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

raw_content:
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

MHL060968

PRINTED: 10/04/2019
FORM APPROVED
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
‘A. BUILDING: COMPLETED
R
B. WING 40/02/2019

6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1

(x4) 10
PREFIX
TAG

V 000;

V 132)

CHARLOTTE, NC 28211

STREET ADDRESS, CITY, STATE, ZIP CODE

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

INITIAL COMMENTS

Acompiaint and follow up survey was completed
on October 2, 2019. The complaint was
unsubstantiated (Intake #NC 00156517).
Deficiencies were cited.

The facility is licensed for the following service
category: 10A NCAC 27G .1400 Day Treatment
for Children and Adolescents with Emotional or
Behavioral Disturbances.

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

G.S. §131E-256 HEALTH CARE PERSONNEL
REGISTRY
(g) Health care facilities shall ensure that the
Department is notified of all allegations against
health care personnel, including injuries of
unknown source, which appear to be related to
any act listed in subdivision (a)(1) of this section.
(which includes:
a. Neglect or abuse of a resident in a healthcare
facility or a person to whom home care services
as defined by G.S. 131E-136 or hospice services
as defined by G.S. 131E-201 are being provided.
b, Misappropriation of the property of a resident
in a health care facility, as defined in subsection
(b) of this section including places where home
care services as defined by G.S. 131E-136 or
hospice services as defined by G.S. 131E-201
are being provided.

c. Misappropriation of the property of a
healthcare facility.

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

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

Facilities must have evidence that all alleged

Division of Health Service Regulation

LABORATORY DIRECTOR'S

STATE FORM

PROVIDER/SUPPLIER REPRESENTJATIVE'S SIGNATURE

1D
PREFIX
TAG

Vv 000

V 132

Executive Divectr Day Ti

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

RECEIVED

By psammons at 5:57 am, Oct 20, 2019

V132

What measures will be put in place to correct the
deficient area of practice.

. At the end of each day, Program Manager
will meet face to face with a staff member from each
group and inquire about any incidents that occurred
during the day. This will be documented on a daily log
. Program Manager will notify Executive
Director of all incidents within 12 hour timeframe.

. Program Manager will receive coaching in
reporting when an incident occurs to the Executive
Director to ensure proper escalation of procedures.

. If any incidents occur Program manager will
check to ensure documents are complete, and
determine what level the incident should be under.

. If the incident rises to a level 2 or 3 Program}
Manager wilf ensure that critical incident information is,
complete.

. Program manager will ensure that
the proper authorities have been contacted and
notified of the incident.

TITLE

NUNC11 If continual

(x8)
COMPLETE
DATE

1016/19

10/16/19

10/14/19

10/14/19

101419

10/149

(Xe) DATE

tion sheet 1 of 12

PRINTED: 10/04/2019
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
MHLo60968 8. WING —______________ 10/02/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
CHARLOTTE, NC 28211

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

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

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1

Continued From page 1 Vv 132 132 Continued From page 1
. Describe your plans to make sure the above happens.
acts are investigated and must make every effort

to protect residents from harm while the . On 10/4/19, Executive director discussed
investigation is in progress. The results of all
investigations must be reported to the
Department within five working days of the initial
notification to the Department.

with Program Manager the prevention steps above,
and reviewed the policy and procedures for
documenting incidents and reported allegations of
abuse.

. Training and Program Improvement team
will provide day treatment staff with refresher training
on Incident Reporting policies and procedures. 10/2119
+ Program Manager will complete coaching
and other progressive documentation in situations in
which the correct documentation procedures are

not followed. 10/1619

Who will monitor the situation to ensure it will not
occur again.

This Rule is not met as evidenced by: . The Executive Director will provide
Based on interview and record review, the facility monitoring to ensure that the interventions about
failed to investigate all allegations of abuse and are being met.

failed to protect clients from harm while the
investigation was in progress affecting 2 of 3
audited staff.

Review on 10/2/19 of Client #1's record revealed:
-Admission date of 3/14/19;

-Diagnoses of Attention Deficit Hyperactivity
Disorder, Disruptive Mood Dysregulation
Disorder, and Oppositional Defiant Disorder;

-11 years old.

Review on 10/2/19 of a Level | incident Report
dated 8/1/19 revealed:

-Client #1 made an allegation against Staff #5
regarding Staff #5 using a choke hold while on
the van.

Interview on 10/2/19 with Client #1 revealed:
-Was brought into the library by Staff #4 who
grabbed his shirt and pushed him against the
Division of Health Service Regulation

STATE FORM 000 NUNC11 continuation sheet 2 of 12

PRINTED: 10/04/2019
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
MHL060968 Be WING —_______—_W. 10/02/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
CHARLOTTE, NC 28211

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

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

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1

Continued From page 2

wall;

-Was put in a choke hold by Staff #5 while on the
van ride home;

-Dates of the incidents are unknown.

Interview on 10/2/19 with the Supervisor
revealed:

-Had a meeting with Client #1's grandmother at
the end of September, 2019 during which the
grandmother reported the allegations involving
Staff #4 and Staff #5;

-Did not complete an internal investigation and
did not suspend either staff;

-Will ensure to complete an internal investigation
on any allegations of abuse in the future.

Interview on 10/2/19 with the Executive Director
revealed:

-Will work closely with the Supervisor and will
discuss a possible re-arrangement of supervisory
duties to increase the Executive Director's time at
the Day Treatment.

130 .0102 HCPR - 24 Hour Reporting V318

What measures will be put in place to correct the
10A NCAC 130 .0102 INVESTIGATING AND
REPORTING HEALTH CARE PERSONNEL deficient area of practice.

The reporting by health care facilities to the . At the end of each day, Program Manager

Department of all allegations against health care
personnel as defined in G.S. 131E-256 (a)(1) will meet face to face with a staff member from each

including injuries of unknown source, shall be group and inquire about any incidents that occurred
done within 24 hours of the health care facility
becoming aware of the allegation. The results of
the health care facility's investigation shall be . Program Manager will notify Executive
submitted to the Department in accordance with
G.S. 131E-256(g).

during the day. This will be documented on a daily log] 10/16/19

Director of ali incidents within 12 hour timeframe. 10/16/19
. Program Manager will receive coaching in

reporting when an incident occurs to the Executive

Director to ensure proper escalation of procedures. | 10/14/19

Division of Health Service Regulation
STATE FORM cd NUNC11 Hf continuation sheet 3 of 12

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIERICLIA,
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

MHL060968
NAME OF PROVIDER OR SUPPLIER
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 17

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

B. WING

Continued From page 3

This Rule is not met as evidenced by:

Based on interview and record review, the facility
failed to notify the Department within 24 hours of
becoming aware of an allegation of abuse against
staff affecting 2 of 3 audited staff.

Review on 10/2/19 of Client #1's record revealed:
-Admission date of 3/14/19;

-Diagnoses of Attention Deficit Hyperactivity
Disorder, Disruptive Mood Dysregulation
Disorder, and Oppositional Defiant Disorder;

-11 years old.

Review on 10/2/19 of a Level | Incident Report
dated 8/1/19 revealed:

-Client #1 made an allegation against Staff #5
regarding Staff #5 using a choke hold while on
the van.

Interview on 10/2/19 with Client #1 revealed:
-Was brought into the library by Staff #4 who
grabbed his shirt and pushed him against the
wall;

-Was put in a choke hold by Staff #5 while on the
van ride home;

-Dates of the incidents are unknown.

Interview on 10/2/19 with the Supervisor
revealed:

-Had a meeting with Client #1's grandmother at
the end of September, 2019 during which the
grandmother reported the allegations involving
Staff #4 and Staff #5;

-Did not complete incident reporting or notification
of the allegations of abuse;

-Will ensure proper notification and
documentation in the future.

Division of Health Service Regulation
STATE FORM

PRINTED:
FORM

10/04/2019
APPROVED

(X3) DATE SURVEY

COMPLETED

R

10/02/2019

STREET ADDRESS, CITY, STATE, ZIP CODE

6220-D THERMAL RD
CHARLOTTE, NC 28211

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

(x8)
COMPLETE
DATE

318 continued from page 3

. If any incidents occur Program manager
will check to ensure documents are complete, and
determine what level the incident should be under,

. If the incident rises to a level 2 or 3
Program Manager will ensure that critical incident
information is complete.

. Program manager will ensure that the
proper authorities have been contacted and notified
of the incident.

Describe your plans to make sure the above happens]
. On 10/4/19, Executive director discussed
with Program Manager the prevention steps above,
and reviewed the policy and procedures for
documenting incidents and reported allegations of
abuse.

. Training and Program Improvement team
will provide day treatment staff with refresher training
on Incident Reporting policies and procedures.

. Program Manager will complete coaching
and other progressive documentation in situations in
which the correct documentation procedures are not
followed.

‘Who will monitor the situation to ensure it will not
occur again.

. The Executive Director will provide
monitoring to ensure that the interventions about are
being met.

NUNC11 if continuat

10/1419

10/1419

10/14/19

10/21/19

1ON6N9

tion sheet 4 of 12

PRINTED: 10/04/2019
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (1) PROVIDER/SUPPLIERICLIA, (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED

R
MHL060968 B. WING ___________ 40/02/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
CHARLOTTE, NC 28211

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES: PROVIDER'S PLAN OF CORRECTION (X8)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE. COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1

Continued From page 4

Interview on 10/2/19 with the Executive Director
revealed:

-Will work closely with the Supervisor and will
discuss a possible re-arrangement of supervisory
duties to increase the Executive Director's time at
the Day Treatment.

27G .0603 Incident Response Requirments V366

What measures will be put in place to correct the
10A NCAC 27G .0603 INCIDENT deficient area of practice.

RESPONSE REQUIREMENTS FOR . At the end of each day, Program Manager
CATEGORY AAND B PROVIDERS will meet face to face with a staff member from each
(a) Category A and B providers shall develop and group and inquire about any incidents that occurred
implement written policies governing their during the day. This will be documented on a daily log| 10/16/19
response to level |, Il or Ill incidents. The policies . Program Manager will notify Executive

oy require the Provieer © respond oy ty need Director of all incidents within 12 hour timeframe. ‘| 10/16/19
attending to the health and safety needs Program Manager will receive coaching in
of individuals involved in the incident; . og rae o ng
(2) determining the cause of the incident: reporting when an incident occurs to the Executive
re) developing and implementing corrective Director to ensure proper escalation of procedures. 10/14/19
measures according to provider specified . . If any incidents occur Program manager
will check to ensure documents are complete, and

timeframes not to exceed 45 days;
(4) developing and implementing measures determine what level the incident should be under. 1014/19

to prevent similar incidents according to provider . If the incident rises to a level 2 or 3
specified timeframes not to exceed 45 days; Program Manager will ensure that critical incident
(5) assigning person(s) to be responsible information is complete. 10/1419
for implementation of the corrections and . Program manager will ensure that the
preventive measures; proper authorities have been contacted and notified
(6) adhering to confidentiality requirements of the incident, 10/14/19
set forth in G.S. 75, Article 2A, 10A NCAC 26B, Describe your plans to make sure the above happens. |
42 CFR Parts 2 and 3 and 45 CFR Parts 160 and . On 10/4/19, Executive director discussed
164; and with Program Manager the prevention steps above,
(7) maintaining documentation regarding and reviewed the policy and procedures for
Subparagraphs (a)(1) through (a)(6) of this Rule. documenting incidents and reported allegations of

(b) In addition to the requirements set forth in abuse.

Paragraph (a) of this Rule, ICF/MR providers .
shall address incidents as required by the federal
regulations in 42 CFR Part 483 Subpart I.

(c) In addition to the requirements set forth in

Training and Program Improvement team
will provide day treatment staff with refresher training
on Incident Reporting policies and procedures. 10/21 19

Division of Health Service Regulation
STATE FORM 030 NUNC1 If continuation sheet 5 of 12

PRINTED: 10/04/2019
FORM APPROVED.

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIERICLIA,
AND PLAN OF CORRECTION IDENTIFICATION NUMBER;

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
A. BUILDING: COMPLETED

R
Be WING 10/02/2019

MHLO060968

STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
CHARLOTTE, NC 28211

NAME OF PROVIDER OR SUPPLIER

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 7

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

DEFICIENCY)

V 366 366 Continued From page 5
+ Program Manager will complete coaching
and other progressive documentation in situations in
which the correct documentation procedures are not

followed. 10/16/19

Continued From page 5

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

Who will monitor the situation to ensure it will not

The policies shall require the provider to respond occur again.

by: . The Executive Director will provide

(1) immediately securing the client record monitoring to ensure that the interventions about are
by: being met.

(A) obtaining the client record;

(B) making a photocopy;

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

(2) convening a meeting of an internal

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

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

(B) gather other information needed;

(C) issue written preliminary findings of fact
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

Division of Health Service Regulation
STATE FORM aid NUNC11 If continuation sheet 6 of 12

PRINTED: 10/04/2019
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
MHL060968 B. WING _____. 10/02/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
CHARLOTTE, NC 28211

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

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1

Continued From page 6 V 366

LME where the client resides, if different. The
final written report shall address the issues
identified by the internal review team, shall
include all public documents pertinent to the
incident, and shall make recommendations for
minimizing the occurrence of future incidents. If
all documents needed for the report are not
available within three months of the incident, the
LME may give the provider an extension of up to
three months to submit the final report; and

(3) immediately notifying the following:

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

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

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

(D) the Department;

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

(F) any other authorities required by law.

This Rule is not met as evidenced by:

Based on interview and record review, the facility
failed to implement their written policy governing
their response to incidents

Review on 10/2/19 of Client #1's record revealed:
-Admission date of 3/14/19;

-Diagnoses of Attention Deficit Hyperactivity
Disorder, Disruptive Mood Dysregulation

Division of Health Service Regulation

STATE FORM $800 NUNC11 If continuation sheet 7 of 12

PRINTED: 10/04/2019
FORM APPROVED
Division of Health Service Regulation

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

R

MHLo60968 B. WING 10/02/2019

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

6220-D THERMAL RD
. LOTTE DAY
ALEXANDER YOUTH NETWORK - CHARI Y 1 CHARLOTTE, NC 28211

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

PROVIDER'S PLAN OF CORRECTION (x8)
(EACH CORRECTIVE ACTION SHOULD BE COMPLETE
CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

V 366) Continued From page 7

Disorder, and Oppositional Defiant Disorder;
-11 years old.

Interview on 10/2/19 with Client #1 revealed:
-Was brought into the library by Staff #4 when he
attempted to elope and Staff #4 who grabbed his
shirt and pushed him against the wall;

-Dates of the incident is unknown.

Interview on 10/2/19 with the Supervisor
revealed:

-Completed a disciplinary write-up for Staff #4's
failure to complete an incident report when Client
#1 attempted to elope and Staff #4 brought Client
#1 to the library to calm down.

Interview on 10/2/19 with the Executive Director
revealed:

-Will work closely with the Supervisor and will
discuss a possible re-arrangement of supervisory
duties to increase the Executive Director's time at
the Day Treatment.

27G .0604 Incident Reporting Requirements V367

What measures will be put in place to correct the
10A NCAC 27G .0604 INCIDENT deficient area of practice.

REPORTING REQUIREMENTS FOR . At the end of each day, Program Manager

CATEGORY AAND B PROVIDERS

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

Division of Health Service Regulation

STATE FORM

NUNC11

will meet face to face with a staff member from each
group and inquire about any incidents that occurred
during the day. This will be documented on a daily log,
. Program Manager will notify Executive
Director of all incidents within 12 hour timeframe.

. Program Manager will receive coaching in
reporting when an incident occurs to the Executive
Director to ensure proper escalation of procedures.
. If any incidents occur Program manager
will check to ensure documents are complete, and
determine what level the incident should be under.

106/19

10/6/19

10/14/19

10/14/19

Ifcontinuation sheet 8 of 12

PRINTED: 10/04/2019
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
MHL060968 BAWING —____—_______ 10/02/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE.
6220-D THERMAL RD
CHARLOTTE, NC 28211

(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)

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1

Continued From page 8 367 Continued From page 8

. If the incident rises to a level 2 or 3
Program Manager will ensure that critical incident
information is complete. 10/14/19
. Program manager will ensure that the
proper authorities have been contacted and notified
of the incident. 10/14/19
(2) client identification information; Describe your plans to make sure the above happens,
(3) type of incident; . On 10/4/19, Executive director discussed
(4) description of incident; with Program Manager the prevention steps above,
(5) status of the effort to determine the and reviewed the policy and procedures for

cause of the incident; and documenting incidents and reported allegations of

(6) other individuals or authorities notified abuse.

or responding. . Training and Program Improvement team
(b) Category A and B providers shall explain any will provide day treatment staff with refresher training
missing or incomplete information. The provider on Incident Reporting policies and procedures. 10/219
shall submit an updated report to all required . Program Manager will complete coaching
report recipients by the end of the next business and other progressive documentation in situations in
day whenever: which the correct documentation procedures are not
(1) the provider has reason to believe that followed. 10/16/19
information provided in the report may be
erroneous, misleading or otherwise unreliable; or
(2) the provider obtains information
required on the incident form that was previously
unavailable.

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

(1) hospital records including confidential
information;

(2) reports by other authorities; and

(3) the provider's response to the incident.
(d) Category A and B providers shall send a copy
of all level Ill incident reports to the Division of
Mental Health, Developmental Disabilities and
Substance Abuse Services within 72 hours of
becoming aware of the incident. Category A
providers shall send a copy of all level III
incidents involving a client death to the Division of
Health Service Regulation within 72 hours of

Secretary. The report may be submitted via mail,
in person, facsimile or encrypted electronic
means. The report shall include the following
information:

(1) reporting provider contact and
identification information;

Who will monitor the situation to ensure it will not
occur again.

. The Executive Director will provide
monitoring to ensure that the interventions about are
being met.

Division of Health Service Regulation
STATE FORM eee NUNC11 If continuation sheet 9 of 12

PRINTED: 10/04/2019
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
MHL060968 B. WING —___—_____. 40/02/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE.
6220-D THERMAL RD
CHARLOTTE, NC 28211

(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)

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 7

V 367| Continued From page 9

becoming aware of the incident. In cases of
client death within seven days of use of seclusion
or restraint, the provider shall report the death
immediately, as required by 10A NCAC 26C,
.0300 and 10A NCAC 27E .0104(e)(18).

(e) Category A and B providers shall send a
report quarterly to the LME responsible for the
catchment area where services are provided.
The report shall be submitted on a form provided
by the Secretary via electronic means and shall
include summary information as follows:

(1) medication errors that do not meet the
definition of a level II or fevel III incident;

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

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

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

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

This Rule is not met as evidenced by:

Based on interview and record review, the facility
failed to report all Level Ill incidents to the LME
responsible for the catchment area where
services are provided within 72 hours of
becoming aware of the incident.

Review on 10/2/19 of Client #1's record revealed:
-Admission date of 3/14/19;

~Diagnoses of Attention Deficit Hyperactivity
Division of Health Service Regulation

STATE FORM ease NUNC11 Hf continuation sheet 10 of 12

PRINTED: 10/04/2019
FORM APPROVED
Division of Health Service Regulation

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

R
MHL060968 B. WING _____.__ 10/02/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
CHARLOTTE, NC 28211

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

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1

Continued From page 10

Disorder, Disruptive Mood Dysregulation
Disorder, and Oppositional Defiant Disorder;
-11 years old.

Review on 10/2/19 of a Level | Incident Report
dated 8/1/19 revealed:

-Client #1 made an allegation against Staff #5
regarding Staff #5 using a choke hold while on
the van,

Review on 10/2/19 of the North Carolina Incident
Response Improvement System revealed:

-No Level II incident reports completed on the
allegations of abuse made by Client #1.

Interview on 10/2/19 with Client #1 revealed:
-Was brought into the library by Staff #4 who
grabbed his shirt and pushed him against the
wall;

-Was put in a choke hold by Staff #5 while on the
van ride home;

-Dates of the incidents are unknown.

Interview on 10/2/19 with the Supervisor
revealed:

-Had a meeting with Client #1's grandmother at
the end of September, 2019 during which the
grandmother reported the allegations involving
Staff #4 and Staff #5;

-No Level [Il incident reports were completed
regarding the allegations of abuse.

-Will ensure to complete Level Ill incident reports
on all allegations of abuse in the future.

Interview on 10/2/19 with the Executive Director
revealed:

-Will work closely with the Supervisor and will
discuss a possible re-arrangement of supervisory
duties to increase the Executive Director's time at
the Day Treatment.

Division of Health Service Regulation
STATE FORM os00 NUNC1I If continuation sheet 11 of 12

PRINTED: 10/04/2019
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
MHLo60968 8, WING ££ ______ 40/02/2019

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
CHARLOTTE, NC 28211

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

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

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1

Continued From page 11 V 367

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

Division of Health Service Regulation
STATE FORM S008 NUNC11 If continuation sheet 12 of 12

document_type: Plan of Correction


state: NC

facility_name: Alexander Youth Network - Charlotte Day Treatment

summary: Statement of Deficiency - MHLCS Follow-up

raw_content:
PRINTED: 07/11/2019

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
MHL060968 07/11/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1
CHARLOTTE, NC 28211
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000} INITIAL COMMENTS V 000

A limited follow up survey for the Type B was
completed on July 11, 2019. This was a limited
follow up survey, only 10A NCAC 27G .0209
Medication Requirements (V120) was reviewed
for compliance. The following was brought back
into compliance: 10A NCAC 27G .0209
Medication Requirements (V120). No
deficiencies were cited.

This facility is licensed for the following service
category: 10A NCAC 27G .1400 Day Treatment
for Children and Adolescents with Emotional or
Behavioral Disturbances.

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

STATE FORM

6899

S5KDE11

TITLE (X6) DATE

If continuation sheet 1 of 1

inspection_type: MHLCS Follow-up

document_type: Statement of Deficiency


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

raw_content:
PRINTED: 05/09/2019

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES AND PLAN pay PROVIDER/SUPPLIER/CLIA) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHLo60968 8. WING 04/30/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY T
CHARLOTTE, NC 28211
(a4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (xs)
PREFIX TAG (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX TAG (EACH CORRECTIVE ACTION SHOULD BE ‘COMOLETE DATE:
REGULATORY OR LSC IDENTIFYING INFORMATION) ‘CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
Vv 000} Vv000

were cited.

Disturbances.

INITIAL COMMENTS

An annual, complaint, and follow up survey was
completed on April 30, 2019. The complaint was
unsubstantiated (Intake # NC150694). Deficiencies

This facility is licensed for the following service
category: 10A NCAC 27G .1400 Day Treatment for
Children and Adolescents with Emotional or Behavioral

DHSR - Mental Health
MAY 2 0 2019
Lic. & Cert. Section

PRINTED: 05/09/2019

FORM APPROVED
Division of Health Service Regulation
Vv 12d Vv 120 What measures will be put in place to correct the deficient area
of practice.
. At the end of each day Program Manager or
another Qualified Professional trained in medication 4/30/19
27G .0209 (E) Medication Requirements administration assigned by program manager will do
check to ensure that all medication counts are accurate.
10A NCAC 27G .0209 MEDICATION es All Charlotte Day Treatment staff will be trained
REQUIREMENTS in Medication administration. 5/13/19
(e) Medication Storage: . Each classroom staff will be responsible for
(1) All medication shalll be stored: their consumer's medication within their classroom. One
‘ locked cabinet inal i staff will give out the meds, and the other staff will back | 5/20/19
(A) lng Securely locked cabinet Ina.cean, weir them up to ensure counts are correct.
lighted, ventilated room between 59 degrees and 86
degrees Fahrenheit; Describe your plans to make sure the above happens.
(B) Ina refrigerator, if required, between 36 s Once a week, RN nurse will go and check
degrees and 46 degrees Fahrenheit. If the refrigerator mesa ion mere seunts and wee sheets (0 5/2/19
is used for food items, medications shall be kept ina Stisune-thatiever/ mine iticets protocol. :
~— . If counts are off the nurse will immediately
separate, locked compartment or container; report to Program Manager and Executive Director and fill
(Cc) separately for each client; out incident report. 5/2/19
(D) Separately for external and internal use ;( E)
in a secure manner if approved by a physician for a Who will monitor the situation to ensure it will not occur
client to self-medicate. again.
(2) Each facility that maintains stocks of controlled
substances shall be currently registered under the x Fi
é dane e All the items on this plan will be
North Carolina Controlled Substances Act, G.S. 90, itarad by thE M
Article 5, including any subsequent amendments. HIRTIOSE BY ENE FORT EME Men@Ber,
This Rule is not met as evidenced by: Based on
interview, record review, and observation, the
facility failed to maintain secure
Division of Health Service Regulation
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (x6) DATE
STATE FORM 839 GNHM11. if continuation sheet_1 of 18

STATEMENT OF DEFICIENCIES AND PLAN
OF CORRECTION

(xa) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

MHLO60968

(02) MULTIPLE CONSTRUCTION (x3) DATE suRVEY

A. BUILDING COMPLETED
R
B. WING 04/30/2019

NAME OF PROVIDER OR SUPPLIER

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY T

STREET ADDRESS, CITY, STATE, ZIP CODE

6220-D THERMAL RD

CHARLOTTE, NC 28211

(x4) 1D
PREFIX TAG

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

ID
PREFIX TAG

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

(x5)
COMPLETE DATE

Division of Health Service Regulation
STATE FORM

6299

GNHM11 If continuation sheet 2 of 21

PRINTED: 05/09/2019
FORM APPROVED

Division of Health Service Regulation

V120] Continued From page 1

Safe storage of medication 4 of 6 audited current clients
(Clients 42, #3, #4, and #5). The findings are:

Review on 4/24/19 of Client #2's record revealed:
-Admission date 8/9/18;

-Diagnoses of Circadian Rhythm Sleep Wake
Disorder, Separation Anxiety Disorder, Attention
Deficit Hyperactivity Disorder (ADHD), History of
Physical Abuse;

-8 years old;

-Physician's order dated 12/5/18 for Vyvanse
(treatment of ADHD) 20mg 1 tab at 12:00pm; -Count
sheet for Vyvanse 20mg revealed there were 8
vyvanse 20mg pills present on the morning of
3/21/19. One was administered at

11am on that date;

-Count sheet for Vyvanse 20mg included the notation
dated 3/21/19 "Counted by PI

(Performance Improvement) and count was off by 2
pills" with the signature of the Performance
Improvement Manager (PIM).

Review on 4/24/19 of Client #3's record revealed:
-Admission date 8/6/18;

-Diagnoses of Oppositional Defiant Disorder,
Attention Deficit Hyperactivity Disorder,

Adjustment Disorder;

-6 years old;

-Physician's order dated 10/16/18 for Adderall XR
(treatment of ADHD) 15mg 1 capsule at 12:00pm; -
Count sheet for Adderrall XR 15mg revealed there
were 14 Adderall XR 15mg pills present on the morning
of 3/21/19. One was administered at

11am on that date;

-Count sheet for Adderrall XR15mg included the
notation dated 3/21/19 "Count was off by 1 capsule”
with the initials of the PIM.

Review on 4/24/19 of Client #4's record revealed:

(x3) DATE SURVEY
COMPLETED

STATEMENT OF DEFICIENCIES AND PLAN
OF CORRECTION

(x1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

R
04/30/2019

MHL060968

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

6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY T

CHARLOTTE, NC 28211

ID
PREFIX TAG

(x5)
COMPLETE DATE

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

(K4) 1D
PREFIX TAG

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

Division of Health Service Regulation

STATE FORM 880 GNHM11 If continuation sheet 3 of 21

PRINTED: 05/09/2019
FORM APPROVED
Division of Health Service Regulation

V 120] Continued From page 2 Vv 120

Admission date 12/27/18;

-Diagnoses of Adjustment Disorder with Mixed
Disturbance of Emotions/Conduct, Oppositional
Defiant Disorder, Attention Deficit Hyperactivity
Disorder, Autism Spectrum Disorder;

-10 years old;

-Physician's order dated 1/16/19 for

Methylphenidate (treatment of ADHD) 10mg 2 tabs at
10:00am and 2:00pm;

-Count sheet for Methylphenidate 10mg revealed
there were 29 pills in the facility just prior to review
on 3/21/19 by the PIM. The date of previous
administration is unclear because the dates had been
crossed out and whited out; -Count sheet for
Methylphenidate 10mg included a notation dated
3/21/19 "count off by 6 tablets” with the initials of the
PIM;

-Count sheet for Methylphenidate 10mg revealed there
were 62 pills in the facility just prior to

review on 4/24/19 by the PIM;

-Count sheet for Methylphenidate 10mg included a
notation dated 4/24/19 "counted by P| and count was
off by 4 pills."

Review on 4/24/19 of Client #5's record revealed:
-Admission date 3/11/19;

-Diagnoses of Oppositional Defiant Disorder,
Attention Deficit Hyperactivity Disorder, Childhood
Onset Fluency Disorder (Stuttering);

-13 years old;

-Physician's order dated 4/2/19 for Focalin XR
(treatment of ADHD) 30mg 1 cap at 9:00am and
Focalin Smg 2 caps at 1:00pm;

-Count sheet for Focalin XR 30mg revealed there
were 12 pills in the facility on 3/21/19. One pill was
administered at 9:00am;

-Count sheet for Focalin XR 30mg included a notation
dated 3/21/19 "Count off by 1 capsule” with the initials
of the PIM;

-Count sheet for Focalin Smg revealed there was

STATEMENT OF DEFICIENCIES AND PLAN (x1) PROVIDER/SUPPLIER/CLIA | (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
OF CORRECTION IDENTIFICATION NUMBER: COMPLETED

A. BUILDING:

R
MHL060968 04/30/2019

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

6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY T
CHARLOTTE, NC 28211

10
PREFIX TAG

(x4) 1D
PREFIX TAG

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

PROVIDER'S PLAN OF CORRECTION (x5)
(EACH CORRECTIVE ACTION SHOULD BE ROBIPLETE WATE:
CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)

Division of Health Service Regulation

STATE FORM ae GNHM11 if continuation sheet 4 of 21

PRINTED: 05/09/2019
FORM APPROVED

Division of Health Service Regulation

V 120] Continued From page 3

47 pills in the facility on 3/21/19. Two pills were
administered at 1:00pm;

-Count sheet for Focalin S5mg included a notation dated
3/21/19 "count was off by 1 pill" with the initials of the
PIM;

-Count sheet for Focalin Smg included multiple cross
outs and pill count re-entries on the count sheet with
notations of "correct count" for each day appearing
that medication counts were off for 8 consecutive
dates of medication administration from 3/28/19
through 4/5/19.

Review on 4/24/19 of Staff #10's record revealed:
-Hire date 9/10/18;
-Hired as Mental Health Counselor.

Review on 4/23/19 of the facility's Incident Reports
revealed:

-Level 1 incident report dated 3/21/19 for Client #2
revealed that during an internal review of
medications, it was discovered that the medication
count was off by 1 pill for Vyvanse

20mg;

-Level 1 incident report dated 3/21/19 for Client #3
revealed that during an internal review of
medications, it was discovered that the medication
count was off by 1 pill for Adderall

15mg;

-Level 1 incident report dated 3/21/19 for Client #4
revealed that during an internal review of
medications, it was discovered that the medication
count was off by 5 pills for

Methylphenidate 10mg;

-Level | incident report dated 3/21/19 for Client #5
revealed that during an internal review of
medications, it was discovered that medication counts
were off by 1 pill each for Focalin XR 30mg and Focalin
Smeg.

Review on 4/26/19 of the facility's Policy on

_|

(x3) DATE SURVEY
COMPLETED

STATEMENT OF DEFICIENCIES AND PLAN 4) PROVIDER/SUPPLIER/CLIA | (2) MULTIPLE CONSTRUCTION
OF CORRECTION IDENTIFICATION NUMBER:

A. BUILDING,
R
MHL060968 B. WING 04/30/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY T
CHARLOTTE, NC 28211

(xs)
‘COMPLETE DATE

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

(xa) ID
PREFIX TAG

Division of Health Service Regulation

STATE FORM 8 GNHM11 If continuation sheet 5 of 21

Division of Health Service Regulation
V 120] Continued From page 4

Storage, Disposal and Control of Medications (Policy 4.8)
effective 1/1/1998 with most recent update on 5/25/10
revealed:

-" Schedule II Controlled Medications: (11) Upon
delivery of Schedule II drugs, an authorized staff
member verifies receipt by adding the count and
initials to the Controlled Drugs Record. Schedule |!
drugs will be placed in the medication closet
immediately; (12) Schedule II drugs are not to be
removed from locked storage until time of
administration and must be signed out at that time;
(13) Two staff members shall count all controlled
medication on a regular basis verify count is correct
The two staff members sing the Controlled Drugs
Record signifying count is accurate. This record is
maintained for three years; (14) If there is a
discrepancy in the count, staff will make every effort
to resolve the discrepancy immediately. If the
discrepancy cannot be resolved, it will be reported
through the Incident Report and accompanying
procedures and recorded on the Controlled Drug
Record..."

Interview on 4/25/19 with Client #2 revealed: -Takes
medication at the facility but does not know the name
of it;

-The medication is "the white pill;"

-Different staff administer medication;

-Never missed receiving his medication.

Interview on 4/25/19 with Client #3 revealed: -Takes
medication at the facility but does not know the name
of it;

-The medication is "the blue pill;"

-Different staff administer medication;

-Never missed receiving his medication.

Interview on 4/25/19 with Client #4 revealed: -Takes
medication at the facility but does not know the name
of it;

PRINTED: 05/09/2019
FORM APPROVED

STATEMENT OF DEFICIENCIES AND PLAN
OF CORRECTION

(a) PROVIDER/SUPPLIER/CLIA

IDENTIFICATION NUMBER: RENE

MHLO60968
NAME OF PROVIDER OR SUPPLIER

6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY T
CHARLOTTE, NC 28211
SUMMARY STATEMENT OF DEFICIENCIES 1D

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

(x4) ID
PREFIX TAG.

Division of Health Service Regulation
STATE FORM

609

(X2) MULTIPLE CONSTRUCTION

GNHM11

(x3) DATE SURVEY
COMPLETED

R
04/30/2019

STREET ADDRESS, CITY, STATE, ZIP CODE

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

(x5)
COMPLETE DATE

If continuation sheet 6 of 21

Division of Health Service Regulation

V120] Continued From page 5

-The medication is the "mint green pill;" -Different
staff administer medication;

-Never missed receiving his medication.

Interview on 4/25/19 with Client #5 revealed:

-Takes medication at the facility;

-Takes "Focalin XR 30;"

-Different staff administer medication;

-Never missed medications at the facility because the
"doctor at mental health send the paperwork."

Interview on 4/25/19 with Staff #10 revealed: -Began
administering medications three weeks ago;

-When administering controlled substance
medications, must have an additional staff present as
a witness;

-After administering the medication to each client, the
staff must make sure to check if the client swallowed
the medication. Staff must then sign the Medication
Administration Record and the count sheet for any
controlled substance medications. The staff witness
does not sign any documents.

Interview on 4/25/19 with the Case Manager revealed:
-When families drop off controlled substance
medications for clients, the medications must be
checked in by staff trained in medication
administration. The controlled substance medication
pills are counted and a Contro! Medication Sheet is
completed documenting the number of pills brought to
the facility. The staff and family member each sign the
Control Medication Sheet verifying the number of pills
brought to the facility.

Interview on 4/25/19 with the Executive Director revealed:

STATEMENT OF DEFICIENCIES AND PLAN (x1) PROVIDER/SUPPLIER/CLIA

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY T

(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES
PREFIX TAG (EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

OF CORRECTION IFICATION NUMBER:
IDENT! Be weBUUORNE COMPLETED
R
MHLO6G0968 04/30/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

6220-D THERMAL RD

CHARLOTTE, NC 28211

PRINTED: 05/09/2019
FORM APPROVED

(x3) DATE SURVEY

(X2) MULTIPLE CONSTRUCTION

(x5)
COMPLETE DATE

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

ID
PREFIX TAG

Division of Health Service Regulation
STATE FORM.

shes, GNHM11 If continuation sheet 7 of 21

PRINTED: 05/09/2019
FORM APPROVED

Division of Health Service Regulation

Continued From page 6

-There should never be any discrepancies between
the number of pills listed on the count sheet and the
actual number of pills present in the facility;

-There have been discrepancies in the past several

weeks;

-Many staff have administered medications in the past
several weeks;

-Registered Nurses will be assigned to oversee medication
administration, controlled substance count, and storage of
medication at the facility.

Observation on 4/25/19 at approximately 11:00am
revealed:

-Medication stored in a cabinet secured with a large
padlock. The medication cabinet is located behind two
locked closet doors.

Review on 4/26/19 of the Plan of Protection
completed by the Executive Director dated 4/26/19
revealed:

“What immediate action will the facility take to ensure
the safety of the consumers in your care? -At the end of
each day, either the Program Manager or a staff
assigned by Program Manager will check to ensure that
all medication counts are accurate.

-All Charlotte Day Treatment staff will be training in
Medication Administration.

-Each classroom staff will be responsible for their
consumer's medication within their classroom. One
staff will give out the meds (medications), and the

other staff will back them up to ensure counts are
correct.

Describe your plans to make sure the above happens.
-Once a week, RN (Registered Nurse) will check
medications, medication counts, and MAR (Medication
Administration Record) sheets to ensure that everything
meets protocol.

STATEMENT OF DEFICIENCIES AND PLAN oa) PROVIDER/SUPPLIER/CLIA) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
OF CORRECTION IDENTIFICATION NUMBER: MII
A, BUILDING: ETE,
R
MHL060968 8. WING 04/30/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY T
CHARLOTTE, NC 28211
(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES ID

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

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

Division of Health Service Regulation

STATE FORM ae GNHM11 If continuation sheet 8 of 21

Division of

V 367)

Health Service Regulation

Continued From page 7

-If counts are off, the nurse will immediately report to
the Program Manager and the Executive Director and
will complete an incident report."

Accurate count records and secure storage were not
maintained for controlled substance

Medications resulting in multiple pills of Adderall,
Methylphenidate, Focalin, and Vyvanse being
unaccounted for. These medications were under the
control and responsibility of the facility and were
prescribed for the treatment of Attention Deficit
Hyperactivity Disorder for clients ranging from 6 - 13
years old. The medications have a high potential for
diversion and misuse. The clients were diagnosed
with mental health needs including, but not limited
to, Attention Deficit Hyperactivity Disorder,
Oppositional Defiant Disorder, Adjustment Disorder,
and Autism Spectrum Disorder. Missing controlled
substance medication is detrimental to the clients’
health, safety, and welfare in that only a limited
amount of controlled substance medications can be
dispensed each month. This deficiency

Constitutes a Type B rule violation. If the violation is
not corrected within 45 days, an administrative penalty
of $200.00 per day will be imposed for each day the
facility is out of compliance beyond the 45th day.

27G .0604 Incident Reporting Requirements

10A NCAC 27G .0604 = INCIDENT

REPORTING REQUIREMENTS FOR

CATEGORY A AND B PROVIDERS

(a) Category A and B providers shall report all level I!
incidents, except deaths, that occur during the
provision of billable services or while the consumer is
on the providers premises or level III incidents and level
|| deaths involving the clients

PRINTED: 05/09/2019
FORM APPROVED

v 367 . What measures will be put in place to correct the
deficient area of practice.
e At the end of each day,
Program Manager will meet | y/sgy15
face to face with a staff
member from each group and
inquire about any incidents
that occurred during the day. | 4/30/19

° — Ifany incidents occur Program
manager will check to ensure
documents are complete, and
determine what level the 4/30/19
incident should be under.

¢ Ifthe incident rises to a level 2
or 3 Program Manager will
ensure that critical incident
information is complete.

. Program manager will ensure
that the proper authorities
have been contacted and
notified of the incident.

—

Division of Health Service Regulation

STATE FORM

ease GNHM11 If continuation sheet 9 of 21

PRINTED: 05/09/2019
FORM APPROVED

Division of Health Service Regulation

Describe your plans to make sure the above
happens.

On 4/30/19, Executive director discussed
with Program Manager the prevention
steps above, and explained to him that
even if an incident doesn’t occur on our
property we as an agency are the clinical
home, and are required to ensure all
documentation is completed.

On 5/20 Program Manager will complete
a refresher to review incident
documentation protocol with his staff to
ensure that they are aware of what
constitutes and incident and how to
document the details.

Program Manager will complete coaching
and other progressive documentation in
situations in which the correct
documentation procedures are not
followed.

Who will monitor the situation to ensure it will not
occur again.

* The Executive Director for the program will
monitor the situation to ensure that it does
not occur again.

STATEMENT OF DEFICIENCIES AND PLAN (x1) PROVIDER/SUPPLIER/CLIA | (2) MULTIPLE CONSTRUCTION (3) DATE SURVEY
NTIFICATION NUMBER: COMPLETED
OF CORRECTION IDENTIFICATION NUMBE cou ie,
R
04/30/2019
MHLO6G0968 B. WING /30/;
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY T
CHARLOTTE, NC 28211

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

Division of Health Service Regulation
STATE FORM 6099 GNHM11 Ifcontinuation sheet 10 of 21

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FORM APPROVED

Division of Health Service Regulation

V 367! Continued From page 8

to whom the provider rendered any service within
90 days prior to the incident to the LME responsible
for the catchment area where services are provided
within 72 hours of becoming aware of the incident.
The report shall be submitted on a form provided by
the

Secretary. The report may be submitted via mail, in
person, facsimile or encrypted electronic means. The
report shall include the following information:

(1) reporting provider contact and identification
information;

(2) client identification information;

(3) type of incident;

(4) description of incident;

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

(6) other individuals or authorities notified or
responding.

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

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

(2) the provider obtains information required
on the incident form that was previously unavailable
(c) Category A and B providers shall submit, upon
request by the LME, other information obtained
regarding the incident, including:

(1) hospital records including confidential
information;

(2) reports by other authorities; and

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

(d) Category A and B providers shall send a copy of all
level Ill incident reports to the Division of

(X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY

COMPLETED

STATEMENT OF DEFICIENCIES AND PLAN
OF CORRECTION

(x4) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

A, BUILDING:

R

MHL060968 04/30/2019

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY T
CHARLOTTE, NC 28211

ID
PREFIX TAG

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

(x4) 1D
PREFIX TAG.

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

Division of Health Service Regulation
STATE FORM 5599 GNHM11 If continuation sheet 11 of 21

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FORM APPROVED
Division of Health Service Regulation

Continued From page 9 V 367

Mental Health, Developmental Disabilities and Substance
Abuse Services within 72 hours of becoming aware of the
incident. Category A providers shall send a copy of all
level Ill

incidents involving a client death to the Division of
Health Service Regulation within 72 hours of

becoming aware of the incident. In cases of client
death within seven days of use of seclusion

or restraint, the provider shall report the death
immediately, as required by 10A NCAC 26C .0300

and 10A NCAC 27E .0104(e)(18). (e) Category A and

B providers shall send a report quarterly to the LME
responsible for the catchment area where services

are provided. The report shall be submitted on a

form provided by the Secretary via electronic means
and shall include summary information as follows:

(1) medication errors that do not meet the
definition of a level II or level Ill incident;

(2) restrictive interventions that do not meet

the definition of a level I! or level Ill incident; (3)
searches of a client or his living area; (4)

seizures of client property or property in the

possession of a client;

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

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

This Rule is not met as evidenced by:

Based on interview and record review, the facility failed to
report all level Il incidents to the Local

Management Entity (LME) responsible for the

STATEMENT OF DEFICIENCIES AND PLAN
OF CORRECTION

(xa) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

A, BUILDING: COMPLETED

R

MHLO60968 04/30/2019

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY T
CHARLOTTE, NC 28211

ID
PREFIX TAG

(x4) 10
PREFIX TAG

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

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

Division of Health Service Regulation

STATE FORM J GNHM11 if continuation sheet 12 of 21

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FORM APPROVED

Division of Health Service Regulation

V 367] Continued From page 10

catchment area where services are provided within 72
hours of becoming aware of the incident. The
findings are:

Review on 4/24/19 of Client #6's record revealed:
-Admission date 12/6/18;

-Diagnoses of Disruptive Mood Dysregulation
Disorder, Attention Deficit Hyperactivity Disorder,
Major Depressive Disorder, Generalized Anxiety
Disorder, Persistent Depressive Disorder,
Borderline Intellectual Functioning; -13 years

old.

Review on 4/24/19 of Former Client #7's record revealed:
-Admission date 7/9/18;

-Diagnoses of Nocturnal Enuresis, Other

Specified Trauma or Stressor Disorder, Attention

Deficit Hyperactivity Disorder, Borderline

Intellectual Developmental Disability, Disruptive

Mood Dysregulation Disorder; - 11 years old.

Review on 4/23/19 of the facility's Incident Reports
revealed:

-Level | incident report dated 3/20/19 regarding an
incident of aggression and suicidal ideation for Client
#6 which resulted in a report to local law
enforcement;

-Level | incident report dated 3/6/19 regarding in
incident of aggression and assault for Former Client
#7 which resulted in a report to law enforcement and
returning the client to the facility.

Interview on 4/25/19 with the Executive Director revealed:
-Will make sure all Level I! incident reports are completed
as needed in the future;

-Did not realize the incident involving Former

STATEMENT OF DEFICIENCIES AND PLAN (x1) PROVIDER/SUPPLIER/CLIA) (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
(OF CORRECTION IDENTIFICATION NUMBER:
e |UMBEI ‘A. BUILDING: COMPLETED
R
MHLO60968 B. WING 04/30/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY T
CHARLOTTE, NC 28211

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

(x4) ID
PREFIX TAG

Division of Health Service Regulation
STATE FORM oes. GNHM11 If continuation sheet 13 of 21

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FORM APPROVED

Division of Health Service Regulation

Continued From page 11

Client #7 needed to be completed as a Level || incident;
-Had instructed the staff to complete a Level II incident
for Client #6. It must have been an oversight that staff
did not complete the Level || report.

What measures will be put in place to correct
the deficient area of practice.

Formal refresher training on physical
restraints will be provided to all staff
on 5/20.

e — Self-awareness training will be
provided to all staff on 5/20.

27E .0108 Client Rights - Training in Sec Rest & ITO

10A NCAC 27E .0108 TRAINING IN
SECLUSION, PHYSICAL RESTRAINT AND

ISOLATION TIME-OUT

(a) Seclusion, physical restraint and isolation
time-out may be employed only by staff who have
been trained and have demonstrated competence in
the proper use of and alternatives to these
procedures. Facilities shall ensure that staff
authorized to employ and terminate these procedures
are retrained and have demonstrated competence at
least annually.

(b) Prior to providing direct care to people with
disabilities whose treatment/habilitation plan includes
restrictive interventions, staff including service
providers, employees, students or volunteers shall
complete training in the use of seclusion, physical
restraint and isolation time-out and shall not use
these interventions until the training is completed and
competence is demonstrated.

(c) A pre-requisite for taking this training is
demonstrating competence by completion of training
in preventing, reducing and eliminating the need for
restrictive interventions.

(d) The training shall be competency-based,
include measurable learning objectives, measurable
testing (written and by observation of behavior) on
those objectives and measurable methods to
determine passing or failing the

All staff will be required to complete
TCI training prior to working with
clients and be required to complete
TCI refreshers every 6 months
following employment with the
company.

Describe your plans to make sure the above
happens.

¢ Executive Director trained as a TCI

trainer has scheduled and will be

conducting TCI refresher and self-

awareness training on 5/20 for all

staff.

¢ All staff have received advance

notification of mandatory requirement

of attendance to scheduled trainings.
TCI refreshers will continue to be
required for all staff every 6 months

Who will monitor the situation to ensure it
will not occur again.

eProgram Manager will ensure that all

Division of Health Service Regulation

STATE FORM ease GNHM11 If continuation sheet 14 of 21

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FORM APPROVED

Division of Health Service Regulation

action plan and as required by the

company.

staff complete TCI trainings and
refreshers as specified by corrective

STATEMENT OF DEFICIENCIES AND PLAN (ay PROVIDER/SUPPLIER/CLIA | (2) MULTIPLE CONSTRUCTION (%3) DATE SURVEY
OF CORRECTION IDENTIFICATION NUMBER: COMPLETED

‘A. BUILDING:
R

MHL060968 04/30/2019

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

6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY T
CHARLOTTE, NC 28211

(x5)
COMPLETE DATE

(xa) 1D SUMMARY STATEMENT OF DEFICIENCIES 10 PROVIDER'S PLAN OF CORRECTION
PREFIX TAG (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX TAG (EACH CORRECTIVE ACTION SHOULD BE
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)

Division of Health Service Regulation
STATE FORM ete GNHM11 If continuation sheet 15 of 21

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FORM APPROVED
Division of Health Service Regulation

V 537) Continued From page 12 course.

(e) Formal refresher training must be completed
by each service provider periodically (minimum
annually).

(f) Content of the training that the service
provider plans to employ must be approved by the
Division of MH/DD/SAS pursuant to Paragraph (g) of
this Rule.

(g) Acceptable training programs shall include,
but are not limited to, presentation of:

(1) refresher information on alternatives to the
use of restrictive interventions;

(2) guidelines on when to intervene
(understanding imminent danger to self and others);
(3) emphasis on safety and respect for the rights
and dignity of all persons involved (using concepts of
least restrictive interventions and incremental steps in
an intervention);

(4) strategies for the safe implementation of
restrictive interventions;

(5) the use of emergency safety interventions
which include continuous assessment and monitoring
of the physical and psychological well-being of the
client and the safe use of restraint throughout the
duration of the restrictive intervention;

(6) prohibited procedures;

(7) debriefing strategies, including their
importance and purpose; and

(8) documentation methods/procedures.(h)
Service providers shall maintain documentation of
initial and refresher training for at least three years.
(1) Documentation shall include:

(A) who participated in the training and the
outcomes (pass/fail);

(B) when and where they attended; and(C)
instructor's name.

STATEMENT OF DEFICIENCIES AND PLAN
OF CORRECTION

oa) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION (3) DATE SURVEY

COMPLETED

A. BUILDING:

R
04/30/2019

MHLO60968 B. WING

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY T

CHARLOTTE, NC 28211

(xay10 SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX TAG (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX TAG (EACH CORRECTIVE ACTION SHOULD BE COMPLETE DAT:
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)

Division of Health Service Regulation

STATE FORM a8 GNHM11 If continuation sheet 16 of 21

Division of Health Service Regulation

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FORM APPROVED

V 537] Continued From page 13

(2) The Division of MH/DD/SAS may
review/request this documentation at any time. (i)
Instructor Qualification and Training Requirements:
(1) Trainers shall demonstrate competence by
scoring 100% on testing in a training program aimed at
preventing, reducing and eliminating the need for
restrictive interventions.

(2) Trainers shall demonstrate competence by
scoring 100% on testing in a training program teaching
the use of seclusion, physical restraint and isolation
time-out.

(3) Trainers shall demonstrate competence by
scoring a passing grade on testing in an instructor
training program.

(4) The training shall be

competency-based, include measurable learning
objectives, measurable testing (written and by
observation of behavior) on those objectives and
measurable methods to determine passing or failing the
course.

(5) The content of the instructor training the
service provider plans to employ shall be approved by
the Division of MH/DD/SAS pursuant to Subparagraph
(j)(6) of this Rule.

(6) Acceptable instructor training programs shall
include, but not be limited to, presentation of:

(A) understanding the adult learner; (B)

methods for teaching content of the course;

(c) evaluation of trainee performance; and (D)
documentation procedures
(7) Trainers shall be retrained at least annually

and demonstrate competence in the use of seclusion,
physical restraint and isolation time-out, as specified
in Paragraph (a) of this Rule.

(8) Trainers shall be currently trained in

STATEMENT OF DEFICIENCIES AND PLAN, (XL) PROVIDER/SUPPLIER/CLIA | (X2} MULTIPLE CONSTRUCTION (x3) DATE SURVEY
OF CORRECTION IDENTIFICATION NUMBER:
BE! A. BUILDING: COMPLETED
R
MHLO60968 B. WING 04/30/2019
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY T
CHARLOTTE, NC 28211

(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES 1D
PREFIX TAG (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX TAG
REGULATORY OR LSC IDENTIFYING INFORMATION)

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

Division of Health Service Regulation

STATE FORM bd

GNHM11 If continuation sheet 17 of 21

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FORM APPROVED
Division of Health Service Regulation

V 537] Continued From page 14 V537

CPR.

(9) Trainers shall have coached experience in
teaching the use of restrictive interventions at least
two times with a positive review by the coach.

(10) Trainers shall teach a program on the use of
restrictive interventions at least once annually.

(11) Trainers shall complete a refresher instructor
training at least every two years. (k) Service providers
shall maintain documentation of initial and refresher
instructor training for at least three years.

(1) Documentation shall include:

(A) who participated in the training and the
outcome (pass/fail);

(B) when and where they attended; and(C)
instructor's name.

(2) The Division of MH/DD/SAS may review/request

this documentation at any time.

(I) Qualifications of Coaches:

(1) Coaches shall meet all preparation
requirements as a trainer.

(2) Coaches shall teach at least three
times, the course which is being coached. (3)
Coaches shall demonstrate competence by
completion of coaching or train-the-trainer
instruction.

(m) Documentation shall be the same preparation as
for trainers.

This Rule is not met as evidenced by:

Based on interview and record review, facility staff
failed to display competency while implementing
physical restraints affecting 1 of 3 audited staff
members (Staff #8). The findings are:

STATEMENT OF DEFICIENCIES AND PLAN
OF CORRECTION

(ki) PROVIDER/SUPPLIER/CLIA | (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

TIFICATI 7
IDENTIFICATION NUMBER: ‘ReRUTEBINE COMPLETED

R

MHLO60968 04/30/2019

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

6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY T
CHARLOTTE, NC 28211
(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES. 1D PROVIDER'S PLAN OF CORRECTION (xs)

PREFIX TAG (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX TAG (EACH CORRECTIVE ACTION SHOULD BE COMPLETE DATE
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)

Division of Health Service Regulation
STATE FORM ene GNHM11 If continuation sheet 18 of 21

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FORM APPROVED

Division of Health Service Regulation

V 537} Continued From page 15 Vv 537

Review on 4/24/19 of Client #1's record revealed:
-Admission date 3/4/19;

-Diagnoses of Obsessive Compulsive Disorder,
Other Specific Impulse Control and Conduct
Disorder, Unspecified Schizophrenia Spectrum and
Other Psychotic Disorder, Unspecified Depression
Disorder, Unspecified Attention Hyperactivity
Disorder; -10 years old.

Interview on 4/25/19 with Client #1 revealed:

-Had not been restrained at the facility;

-Staff #1 grabbed him by the wrist and the neck the
day his most recent Child and Family Team (CFT)
meeting (4/12/19), but he was not grabbed by his legs
or feet.

Review on 4/22/19 of Staff #8's record revealed:
-Hire date 9/12/16;

-Employed as Mental Health Counselor; -Completed
training in Seclusion, Physical Restraint and Isolation
Time-Out on 6/25/18.

Review on 4/22/19 of Staff #9's record revealed
-Hire date 2/25/19;

-Employed as Mental Health Counselor; -Completed
training in Seclusion, Physical Restraint and Isolation
Time-Out on 3/1/19.

Review on 4/24/19 of the Video Surveillance of the
facility for 4/12/19 at approximately 2:12 pm - 2:20pm
revealed:

-2:12pm: Client #1 walked out of the classroom and
was redirected by staff back to the classroom. Client
#1 walked into a large storage area inside the
classroom;

-2:19pm: Staff #8 went to talk with Client #1; -2:20pm:
Staff #8 dragged Client #1 by the feet out of the
classroom storage area and into the

STATEMENT OF DEFICIENCIES AND PLAN (xa) PROVIDER/SUPPLIER/CLIA | (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
OF CORRECTION IDENTIFICATION NUMBER: AoBUILDING? COMPLETED
R
MHLoeo968 04/30/2019

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

6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY T

CHARLOTTE, NC 28211

1D
PREFIX TAG

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

0s)
‘COMPLETE DATE

(xa) ID
PREFIX TAG

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

Division of Health Service Regulation
STATE FORM Ld GNHM11 If continuation sheet 19 of 21

Division of Health Service Regulation

Vv 537

Continued From page 16

actual classroom area. Staff #9 was at her side but did
not touch Client #1. Client #1 kicked and attempted to
fight with Staff #8. Within minutes, Client #1 and Staff
#8 calmly walked from the classroom without incident.

Interview on 4/23/19 with Staff #8 revealed: -
Identified job responsibilities to include "provide
strategies and coping skills to manage behaviors
..remove kids when aggressive or upset to process
feelings on what is going on...;"

-Client #1 is an attention-seeking child who has a
history of self-harm, banging his head and stomping his
feet and has a hard time accepting

"NO;"

-When Client #1 was argumentative and upset
demanding to join his CFT meeting prior to the team
being ready, he became upset and refused to move.
Staff #8 "grabbed [Client #1] by his upper arm and
took him back to classroom;" -Staff #8 and Staff #9
grabbed Client #1 by the arms and "pulled [Client #1]
out of the closet;" -Client #1 eventually joined the
CFT Meeting.

Interview on 4/23/19 with Staff #9 revealed: -Identified
job responsibilities to include "keep clients in a safe
environment and in compliance with the rules;"

-Client #1 was looking to enter his CFT Meeting and was
upset that the rest of the CFT was not ready for him to
join, so Client #1 went into a storage area for "quiet
time" and refused to leave. Client #1 began to tantrum
and fell to the ground. Staff #8 grabbed Client #1 by the
arm and walked to another classroom. Staff #9 denied
touching Client #1.

Interview on 4/25/19 with the Executive Director revealed:
-Staff #8 was suspended regarding another

PRINTED: 05/09/2019
FORM APPROVED

STATEMENT OF DEFICIENCIES AND PLAN
OF CORRECTION

a) PROVIDER/SUPPLIER/CLIA

CATION NUMBER:
IDENTIFICATION ‘A. BUILDING:

MHL060968 B. WING

(X2) MULTIPLE CONSTRUCTION

(x3) DATE SURVEY
COMPLETED

R
04/30/2019

NAME OF PROVIDER OR SUPPLIER

6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY T
CHARLOTTE, NC 28211

STREET ADDRESS, CITY, STATE, ZIP CODE

(x4) ID
PREFIX TAG

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

1D
PREFIX TAG

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

(xs)
COMPLETE DATE

Division of Health Service Regulation

STATE FORM 399

GNHM11

If continuation sheet 20 of 21

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Division of Health Service Regulation

V 537] Continued From page 17 Vv 537

matter;

-Staff #9 was coached regarding the incident; -Staff
will continue to be trained on appropriate physical
restraints.

Eeeuhve vector | Leonard Shobak CC 5 17/19

Division of Health Service Regulation

STATE FORM a GNHM11 Hfcontinuation sheet 21 of 21

inspection_type: MHLCS Annual, Complaint, and Follow-up