2023
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

34G303 10/20/2023

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD

CHARLOTTE, NC 28212

MONROE ROAD

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

PROVIDER'S PLAN OF CORRECTION (x5)

(x4) ID
PREFIX
TAG

COMPLETION
DATE

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

DEFICIENCY)

W 242 | Continued From page 6

Review of the PCP revealed an ABI dated 9/26/23
which notes the client to have no independence
with flossing teeth. The ABI also noted client #2
has a need with no independence in emptying the
garbage outside and sweeping.

Interviews to verify client programming were
difficult as the facility QIDP, home manager and
administrator are no longer employed or were
unavailable. Interview with the acting QIDP by
phone during the survey exit verified her review
noted a lack of active treatment programming and
program development to meet the client's needs.
PROGRAM DOCUMENTATION

CFR(s): 483.440(e)(1)

W 252

Data relative to accomplishment of the criteria
specified in client individual program plan
objectives must be documented in measurable
terms.

This STANDARD is not met as evidenced by:
The facility failed to assure data for the objective
training included in the person centered plans
(PCPs) for 6 of 6 clients in the home (#1, #2, #3,
#4, #5 and #6) was documented adequately to
determine accomplish of the objectives as
evidenced by interview and record verification.
The findings are:

A. Interview with acting administrative staff
revealed client #4's current PCP had reportedly
occurred 8/25/23, however the PCP was
unavailable for review. Review of client #4's most
recent available PCP dated 8/10/22 revealed the
client to have one objective to choose and

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:L3TL11

W 242

W 252

Facility ID: 924981

If continuation sheet Page 7 of 17

PRINTED: 10/30/2023
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

34G303 10/20/2023

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD

CHARLOTTE, NC 28212

MONROE ROAD

participate in an activity and 3 other service goals
(OSGs) for communication skills, exercise and
clean her gums. Review of the cleaning her
gums OSG revealed data should be taken daily.
Review of the client's only objective and other
OSGs revealed data for each should be taken
weekly.

Review of program data for the past 6 months for
client #4's only objective and OSGs revealed
either no data or not enough data was
documented for each of her programs for the
past 6 months except for 9/23 where her
communication skills OSG had the prescribed
amount of data. The facility failed to assure data
was taken as prescribed to measure
accomplishment of the objectives as part of a
continuous active treatment program.

B. Interview with acting administrative staff
revealed client #5's current PCP had reportedly
occurred 9/8/23, however the PCP was
unavailable for review. Review of client #5's most
recent available PCP dated 8/5/22 revealed the
client to have 3 objectives to toilet on a schedule,
deliver friendship trays and participate in a
social/leisure task. Further review also revealed
the client to have 4 OSGs for oral care, sign
bathroom, shampoo hair and walk. Review of the
client's toileting schedule program and OSG
program for oral care revealed program data
should be taken on a daily basis. Further review
of the client's other programs and OSGs revealed
all of the others only required weekly data
collection.

Review of program data for the past 6 months for
client #5 revealed data for the 2 programs
requiring daily documentation (toileting schedule

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:L3TL11

Facility ID: 924981

(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 COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 252 | Continued From page 7 W 252

If continuation sheet Page 8 of 17

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G303
NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

PRINTED: 10/30/2023

FORM APPROVED

OMB NO. 0938-0391

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD
CHARLOTTE, NC 28212

(X3) DATE SURVEY

COMPLETED

10/20/2023

and OSG-oral care) were not documented at all
or with limited data for the past 6 months.
Further review of data for client #5's other
programs and other OSGs revealed no data for
any program was taken during 8/23, 7/23 or 6/23.
The facility failed to assure data was taken as
prescribed to measure accomplishment of the
objectives as part of a continuous active
treatment program.

C. Review of client #6's PCP dated 1/10/23
revealed the client to have 3 objectives to dry her
body after showering, deliver friendship trays and
exercise. Further review of the PCP revealed the
client to have 3 OSGs for washing hands,
toothbrushing and communication. Continued
review of the client's programming revealed client
#6's drying body program and OSGs for washing
hands and toothbrushing required daily data
documentation while the client's objective for
delivering friendship trays and exercise along with
the OSG for communication only required
documentation to be taken weekly.

Review of program data for the past 6 months
revealed data was not taken or was not taken
with sufficient frequency for the 3 programs that
require daily documentation (drying body,
OSG-washing hands, OSG-brushing teeth).
Further review of program data for the other
objectives (delivering trays, exercising and
OSG-communication) revealed no data was
taken during the months of 8/23, 7/23 or 6/23.
The facility failed to assure data was taken as
prescribed to measure accomplishment of the
objectives as part of a continuous active
treatment program.

D. Review of client #1's PCP dated 4/8/23

FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID:L3TL11

Facility ID: 924981

(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 COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 252 | Continued From page 8 W 252

If continuation sheet Page 9 of 17

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G303
NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD
CHARLOTTE, NC 28212

PRINTED: 10/30/2023
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

10/20/2023

revealed the client had 4 objectives to choose an
activity, reach for the tissue holder and then tear,
annunciate the first word from a list, and will stop
at the door. Continued review of the client's
programming revealed client #1's reach for tissue
holder and tear, grab her toothbrush, and stop the
door required daily data documentation while the
client's objective for choose an activity and
annunciate the first word, only required
documentation to be taken weekly.

Review of program data for the past 6 months
revealed data was not taken with sufficient
frequency as written for the 4 programs (reach for
the tissue holder and tear, grab her toothbrush,
annunciate the first word from a list, and stop the
door) during the months of 10/23, 9/23, and 5/23.
Further review of program data for the objectives
(choose an activity, reach for the tissue holder
and tear, grab her toothbrush, annunciate the first
word from a list, and stop the door) revealed no
data was taken during the months of 8/23, 7/23 or
6/23. The facility failed to assure data was taken
as prescribed to measure accomplishment of the
objectives as part of a continuous active
treatment program.

E. Review of client #2's PCP dated 10/02/23
revealed the client had 3 objectives to work on
single digit addition, select an outfit, and exercise.
Further review of the PCP revealed the client had
2 OSGs for grab a toothbrush and applying lotion.
Continued review of the client's programming
revealed client #2's OSGs for grab a toothbrush
and applying lotion required daily data
documentation while the client's objective for
work on single digit addition, select an outfit, and
exercise along with the OSG for communication
only required documentation to be taken weekly.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:L3TL11

Facility ID: 924981

(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 COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 252 | Continued From page 9 W 252

If continuation sheet Page 10 of 17

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G303
NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

PRINTED: 10/30/2023

FORM APPROVED

OMB NO. 0938-0391

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD
CHARLOTTE, NC 28212

(X3) DATE SURVEY

COMPLETED

10/20/2023

Review of program data for the past 6 months
revealed data was not taken or was not taken
with sufficient frequency for the 2 programs that
require daily documentation (OSGs grab a
toothbrush and applying lotion). Further review of
program data for the other objectives (work on
single digit addition, select an outfit, and exercise)
revealed no data was taken during the months of
8/23, 7/23, 6/23, and 5/23. The facility failed to
assure data was taken as prescribed to measure
accomplishment of the objectives as part of a
continuous active treatment program.

F. Review of client #3's PCP dated 6/13/23
revealed the client to have 6 objectives to place
elbow over mouth, picks up utensil to eat, stop in
front of door, exercise 5 minutes, point to the
letter staff say, vocalizes in 10 seconds, and 1
OSG to brush her teeth. Continued review of the
client's programming revealed client #6's pick up
utensil to eat and stop in front of door required
daily data documentation while the client's
objective for place elbow over mouth, exercise 5
minutes, point to the letter staff say, vocalizes in
10 seconds, and OSG brush her teeth only
required documentation to be taken weekly.

Review of program data for the past 6 months
revealed data was not taken or was not taken
with sufficient frequency for the 2 programs that
require daily documentation (picks up utensil to
eat and stop in front of the door) for months
10/23, 9/23, and 5/23. Further review of program
data for the other objectives ( place elbow over
mouth, exercise 5 minutes, point to letter staff
say, vocalizes 10 second, and OSG-toothbrush)
revealed no data was taken during the months of
8/23, 7/23 or 6/23. The facility failed to assure

Event ID:L3TL11

FORM CMS-2567(02-99) Previous Versions Obsolete

Facility ID: 924981

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION %5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 252 | Continued From page 10 W 252

If continuation sheet Page 11 of 17

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G303
NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

PRINTED: 10/30/2023
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

10/20/2023
STREET ADDRESS, CITY, STATE, ZIP CODE

7621 MONROE ROAD
CHARLOTTE, NC 28212

CFR(s): 483.440(F)(1)(ii)

The individual program plan must be reviewed at
least by the qualified mental retardation
professional and revised as necessary, including,
but not limited to situations in which the client is
failing to progress toward identified objectives
after reasonable efforts have been made.

This STANDARD is not met as evidenced by:
The facility failed to assure objectives contained
in the person centered plans (PCPs) for 6 of 6
clients in the group home (#1, #2, #3, #4, #5 and
#6) were reviewed and revised by the qualified
intellectual disabilities professional (QIDP) when
necessary including when the clients are failing to
make progress on the objectives as evidenced by
interview and record verification. The findings
are:

A. For client #4, review of the client's most recent
available PCP dated 8/10/22 revealed the client
to have only one objective which is trained weekly
to choose and participate in an activity and 3
other service goals (OSGs) for communication
and exercise trained weekly and clean gums
which is to be trained daily. Review of program
data for the past 6 months revealed limited or no
data to be taken on the client's programs.

Further review of the client's PCP revealed the
client's last QIDP note was dated 7/5/23.
However, the program review section did not
contain any program changes or training even
though no data was taken on any of the client's

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:L3TL11

(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 COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 252 | Continued From page 11 W 252
data was taken as prescribed to measure
accomplishment of the objectives as part of a
continuous active treatment program.
W 257 | PROGRAM MONITORING & CHANGE W 257

Facility ID: 924981 If continuation sheet Page 12 of 17

PRINTED: 10/30/2023
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

34G303

10/20/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD

MONROE ROAD
CHARLOTTE, NC 28212

programs for 7/23, 6/23 or 5/23. Interviews to
verify client programming were difficult as the
facility QIDP, home manager and administrator
are no longer employed or were unavailable.
Interview with the acting QIDP by phone during
the survey exit verified her review noted a lack of
active treatment programming, documentation
and program review and revisions.

B. For client #5, review of the client's most recent
available PCP dated 8/5/22 revealed the client to
have 3 objectives to toilet on a schedule which is
to be trained daily and deliver friendship trays and
complete a social/leisure activity trained weekly.
Further review of the PCP revealed the client to
also have 4 OSGs to complete oral care trained
daily and sign bathroom, shampoo hair and
participate in walking all completed weekly.

Continued review of the client's PCP revealed the
client's last QIDP notes were dated 3/10/23 and
7/12/23. However, the program review section
did not contain any program changes or noted
training even though issues with taking data or
accurate data was noted for each of the client's
programs for each months review by the facility
habilitation specialist. Interviews to verify client
programming were difficult as the facility QIDP,
home manager and administrator are no longer
employed or were unavailable. Interview with the
acting QIDP by phone during the survey exit
verified her review noted a lack of active
treatment programming, documentation and
program review and revisions.

C. For client #6, review of the client's PCP dated
1/10/23 revealed to have 3 objectives to dry her

body after showering trained daily and programs
to deliver friendship trays and exercise which are

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:L3TL11

Facility ID: 924981

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION %5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 257 | Continued From page 12 W 257

If continuation sheet Page 13 of 17,

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G303
NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

PRINTED: 10/30/2023
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

10/20/2023
STREET ADDRESS, CITY, STATE, ZIP CODE

7621 MONROE ROAD
CHARLOTTE, NC 28212

trained weekly. Further review of the PCP
revealed the client to also have 3 OSGs to daily
wash hands and brush teeth and communication
trained weekly.

Continued review of the client's PCP revealed the
client's last QIDP note to be dated 1/5/22. No
QIDP reviews were completed to review or revise
the client's programs in over 1 1/2 years.
Interviews to verify client programming were
difficult as the facility QIDP, home manager and
administrator are no longer employed or were
unavailable. Interview with the acting QIDP by
phone during the survey exit verified her review
noted a lack of active treatment programming,
documentation and program review and
revisions.

D. For client #1, review of the client's PCP dated
4/8/23 revealed 4 objectives to choose an activity,
reach for the tissue holder and then tear,
annunciate the first word from a list, and will stop
at the door. Continued review of the client's
programming revealed client #1's reach for tissue
holder and tear, grab her toothbrush, and stop the
door required daily data documentation while the
client's objective for choose an activity and
annunciate the first word, only required
documentation to be taken weekly.

Continued review of the client's PCP revealed
QIDP reviews were not completed for the past 6
months to review or revise the client's programs.
Interviews to verify client programming were
difficult as the facility QIDP, home manager and
administrator are no longer employed or were
unavailable. Interview with the acting QIDP by
phone during the survey exit verified her review
noted a lack of active treatment programming,

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:L3TL11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION %5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 257 | Continued From page 13 W 257

Facility ID: 924981 If continuation sheet Page 14 of 17

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G303
NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

PRINTED: 10/30/2023
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

10/20/2023

STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD
CHARLOTTE, NC 28212

documentation and program review and
revisions.

E. For client #2, review of the client's PCP dated
10/02/23 revealed 3 objectives to work on single
digit addition, select an outfit, and exercise.
Further review of the PCP revealed the client had
2 OSGs for grab a toothbrush and applying lotion.
Continued review of the client's programming
revealed client #2's OSGs for grab a toothbrush
and applying lotion required daily data
documentation while the client's objective for
work on single digit addition, select an outfit, and
exercise along with the OSG for communication
only required documentation to be taken weekly.

Continued review of the client's PCP revealed
QIDP reviews were not completed for the past 6
months to review or revise the client's programs.
Interviews to verify client programming were
difficult as the facility QIDP, home manager and
administrator are no longer employed or were
unavailable. Interview with the acting QIDP by
phone during the survey exit verified her review
noted a lack of active treatment programming,
documentation and program review and
revisions.

F. For client #3, review of the client's PCP dated
6/13/23 revealed the client to have 6 objectives to
place elbow over mouth, picks up utensil to eat,
stop in front of door, exercise 5 minutes, point to
the letter staff say, vocalizes in 10 seconds, and 1
OSG to brush her teeth. Continued review of the
client's programming revealed client #6's pick up
utensil to eat and stop in front of door required
daily data documentation while the client's
objective for place elbow over mouth, exercise 5
minutes, point to the letter staff say, vocalizes in

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:L3TL11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION %5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 257 | Continued From page 14 W 257

Facility ID: 924981 If continuation sheet Page 15 of 17

PRINTED: 10/30/2023
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

34G303 10/20/2023

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD

CHARLOTTE, NC 28212

MONROE ROAD

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

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

(8)
COMPLETION
DATE

(x4) ID
PREFIX
TAG

DEFICIENCY)

W 257 | Continued From page 15

10 seconds, and OSG brush her teeth only
required documentation to be taken weekly.

Continued review of the client's PCP revealed
QIDP reviews were not completed for the past 6
months to review or revise the client's programs.
Interviews to verify client programming were
difficult as the facility QIDP, home manager and
administrator are no longer employed or were
unavailable. Interview with the acting QIDP by
phone during the survey exit verified her review
noted a lack of active treatment programming,
documentation and program review and
revisions.

PROGRAM MONITORING & CHANGE

CFR(s): 483.440(f)(2)

W 260

At least annually, the individual program plan
must be revised, as appropriate, repeating the
process set forth in paragraph (c) of this section.
This STANDARD is not met as evidenced by:
The facility failed to assure the person centered
plans (PCPs) for 2 of 6 clients (#4 and #5) in the
group home were revised, updated and available
as required as evidenced by interview and record
verification. The finding is:

Review of available PCPs on 10/19/23 revealed
client #4's and client #5's PCPs to be dated
8/10/22 and 8/5/22, respectively.

Interview with available administrative staff
revealed the facility qualified intellectual
disabilities professional (QIDP) recently left her
job and apparently a more updated PCP for each
client is inaccessible on her old computer.
Further interview revealed the team has not had
access to these PCPs which details the most

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:L3TL11

W 257

W 260

Facility ID: 924981

If continuation sheet Page 16 of 17

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G303
NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

PRINTED: 10/30/2023
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

10/20/2023
STREET ADDRESS, CITY, STATE, ZIP CODE

7621 MONROE ROAD
CHARLOTTE, NC 28212

updated information and plans for the clients for
the coming year.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:L3TL11

(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 COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 260 | Continued From page 16 W 260

Facility ID: 924981 If continuation sheet Page 17 of 17


state: NC

facility_name: Monroe Road

summary: Statement of Deficiency - MHLCS Complaint

raw_content:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G303
NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

PRINTED: 12/22/2022

FORM APPROVED

OMB NO. 0938-0391

STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD
CHARLOTTE, NC 28212

(X3) DATE SURVEY

COMPLETED

c
12/21/2022

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 000 | INITIAL COMMENTS Ww 000
A complaint survey was completed on 12/21/22
for intake #NC00196141 ans #NC00196248. No
deficiencies were cited.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that

other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days

following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14

days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued

program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID:ZUYO11

Facility ID: 924981

If continuation sheet Page 1 of 1

inspection_type: MHLCS Complaint

document_type: Statement of Deficiency


summary: Statement of Deficiency - MHLCS Follow-up

raw_content:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
(X1) PROVIDER/SUPPLIER/CLIA

STATEMENT OF DEFICIENCIES

PRINTED: 11/06/2022
FORM APPROVED
OMB NO. 0938-0391

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
346303 B. WING 10/20/2022
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
MONROE ROAD 7621 MONROE ROAD
CHARLOTTE, NC 28212
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 000. INITIAL COMMENTS W 000
This facility is in compliance with the
CONDITIONS OF PARTICIPATION for
Intermediate Care Facilities for Individuals with
Intellectual Disabilities found at 42 CFR 483.400
THROUGH 483.460 AND 42 CFR 483.480
(General/Health Requirements).
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued

program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete Event 1D:4ZL611

Facility ID: 924981 If continuation sheet Page 1 of 1

inspection_type: MHLCS Follow-up


summary: Statement of Deficiency - MHLCS Annual

raw_content:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G303
NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

PRINTED: 09/09/2021
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

09/08/2021
STREET ADDRESS, CITY, STATE, ZIP CODE

7621 MONROE ROAD
CHARLOTTE, NC 28212

(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 COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 000 | INITIAL COMMENTS Ww 000
This facility is in compliance with the Conditions
of Participation for Intermediate Care Facilities for
Individuals with Intellectual Disabilities found at
42 CFR 483.400 through 483.460 and 42 CFR
483.480 (GENERAL/HEALTH
REQUIREMENTS).
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued

program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID:U4A411

Facility ID: 924981 If continuation sheet Page 1 of 1

inspection_type: MHLCS Annual


raw_content:
PRINTED: 10/21/2020
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES

(X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
R
346303 10/14/2020

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD

MONROE ROAD
CHARLOTTE, NC 28212

(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 COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 000 | INITIAL COMMENTS Ww 000

Arevisit was conducted on 10/14/2020 for all
previous deficiencies cited on 1/8/2020. All
deficiencies have been corrected, and no new
noncompliance was found. The facility is in
compliance with all regulations surveyed.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued
program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: COYM12 Facility ID: 924981 If continuation sheet Page 1 of 1


summary: Plan of Correction - MHLCS Annual

raw_content:
PRINTED: 01/20/2020
DEPARTMENT OF HEALTHAND HUMAN SERVICES FORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY

ND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED

34G303 B. WING
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD

CHARLOTTE, NC 28212

01/08/2020

MONROE ROAD

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

DEFICIENCY)

W 227 | INDIVIDUAL PROGRAM PLAN W227
CFR(s): 483.440(c)(4)

' 4ealth

The individual program plan states the specific

objectives necessary to meet the client's needs,
as identified by the comprehensive assessment R i Q fi
required by paragraph (c)(3) of this section.

art, Sec. 2n
This STANDARD is not met as evidenced by:
Based on review of records and interview, the
team failed to ensure the individual habilitation
plan (IHP) for 1 of 3 sampled clients (#5) included W 227
objective training to address needs relative to
behavior management. The finding is: RHA Health Services will ensure tugvegeo

all individuals supported (as needed)

Observations in the group home on 1/8/20 will have Behavior
revealed client #5 to be verbally prompted at Support Plans (BSPs) in place to
various times throughout the morning to complete address behaviors which can
morning tasks and hygiene activities. Continued affect themselves
observations revealed client #5 to refuse initial and their peers’ health and safety.
verbal prompts by staff multiple times and then to Client #5 now has a new BSP to
follow through with staff requests (make bed, address her identified target
choose/participate in leisure activity, shower and behaviors. The IDT members will

pack lunch). Observation at 8:05 AM revealed
client #5 to be verbally prompted by staff A to put
on her coat in preparation of leaving the group
home. Client #5 was observed to take the coat of
client #4 and put it on. Continued observation
revealed staff A to redirect client #5 to put on her
own coat to which the client refused. After

monitor and document behaviors
displayed as they occur and will review
monthly with the Psychologist and othet
IDT members. All Behavior Support
Plans continue to be monitored
monthly and adjusted as needed to

multiple efforts to redirect client #5, staff A best support the individuals’ needs.
provided client #5's coat to client #4 and all HSR - Mental Health
clients left the group home. Observation on the

facility van at 8:20 AM revealed client #5 to sit on MAR 10 2020

the van with the lap belt of her seatbelt on and the
shoulder strap behind her back. Staff B was

observed to prompt client #5 to put her shoulder Lic. & Cert. Section
strap on correctly/to which the client refused.

Regional Administrator

Any deficienc Zeding win an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it i determined that
ther safeguaris-provide sulficientpprotection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued
program participation.

TITLE (6) DATE

1/21/2020

FORM CMS-2667(02-99) Previous Versions Obsolete Event ID: COYM11 Facility ID: 924981 If continuation sheet Page 1 of 3

PRINTED: 01/20/2020
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
346303 B. WING 01/08/2020

STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD
CHARLOTTE, NC 28212

NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

(xa) 1D SUMMARY STATEMENT OF DEFICIENCIES iP) PROVIDER'S PLAN OF CORRECTION «s)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
Continued From page 1 W227 W227
| 1/9/2020
Review of records for client #5 on 1/8/20 revealed RHA Health Services will ensure
an IHP dated 10/4/19 with current objectives Client #5 has a program developed

relative to exercise, laundry, set table and
community integration. Further review of records
for client #5 revealed no behavior support plan or
guidelines to address refusal or non-compliance
behavior. Additional review of the 10/2019 IHP
revealed client #5 is able to sit in a seat on the
van and buckle/unbuckle the seat belt.

to address non-compliance with
properly wearing a seatbelt to ensure
her ongoing health and safety. The
program will be monitored monthly
by the Habiliation Specialist and QP.
The IDT members will ensure the
program is modified as needed to

Interview with staff B on 1/8/20 revealed client #5 best support the individual.
will at times wear other client's clothing especially
if it has a hood. Steff B further indicated
sometimes client #5 can be redirected to wear
her own clothing if she is presented with
something that she likes or prefers. Additional
interview with staff B revealed it has been an
ongoing, everyday issue for client #5 to refuse to
wear her seat belt correctly, placing the shoulder
strap behind her back. Interview with the
Habilitation specialist and facility qualified
intellectual disabilities professional (QIDP)
verified client #5 has recently had an increase in
refusal behavior. Further interview with the
habilitation specialist and QIDP verified client #5
should have formal training to address the
increase in non-compliance behavior.

W 382 | DRUG STORAGE AND RECORDKEEPING W 382
CFR(s): 483.460(I)(2)

The facility must keep all drugs and biologicals
locked except when being prepared for
administration.

This STANDARD is not met as evidenced by:
Based on observation and interview, the facility

FORM CMS-2567 (02-88) Previous Versions Obsolete Event ID: COYM11 Facility ID: 924981 If continuation shéet Page 2 of 3

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 01/20/2020
FORM APPROVED
OMB NO. 0938-0391

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

346303

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

B. WING

NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

(x3) DATE SURVEY
COMPLETED

01/08/2020

STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD
CHARLOTTE, NC 28212

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

(x4) 1D
PREFIX
TAG

Continued From page 2

failed to assure all drugs and biologicals were
kept locked except when being prepared for
administration. The finding is:

Observation in the group home on 1/8/20 at 6:15
AM revealed the facility home manager (HM) to
knock and enter the bedroom of client #2 with the
group home medication cart. The HM was
observed to unlock the medication cart and take
out medications, After reviewing medications the
HM indicated she needed to call the facility nurse
as she had a question about client #2's
medications. Continued observation revealed the
HM to leave client #2's medications on top of the
medication cart and to exit client #2's room to get
the phone for the group home. It should be noted
the surveyor at this time exited the clients room
with the HM and observed client #2's door to
remain partially open while the HM went up the
hallway of the group home, entered another
clients roam looking for the group home phone
and then returned to client #2's room.

Interview with the HM on 1/8/20 revealed
medications should never be left unlocked or left
out unattended. Further interview with the HM
revealed she should never have left medications
out in client #2's room while going to get the
phone. The HM further reported she forgot and
lost focus while trying to ensure she was giving
client #2 the proper medications. Interview with
the facility nurse and qualified intellectual
disabilities professional further verified
medications should not have been left unlocked
or unattended at anytime.

$$  —______—_—_—_+

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

DEFICIENCY)

Xs)
COMPLETION
DATE

W 382 W 382

RHA Health Services will ensure all
direct support staff and supervisors

are in-serviced on proper medication
storage procedures to ensure all
medications are locked and properly
secured. The Home Manager will be
re-trained by the QP on the correct
medication storage procedures. This
process will be monitored monthly

by the QP, LPN and/or Habilitation
Specialist to ensure the Home Manager
is following the correct Medication
Administration procedures. The
Medication Observation Assessment will
continue to be reviewed monthly by the
CQi Committee.

FORM CMS-2567 (02-99) Previous Versions Obsolete

Event ID: COYM11

a

Facility ID: £24981

3/8/2020

If continuation sheet Page 3 of 3

HEALTH SERVICES

January 21, 2020

Ms. Kaila Mitchell

Facility Compliance Consultant II

Mental Health Licensure & Certification Section
NC Division of Health Service Regulation

952 Old US Highway 70

Black Mountain, NC 28711-4501

RE: MHL-060-222 Monroe Road

Dear Ms. Mitchell:

Please see the enclosed Plan of Correction (POC) for the deficiencies sited at the
Monroe Road Group Home during your annual survey visit on 1/8/2020. We have
implemented the POC and invite you to return to the facility on or around
3/8/2020 to review our POC items.

Please contact me with any further issues or concerns regarding the Monroe Road
Group Home (MHL-060-222).

Sincerely,

Anee

Katherine Benton DHSR - Mental Health
Regional Administrator

RHA Health Services, LLC
kbenton@rhanet.org ' Lic, & Cert. section

Kannapolis Unit 195 Ervin Woods Dr. Kannapolis, NC 28081 704-925-8041 (0) 704-925-8140 (F)

NC DEPARTMENT OF ROY COOPER + Govemor
HE MANDY COHEN, MD, MPH = Secretary

ALTH AND
‘ HUMAN SERVICES MARK PAYNE © Director, Division of Health Service Regulation

January 21, 2020

Katherine Benton, Administrator
RHA Health Services, Inc.

195 Ervin Woods Drive
- Mental Health
Kannapolis, NC 28081 DHSR - Mental Hea’

Re: Recertification Completed January 8, 2020
Monroe Road
Provider Number# 34G303 Lic. & Cert. Section
MHL# 060-222
E-mail Address: kbenton@rhanet.org

Dear Ms. Benton:

Thank you for the cooperation and courtesy extended during the recertification survey
completed January 8, 2020. This survey was required for continued participation in the Medicaid
program.

Enclosed you will find all deficiencies cited listed on the Statement of Deficiencies Form (CMS-
2567). The purpose of the Statement of Deficiencies is to provide you with specific details of the
practices that do not comply with regulations. You must develop one Plan of Correction that
addresses each deficiency listed on the CMS-2567 form and return it to our office within ten
days of receipt of this letter. Below you will find details of the type of deficiencies found, the
time frames for compliance and what to include in the Plan of Correction.

Type of Deficiencies Found
« Standard level deficiencies were cited.

Time Frames for Compliance
° Standard level deficiencies must be corrected within 60 days from the exit of the

survey, which is March 8, 2020.

What to include in the Plan of Correction
Indicate what measures will be put in place to correct the deficient area of practice (i.e.
changes in policy and procedure, staff training, changes in staffing patterns, etc.).
e Indicate what measures will be put in place to prevent the problem from occurring again.
e Indicate who will monitor the situation to ensure it will not occur again.
e Indicate how often the monitoring will take place.
e Sign and date the bottom of the first page of the CMS-2567 Form.

MENTAL HEALTH LICENSURE & CERTIFICATION SECTION
NC DEPARTMENT OF HEALTH AND HUMAN SERVICES * DIVISION OF HEALTH SERVICE REGULATION

LOCATION: 4800 Umstead Drive, Williams Building, Raleigh, NC 27603
MAILING ADDRESS: 2718 Mail Service Center, Raleigh, NC 27699-2718
www.nedhhs.gov/dhsr « TEL: 919-855-3795 * FAX: 919-715-8078

AN EQUAL OPPORTUNITY / AFFIRMATIVE ACTION EMPLOYER

January 21, 2020
RHA Health Services, Inc.
Ms. Katherine Benton

Make a copy of the Statement of Deficiencies with the Plan of Correction to retain for your
records. Please do not include confidential information in your plan of correction and
please remember never to send confidential information (protected health information)
via email.

Send the original completed form to our office at the following address within 10 days of receipt
of this letter.

Mental Health Licensure and Certification Section
NC Division of Health Service Regulation
2718 Mail Service Center
Raleigh, NC 27699-2718

Please be advised that additional W tags may be cited during the Life Safety Code portion of the
recertification survey.

A follow up visit will be conducted to verify all deficient practices have been corrected. If we can
be of further assistance, please call me at (828) 750-2664.

Sincerely,

fet

Kaila Mitchell

Facility Compliance Consultant II

Mental Health Licensure & Certification Section
Enclosures

Cc: —qmemail@cardinalinnovations.org

document_type: Plan of Correction


summary: Statement of Deficiency - MHLCS Annual

raw_content:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G303
NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

SUMMARY STATEMENT OF DEFICIENCIES

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

PRINTED: 01/20/2020

FORM APPROVED

OMB NO. 0938-0391

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD
CHARLOTTE, NC 28212

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

(X3) DATE SURVEY

COMPLETED

01/08/2020

(8)

COMPLETION
DATE

W 227 | INDIVIDUAL PROGRAM PLAN

CFR(s): 483.440(c)(4)

The individual program plan states the specific
objectives necessary to meet the client's needs,
as identified by the comprehensive assessment
required by paragraph (c)(3) of this section.

This STANDARD is not met as evidenced by:
Based on review of records and interview, the
team failed to ensure the individual habilitation
plan (IHP) for 1 of 3 sampled clients (#5) included
objective training to address needs relative to
behavior management. The finding is:

Observations in the group home on 1/8/20
revealed client #5 to be verbally prompted at
various times throughout the morning to complete
morning tasks and hygiene activities. Continued
observations revealed client #5 to refuse initial
verbal prompts by staff multiple times and then to
follow through with staff requests (make bed,
choose/participate in leisure activity, shower and
pack lunch). Observation at 8:05 AM revealed
client #5 to be verbally prompted by staff A to put
on her coat in preparation of leaving the group
home. Client #5 was observed to take the coat of
client #4 and put it on. Continued observation
revealed staff A to redirect client #5 to put on her
own coat to which the client refused. After
multiple efforts to redirect client #5, staff A
provided client #5's coat to client #4 and all
clients left the group home. Observation on the
facility van at 8:20 AM revealed client #5 to sit on
the van with the lap belt of her seatbelt on and the
shoulder strap behind her back. Staff B was
observed to prompt client #5 to put her shoulder
strap on correctly to which the client refused.

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

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that

W 227

TITLE

(X6) DATE

other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days

following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14

days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued

program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: COYM11

Facility ID: 924981

If continuation sheet Page 1 of 3

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G303
NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

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

(x4) ID
PREFIX
TAG

PRINTED: 01/20/2020

FORM APPROVED

OMB NO. 0938-0391

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD
CHARLOTTE, NC 28212

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

ID
PREFIX
TAG

(X3) DATE SURVEY

COMPLETED

01/08/2020

(8)
COMPLETION
DATE

W 227 | Continued From page 1

Review of records for client #5 on 1/8/20 revealed
an IHP dated 10/4/19 with current objectives
relative to exercise, laundry, set table and
community integration. Further review of records
for client #5 revealed no behavior support plan or
guidelines to address refusal or non-compliance
behavior. Additional review of the 10/2019 IHP.
revealed client #5 is able to sit in a seat on the
van and buckle/unbuckle the seat belt.

Interview with staff B on 1/8/20 revealed client #5
will at times wear other client's clothing especially
if it has a hood. Staff B further indicated
sometimes client #5 can be redirected to wear
her own clothing if she is presented with
something that she likes or prefers. Additional
interview with staff B revealed it has been an
ongoing, everyday issue for client #5 to refuse to
wear her seat belt correctly, placing the shoulder
strap behind her back. Interview with the
Habilitation specialist and facility qualified
intellectual disabilities professional (QIDP)
verified client #5 has recently had an increase in
refusal behavior. Further interview with the
habilitation specialist and QIDP verified client #5
should have formal training to address the
increase in non-compliance behavior.

DRUG STORAGE AND RECORDKEEPING
CFR(s): 483.460(1)(2)

W 382

The facility must keep all drugs and biologicals
locked except when being prepared for
administration.

This STANDARD is not met as evidenced by:
Based on observation and interview, the facility

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: COYM11

W 227

W 382

Facility ID: 924981

If continuation sheet Page 2 of 3

PRINTED: 01/20/2020
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

34G303 01/08/2020

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD

MONROE ROAD
CHARLOTTE, NC 28212

failed to assure all drugs and biologicals were
kept locked except when being prepared for
administration. The finding is:

Observation in the group home on 1/8/20 at 6:15
AM revealed the facility home manager (HM) to
knock and enter the bedroom of client #2 with the
group home medication cart. The HM was
observed to unlock the medication cart and take
out medications. After reviewing medications the
HM indicated she needed to call the facility nurse
as she had a question about client #2's
medications. Continued observation revealed the
HM to leave client #2's medications on top of the
medication cart and to exit client #2's room to get
the phone for the group home. It should be noted
the surveyor at this time exited the clients room
with the HM and observed client #2's door to
remain partially open while the HM went up the
hallway of the group home, entered another
clients room looking for the group home phone
and then returned to client #2's room.

Interview with the HM on 1/8/20 revealed
medications should never be left unlocked or left
out unattended. Further interview with the HM
revealed she should never have left medications
out in client #2's room while going to get the
phone. The HM further reported she forgot and
lost focus while trying to ensure she was giving
client #2 the proper medications. Interview with
the facility nurse and qualified intellectual
disabilities professional further verified
medications should not have been left unlocked
or unattended at anytime.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: COYM11

Facility ID: 924981

(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 COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 382 | Continued From page 2 W 382

If continuation sheet Page 3 of 3


raw_content:
PRINTED: 03/04/2019
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES

(X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
R
346303 02/28/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD

MONROE ROAD
CHARLOTTE, NC 28212

(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 COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 000 | INITIAL COMMENTS Ww 000

Arevisit was conducted on 2/28/19 for all
previous deficiencies cited on 12/19/18. All
deficiencies have been corrected, and no new
noncompliance was found. The facility is in
compliance with all regulations surveyed.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued
program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:SP2H12 Facility ID: 924981 If continuation sheet Page 1 of 1


summary: Statement of Deficiency - MHLCS Annual

raw_content:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G303
NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

SUMMARY STATEMENT OF DEFICIENCIES

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

PRINTED: 01/04/2019

FORM APPROVED

OMB NO. 0938-0391

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD
CHARLOTTE, NC 28212
ID PROVIDER'S PLAN OF CORRECTION
PREFIX (EACH CORRECTIVE ACTION SHOULD BE

TAG CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

(X3) DATE SURVEY

COMPLETED

12/19/2018

(8)

COMPLETION
DATE

W 153 | STAFF TREATMENT OF CLIENTS

CFR(s): 483.420(d)(2)

The facility must ensure that all allegations of
mistreatment, neglect or abuse, as well as
injuries of unknown source, are reported
immediately to the administrator or to other
Officials in accordance with State law through
established procedures.

This STANDARD is not met as evidenced by:
Based on observation, record review and
interviews, the facility failed to ensure an injury
was reported to the administrator immediately for
1 of 3 sampled clients (#3). The finding is:

Observations conducted in the group home on
12/18/18 at 4:50 PM revealed client #3 had an
open, excoriated area approximately 1/2 inch in
diameter on her left hand near the base of her
thumb. Interview conducted with direct care staff
at that time revealed no knowledge of how or
when the injury to client #3's left hand occurred.

Review of incident/accident reports for client #3,
conducted on 12/19/18, revealed the most recent
incident involving injury to client #3 was dated
5/11/18 and documented client #3 was scratched
on the arm by another client on that date.
Interviews conducted with the qualified intellectual
disabilities professional (QIDP) and the nurse
revealed the injury to client #3's hand had not
been reported to the QIDP or the nurse and no
treatment treatment had been documented as
having been completed. Further interview with
the nurse verified the injury to client #3's hand
should have been reported to the nurse and the
QIDP immediately.

W 331 | NURSING SERVICES

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

W 153

W 331

TITLE

(X6) DATE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued

program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID:SP2H11

Facility ID: 924981 If continuation sheet Page 1 of 6

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G303
NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD
CHARLOTTE, NC 28212

PRINTED: 01/04/2019
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

12/19/2018

CFR(s): 483.460(c)

The facility must provide clients with nursing
services in accordance with their needs.

This STANDARD is not met as evidenced by:
Nursing services failed to provide services in
accordance with client needs relative to ensuring
staff are properly trained in the administration of
medications procedures for 4 of 4 clients
observed during medication administration (#2,
#3, #5 and #6) as evidenced by observations and
interviews. The findings are:

A. Nursing services failed to ensure staff was
knowledgeable of the appropriate procedures for
administering medications relative to sanitation,
client participation, and client teaching for client
#3. For example:

Observations of the medication administration for
client #3 on 12/19/18 at 7:11 AM revealed client
#3 to receive Cymbalta 30 mg, Cymbalta 60 mg,
Vitamin D, and Claritin. Further observation
revealed staff to punch medications into her
ungloved hand and subsequently into a med cup,
after she had used her ungloved hand to cover
her mouth from her cough. Continued
observations revealed staff did not provide
teaching to client #3 about the medications, their
purpose, or possible side effects. Further
observations revealed staff did not encourage
client #3's participation in the med administration
except for the pouring of client #3's water with
which to swallow her medications. Further
observations revealed staff to use a plastic spoon
to scrape medications out of the med cup for
client #3 after client #3 put the med cup to her

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:SP2H11

Facility ID: 924981

(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 COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 331 | Continued From page 1 W 331

If continuation sheet Page 2 of 6

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G303
NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD
CHARLOTTE, NC 28212

PRINTED: 01/04/2019
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

12/19/2018

mouth. Subsequent observation revealed the staff
to return the contaminated spoon to the large
container of clean spoons.

Interview with the facility nurse on 12/19/18
confirmed staff should have used gloved/clean
hands and thrown away the contaminated spoon
to prevent the spread of germs. Continued
interview with the facility nurse conformed staff
should have provided teaching to client #3 about
her medications,their purpose and possible side
effects, and encouraged participation at each
step of the medication pass for client #3.

B. Nursing services failed to ensure staff was
knowledgeable of the appropriate procedures for
administering medications relative to privacy,
sanitation, client participation, and client teaching
for client #2. For example:

Observations of the medication administration for
client #2 on 12/19/18 at 6:08 AM revealed staff to
enter client #2's room without knocking and
proceeded to administer medications, leaving the
door open as other clients passed by. Further
observation revealed client #2 sitting on her bed
in her room where she remained during the
medication pass. Continued observation
revealed #2 to receive Inhospitable 500 mg,
Abilify 2 mg, Zyrtec 10 mg, Zoloft 100 mg,
Synthroid 137 mg and Vit D. Continued
observations revealed staff to punch all
medications into her ungloved hand, later
transferring them into a medication cup. Further
observations revealed staff broke a medication
which fell onto a used bubble pack, which she
proceeded to add to the medication cup and
administer to client #2. Continued observations
revealed staff did not provide teaching about the

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:SP2H11

Facility ID: 924981

(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 COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 331 | Continued From page 2 W 331

If continuation sheet Page 3 of 6

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G303
NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

PRINTED: 01/04/2019
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

12/19/2018
STREET ADDRESS, CITY, STATE, ZIP CODE

7621 MONROE ROAD
CHARLOTTE, NC 28212

medications, their use or side effects to client #2.
Subsequent observations revealed staff did not
encourage client #2's participation in the med
administration except for the pouring of client #2's
water for administration of medications, which
client #2 did independently.

Interview with the facility nurse confirmed staff
should have provided privacy, used gloved
hands, provided teaching to client #2 about her
medications their purpose and possible side
effects, and encouraged participation at each
step of the medication pass for client #2.

C. Nursing services failed to ensure staff was
knowledgeable of the appropriate procedures for
administering medications relative to privacy,
sanitation, client participation, and client teaching
for client #5. For example:

Observations of the medication administration for
client #5 on 12/19/18 at 6:18 AM revealed client
#5 to be seated at the breakfast table preparing
to eat breakfast. Continued observations revealed
staff to enter client #5's room without knocking or
permission, pulling the medication cart with her.
Further observations revealed staff to request
client #5 to come to her room to take her
medication, which she did. Continued
observations revealed client #5 to receive Oscal
for her morning medication. Further observation
revealed staff to punch the medication into her
ungloved hand, later transferring the medication
into a medication cup. Further observations
revealed staff did not engage client #5 in sign
language or participation in the med pass.
Further observations revealed staff did not
provide teaching about the medications, their use
or side effects to client #5. Subsequent

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:SP2H11

(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 COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 331 | Continued From page 3 W 331

Facility ID: 924981 If continuation sheet Page 4 of 6

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G303
NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

STREET ADDRESS, CITY, STATE, ZIP CODE
7621 MONROE ROAD
CHARLOTTE, NC 28212

PRINTED: 01/04/2019
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

12/19/2018

observations revealed staff did not encourage
client #5's participation in the med administration
except for the pouring of client #5's water for
administration of medications, which client #5
accomlished with hand over hand assistance
from staff.

Interview with the facility nurse on 12/19/18
confirmed staff should utilize sign lanuage with
client #5 for her med pass. Continued interview
with the facilty nurse confirmed staff should have
provided teaching to client #5 about her
medications, their purpose and possible side
effects, along with encouraging participation at
each step of the medication pass for client #5.

D. Nursing services failed to ensure staff was
knowledgeable of the appropriate procedures for
administering medications relative to sanitation,
client participation, and client teaching for client
#6. For example:

Observations of the medication administration for
client #6 at 6:30 AM on 12/19/18 at revealed
client #6 to be sitting on her bed in her bedroom.
Continued observations revealed client #6 to
receive Colase 50 mg, Keppra 500mg, and
Lactalose 15 cc. Further observations revealed
staff to punch all medications into her ungloved
hand, later transferring them into a medication
cup. Continued observations revealed staff did
not provide teaching about the medications or
their use or side effects to client #6. Subsequent
observations revealed staff did not encourage
client #6's participation in the med administration
except for the pouring of client #6's water for
administration of medications, which client #6 did
with assistance from staff.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:SP2H11

Facility ID: 924981

(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 COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 331 | Continued From page 4 W 331

If continuation sheet Page 5 of 6

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

34G303
NAME OF PROVIDER OR SUPPLIER

MONROE ROAD

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

PRINTED: 01/04/2019
FORM APPROVED
OMB NO. 0938-0391

(X3) DATE SURVEY
COMPLETED

12/19/2018
STREET ADDRESS, CITY, STATE, ZIP CODE

7621 MONROE ROAD
CHARLOTTE, NC 28212

Interview with the facility nurse confirmed staff
should have used gloved hands, provided
teaching to client #6 about her medications, their
purpose and possible side effects, and
encouraged participation at each step of the
medication pass for client #6.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID:SP2H11

(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 COMPLETION
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
W 331 | Continued From page 5 W 331

Facility ID: 924981 If continuation sheet Page 6 of 6