summary: Plan of Correction - MHLCS Complaint

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FORM APPROVED

Division of Health Service Requtation
STATEMENT OF DEFICIENCIES (Xt) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(%3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
“A. BUILDING:

c
02/18/2021

MHiLO11-204 B. WING

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

882 ELIADA HOME ROAD
ASHEVILLE, NC 26806

CUMMINGS COTTAGE

(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH 8)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVE ACTION SHOULD BE CROSS- COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

(LOA NCAC 27 .0201: Within this rule, the Facili
Iwas cited with poor Performance and Quality

¥ 000)

INITIAL COMMENTS

A compiaint survey was completed on February | Improvement oversight to management of
18, 2021. The complaints were substantiated documents. To correct this the Facility has
(Intake #’s NC00168665, NC00167645, developed cedure that outlines where
NC00171325; NC00171862, and NC00173943). eve ope “, an q f “ .
| Deficiencies were cited. review and modification of current strategies to|
laddress the student’s current behaviors
This facility is licensed for the following service petween biweekly CFT meetings and monthly
category. 10A NCAG 27.1900 Psychiatric PCP review is located. The review and
; Residential Treatment Facility for Children and dification of strategies will continue to b
; Adolescents. moar Tategies wi —— i
i included in Multidisciplinary Team (MDT},
¥ 105] 27G .0201 (A) (1-7) Goveming Body Policies V 105 Weekly Clinical Case Review (CCR), nightly
nursing reports, daily updates, and shift notes |
| 10A NCAC 27G .0201 GOVERNING BODY as well as the debriefing incident reports. The !
| POLICIES new Performance and Quality Improvement

; (a) The governing body responsible for each

facility or service shail develop and implement Director and the Performance and Quality

written policies for the following: Improvement coordinator will conduct
| (1) delegation of management authority for the quarterly audits to ensure updates are
; operation of the facility and services; loccurring within one or all of these documents |
| (2) criteria for admission; '

(8) criteria for discharge; to prevent this from occurring again

(4) admission assessments, including: i .
| (A) who will perform the assessment: and See attachment: I
(B) time frames for completing assessment. |

| (5) client record management, including: i he policies requested during the complaint

| (A) persons authorized to document; j urvey were; |
(B) transporting records;
(C) safeguard of records against loss, tampering, dmission Criteria Policy

; defacement or use by unauthorized persons; Restrictive Intervention Policy

(D) assurance of record accessibility to

| authorized users at all times; and

| (E) assurance of confidentiality of records.
(6) screenings, which shail include: [The Restrictive Intervention policy was revised
| (A) an assessment of the individual's presenting i ito clarify that although Facility strives to have

problem or need; .
(B) an assessment of whether or not the facility en RN present throughout the Restrictive

intake Admission Policy

can provide services to address the individual's Intervention, emergency situations occur in
needs; and which a student's safety is in imminent danger,
Division of Health Service Regulation
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVES SIGNATURE TIME 6) DATE

STATE FORM see LHPP11 Hf continuation sheet 1 of 124

Division of Health Service Reg
‘STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(1) PROVIDER/SUPPLIERICLIA

IDENTIFICATION NUMBER: A BUILDING:

MHL011-204 B. WING
NAME OF PROVIDER OR SUPPLIER

CUMMINGS COTTAGE

ASHEVILLE, NC 28806

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

(x4) ID
PREFIX |
TAG

PREFIX
TAG

Continued From page 1

(C) the disposition, including referrals and |
recommendations,
(7) quality assurance and quality improvement |
activities, including: i
(A) composition and activities of a quality |
assurance and quality improvement committee;
(B) written quality assurance and quality
| improvement plan;
(C) methods for monitoring and evaluating the
quality and appropriateness of client care,
inctuding delineation of client outcomes and
utilization of services;
(D) professional or clinical supervision, including
@ requirement that staff who are not qualified
professionals and provide direct client services '
shall be supervised by a qualified professional in |
| that area of service; ;
{E) strategies for improving client care;
{F) review of staff qualifications and a
determination made to grant
treatment/habilitation privileges:
(G) review of all fatalities of active clients who
/ were being served in area-operated or contracted
residential programs at the time of death;
(H) adoption of standards that assure operational
and programmatic performance meeting
applicable standards of practice. For this
purpose, "applicable standards of practice"
| means a level of competence established with
reference to the prevailing and accepted
methods, and the degree of knowledge, skill and
care exercised by other practitioners in the field;

Division of Health Service Regulation
STATE FORM

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD

PRINTED: 03/09/2021
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
02/18/2021

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

COMPLETE
DATE

land restrictive interventions are immediately
necessary to prevent further harm. In an |
lemergency situation, where a student’s health |
jor wellbeing is at risk, staff certified in TC] and
jCPR have always monitored the restrictive
intervention until an RN arrives which is in
compliance with DHSR rule 10A NCAC 27E
.0104:

|The language in our restrictive intervention
policy was revised to clarify that an RN is not
required to be present before a restrictive
intervention is initiated but are required to
monitor the student’s vitals and mental health
within one hour of a restrictive intervention.

See attachment:

lEliada revised our Behavior Support and {
Management Policy in mid-2020 to reflect our |
decision not to use seclusion as a behavior |
management intervention.

Eliada revised our Intake/Admission Policy to |
jreflect the use of pre-placement interviews or
isits of students and their families as part of

ur referral and admission process. Also added
ito the policy is the Admission assessments
iconducted by the RN and Intake staff.

LHPP14 Woontinuation sheet 2 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Heaith Service Regulation
STATEMENT OF DEFICIENCIES 0X1) PROVIDER/SUPPLIERICLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

ie]

B. WING 02/18/2021

MHL011-204

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

CUMMINGS COTTAGE 882 ELIADA HOME ROAD

ASHEVILLE, NC 28806

SUMMARY STATEMENT OF DEFICIENCIES:
(EACH DEFICIENCY MUST 8E PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

Continued From page 2

This Rule is not met as evidenced by: Based on
record reviews and interviews the governing body
failed to ensure their incident reporting system
was followed and failed to implement policies to
assure their operational and programmatic
performance was meeting applicable standards of
practice. The findings

are:

Review on 2/16/21 of Client 4's record revealed:
-Date of Admission: 1/26/21.

~Age: 15.

-Diagnoses: Major Depressive Disorder,

; recurrent, severe; Unspecified Trauma and
Stressor Related Disorder; Cannabis Abuse,
Uncomplicated; Sedative, Hypnotic or Anxiolytic
Abuse, Uncomplicated.

-Comprehensive Clinical Assessment dated
11/30/20 with addendum dated 12/16/20
indicated: Client ineffectively transitioned into
level 3 placement; Encountered challenges with
emotional regulation, self-harming behavior and
impulsivity; Participated in self-injurious behavior
twice in one week; 12/12/20 resulted in client
being taken to the hospital to tend to her wounds;
While under observation on 12/15/20 client
re-injured her wounds using a razor she
smuggled into the facility; She reports having
suicidal ideation with a plan to bleed herself out;
Has been placed in an inpatient hospital due to
an emotional breakdown and commitment to
harming herself; Recommend placement in a
Psychiatric Residential Treatment Facility (PRTF)
fo provide structure and supervision to alleviate
recurrences of self-injurious behaviors; Due to
the client's level of functioning, an unlocked
facility is detrimental to her care.

Division of Health Service Regulation

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

Additional policies and documents not
requested by the surveyors, but are noted in
the Survey are attached as follows;

Job Descriptions

{Client Rights

(Client Records
(Confidentiality

‘etention of Records

QI meeting schedules
Credentialing forms
Debriefing Protocols
Referral Logs with reasons for denial
Safety Committee
Annual Risk Assessment
IBBI Admission Summary
Peer Review

8608 LHPP 11

fcontinuation sheet 3 of 124

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FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES: (Xt) PROVIDER/SUPPLIER/CLIA {X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED

A. BUILDING:

c
02/18/2021

5. WING

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

882 ELLADA HOME ROAD
ASHEVILLE, NC 28806

CUMMINGS COTTAGE

OID | ‘SUMMARY STATEMENT OF DEFICIENCIES 10 PROVIDER'S PLAN OF CORRECTION (EACH 6)
PREFIX | (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVE ACTION SHOULD BE CROSS- COMPLETE
tas! REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

Continued From page 7

unsafe behavior" including running off campus
and into the road, The client was transitioned to
the hospital to be [VC'd.

9/21/20: FC #7 climbed onto the roof of a
building, tied wire around his neck and attempted
to leap off the roof. Staff pulled the client from the |
edge of the roof and removed the wire from his
neck. The client was "taken to the hospital due to
increased suicidal ideation and attempts, as well
as increased and intensive headbanging."
9/21/20: NAC #25 engaged in headbanging, cut |
her forearm repeatedly and attempted to climb
the fence of another program "to get onto the roof
and jump off." The client was brought to the | |
hospital by police for IVC. | i
10/02/20: FC #6 attempted to jump in front of |
cars that were passing by and stated she wanted
to be run over. She also attempted to strangle
herself with a hoodie.

11/01/2020: FC #6 engaged in headbanging and
tan into oncoming traffic and yelled "please hit
me." The client lay in the middle of the road and
staff directed traffic. The client was IVC'd.
11/07/20: Client #2 hit herself in the head with | i
closed fists and proceeded to bang her head
against a flag pole and a brick wall. She
continued this behavior for several hours. i
11/08/2020: Client #1 banged her head vigorously |
banged her head against a concrete wall.
12/07/20: Client #2 banged her head on the floor
"with increased intensity" and also vomited.
12/20/20: Client #2 was attempting to self-injure '
herself by banging her head on the wall "for an
extended period of time."

12/25/20: Client #1 aggressively scratched at her
arms, pulled at her hair and engaged in
headbanging behavior with increased frequency
and intensity.

12/26/20: Client #2 hit her head with increasing
intensity against the bed, the floor, her knee and
Division of Health Service Regulation
STATE FORM eso LHPP11 \f continuation sheet 8 of 124

PREFIX
TAG

Vv 105

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES:
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(Xt) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

MHLO11-204

B. WING.

STREET ADDRESS, CITY, STATE, ZiP CODE

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 03/09/2021
FORM APPROVED

882 ELIADA HOME ROAD

CUMMINGS COTTAGE
ASHEVILLE, NG 28806

(X4) ID . SUMMARY STATEMENT OF DEFICIENCIES

1 (EACH DEFICIENCY MUST BE PRECEDED BY FULL

i REGULATORY OR LSC IDENTIFYING INFORMATION)
|

if

| Continued From page 4

| 2/3/21 revealed:
| -"We have not had an actual suicide attempt but
we have had behaviors.”

Interview on 2/16/21 with the Chief Executive
Officer (CEO), the COO, and the Clinical Director
revealed:

-DRNC was at the facility last week.

-The COO stated, "We report serious injuries."

A review on 2/8/21-2/10/21 and 2/15/21 of the

| PRTF incident Reports and PRTF Restrictive
Intervention Incident Reports for ali clients for the
period of 1/1/20-2/12/21 revealed:

-390 restraints and/or seciusions

-Significant self-harm incidents included the
following:

1/21/20: Non-Audited Client (NAC) #11 "used
anything she coutd" to cut her arm and neck. She
cut open two previous wounds to the point "they
were bleeding extensively." She was transported
to the hospital by police and was placed under an
involuntary committment (IVC).

1/22/20: NAC #10 repeatedly banged his head
‘on the wail and then vomited gastric contents.

; Had abrasion on forehead approximately 2.5
cmx2.5x0.1 cm. He was transported to the

; hospital by Emergency Medical Services (EMS).
1/24/20: NAC #10 Upon returning from the
hospital with a concussion, banged his head
against a concrete wall and window, climbed on a
picnic table and jumped up and down hitting his
head on a light panel and hit his head with his fist.
2/04/20; NAC #8 disclosed that she tried to drown
herself in the shower.

3/25/20: NAC #16 tried to strangle himself by
wrapping yarn tightly around his neck.

3/28/20: NAC #16 "tied a pillow case around his
neck and turned red.“

3/31/20: NAG #16 wrapped yam tightly around his

Division of Health Service Regulation

‘STATE FORM

PREFIX
TAG.

Vv 105

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

After reviewing the training, Eliada revised our
Disability Rights Policy and procedure to bring
us into compliance with Disability Rights. To
correct this Eliada reported all Restrictive
Interventions to Disability rights for 2020 and
per'y 2021. Per our new reporting policy, Eliada
Homes, Inc. updated our Disability Rights North

‘arolina (DRNC) policy and procedures for
feporting serious occurrences In accordance

ith federal Medicaid law [42 C.F.R. §
\483.374(b)]. Serious occurrences and incidents
will be reported to Disability Rights separately
from the Incident Response and Improvement
System (IRIS). Serious occurrences that will be
eported include a resident's death, a serious
injury to a resident, a resident's suicide
jattempt, and the use of restrictive intervention.
{Cottage Supervisors will report any serious
loccurrence involving a resident to both the
State Medicaid agency and the State-
designated Protection and Advocacy system by
Ino later than close of business the next
business day after a serious occurrence. This
jwas implemented 2.19.2021. This will be
monitored monthly by the Residential Director.
see attached

Within this section is a letter from our medical
Brestr Dr. Gerald Travis, child psychiatrist.
Upon review of this information, he and the
(clinical director differentiated between what
jwas an actual serious occurrence vs behavior.
His letter speaks to this information. We are in
jagreement that any child hospitalized or IVC

LHPP11 Hf continuation

(X3) DATE SURVEY
COMPLETED

c
02/18/2021

es)
COMPLETE

sheet 5 of 124

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FORM APPROVED
Division of Health Service Regulation

STATEMENT OF OEFICIENCIES (41) PROVIDER/SUPPLIER/CLIA (%2} MULTIPLE CONSTRUCTION. (X3) DATE SURVEY

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

c
MHL011-204 B.WING 02/18/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

CUMMINGS COTTAGE

x4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH
PREFIX {EACH DEFICIENCY MUST BE PRECEDED BY FULL CORRECTIVE ACTION SHOULD BE GROSS-
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) REFERENCED TO THE APPROPRIATE
DEFICIENCY)
V 105] Continued From page 5 ! v405 Imedical director will continue to work with the
| i A
| neck. | jteam to discern behavior vs serious attempt. |
| 4114/20: NAC #17 ingested 21 tablets of a | The agency will continue to report as required.
controlled medication. She was transported by Effective immediately.

EMS and admitted to the hospital. |
4/30/20: NAC #17 used glass to self-harm while (All incidents were reported in IRIS. |
in the shower and was IVC'd.

5/07/20: NAC #17 made suicidal statements and [The Facility has attached the Performance and
approached moving vehicles in the roadway and (Quality Improvement philosophy, plan and
| pa . get Wad 7 he ere. ; pq burpose to demonstrate the goals, outcomes
| 5/12/20: NAC #48 had glass in her hand and | land systems used to meet the objectives |
| attempted to cut her throat with the glass. \ identified. This plan is for identified i
| 6/23/20: NAC #22 wrapped a sweater, an ita C departments and will be expanded upon the |
oremet cable and telephone cable around her In\ \ farrival of the new Performance and Quality
6/24/20: NAC #22 attempted "to strangle hersel™ Ves improvement Director by April 2021 :
| by tying a sweater around her throat and then 1
later attempted to wrap a comforter around her Etiada is also upgrading our Electronic Health |
| neck. The client was transported to the hospital | Record to Echo Vantage which will greatly i
| by police for IVC. improve the Facility goal to evaluate the

7/10/20: NAC #22 attempted to strangle herself
with a sweater and engaged in "intensé |
headbanging" for a couple of hours. The nurse ! provide. This will allow for additional outcome |
performed a concussion assessment and the i

imeasurements within the system rather than
| client was transported fo the hospital by police for butside of the system which will increase the

provi. Ths and efficiency of the services we

i
iano: FC #5 was "choking herself with a | frequency and timeliness of data review. Eliada |
bungee cord” which she had wrapped twice j jas been working on this upgrade for 6 months ;
around her neck. She also attempted to walk into and the go live date is April 1, 2021. |

the road as cars were passing by.
_ 7113/20: NAC #23 was "headbanging in rapid
succession with high intensity" and she later -
vomited and "collapsed to the floor” and lost
consciousness. The client was transported to the |
emergency department. . '
7/14/20: NAC #22 beat her head against the wall |
with great force at least 10 times and attempted
to choke herself with a blanket.
7114/20: NAC #24 attempted to strangle herself |
with bedsheets in her room and also engaged in
eg
Division of Health Service Regulation
STATE FORM e808 LHPP11 IFcontinuation sheet 6 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY

c
02/18/2021

MHLO11-204 B. WING

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD

CUMMINGS COTTAGE
v ASHEVILLE, NC 28806

(x4) 1D ‘SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVEACTION SHOULD BE CROSS- COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

V 105) Continued From page 6 Vv 105

headbanging. She experienced sensitivity to light f
and was stumbling when standing. The client
was transported to the emergency department.
7/15/20: NAC #22 attempted to choke herself with
blankets, shirts, and anything else in her room.
She began to engage in headbanging with high
intensity. The nurse noted a contusion on the |
client's forehead.
7149120; NAC #23 engaged in frequent and !
intense headbanging paired with vomiting and
scratching her arms until they bled. The nurse
noted a quarter sized light purple bruise in the

center of client's forehead. The client was {VC'd. px! Q We. Cle a.
| 7/25/20: NAC #23 engaged in headbanging

| behaviors and vomited. |
| 7/26/20: FC #5 attempted “to choke herself
several times with various things found on
campus” including a rope and haybale ties. Later
in the evening, the same client exited the cottage
again and she wrapped a hay barrel cord around
her neck and it became stuck and resulted in her
face turning blue.

8/2/20: NAC #20 attempted to choke herself with
headphones and engaged in headbanging
behaviors.

8/6/20: NAC #22 attempted to choke herself by H
wrapping cords around her neck. !
8/18/20: NAC #20 tightly wrapped headphones | i
around her neck and was “struggling to breathe.”
8/19/20: NAC #22 engaged in headbanging for a i |
prolonged period of time "from 11am until after !
5pm."
8/22/20: NAC #22 wrapped a sweater and socks 1
around her neck and "was turing purple. j H
8/24/20: NAC #22 engaged in a self-injurious i |
cycle which "continued for hours." She attempted
: to choke herself, engaged in headbanging, !
punched herself and was "kneeing herseff in the Hl
| face." The client was IVC'd. H
; 9/07/20: NAC #20 engaged in "several hours of |
Division of Health Service Reguiation
STATE FORM 8898 LHPP11 if continuation sheet 7 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (%1) PROVIDER/SUPPLIER/CLIA.
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A, BUILDING:

(X3) DATE SURVEY
COMPLETED

c
02/18/2021

B. WING

MHL011-204

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ASHEVILLE, NC 28806
Li?) PROVIDER'S PLAN OF CORRECTION (EACH
PREFIX CORRECTIVEACTION SHOULD BE CROSS- COMPLETE

TAG REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

CUMMINGS COTTAGE

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

v 105) Continued From page 7

| unsafe behavior" including running off campus :
| and into the road. The client was transitioned to i |
| the hospital to be IVC'd.
| 9/21/20: FC #7 climbed onto the roof of a '
| building, tied wire around his neck and attempted
to leap off the roof. Staff pulled the client from the
edge of the roof and removed the wire from his i
neck. The client was "taken to the hospital due to
| Increased suicidal ideation and attempts, as well i t
| as increased and intensive headbanging.” t i
; 9/21/20: NAC #25 engaged in headbanging, cut |
| her forearm repeatedly and attempted to climb xy Via Als weed
| the fence of another program "to get onto the roof t O
| and jump off." The client was brought to the !
| hospital by police for IVC. | :
| 10/02/20: FC #6 attempted to jump in front of i
| cars that were passing by and stated she wanted |
| to be run over. She also attempted to strangle
herself with a hoodie. |
11/01/2020: FC #6 engaged in headbanging and
tan into oncoming traffic and yelled “please hit H
me." The client lay in the middle of the road and
| staff directed traffic. The client was IVC'd. i
11/07/20: Client #2 hit herself in the head with
| closed fists and proceeded to bang her head
against a flag pole and a brick wall. She
continued this behavior for several hours. |
; 11/08/2020: Client #1 banged her head vigorously
| banged her head against a concrete wail. ! :
, 12/07/20: Client #2 banged her head on the floor
“with increased intensity" and also vomited. i i
12/20/20: Client #2 was attempting to self-injure ! t
| herself by banging her head on the wall "for an
i extended period of time." | t
| 12/25/20: Client #1 aggressively scratched at her | j
| arms, pulled at her hair and engaged in :
| headbanging behavior with increased frequency i
and intensity.
12/25/20: Client #2 hit her head with increasing !
intensity against the bed, the floor, her knee and
Rivision of Health Service Reguiation
STATE FORM =“ LHPP11 Hf continuation sheet 8 of 124

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PRINTED: 02/09/2021
FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (1) PROVIDER/SUPPLIERICLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A, BUILDING:

(X3) DATE SURVEY
COMPLETED

c
02/18/2021

MHL011-204 B. WING

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

882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

CUMMINGS COTTAGE

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

DEFICIENCY)

1
¥ 105 | Continued From page 8

Staffs elbow and also punched hit herself in the |
head with a closed fist.

1106/21: Client #3 engaged in headbanging
behavior, then inappropriately exited the cottage
and “continued her attempts to engage in unsafe
behavior" and attempted to walk into traffic. i
1/06/21: Client #2 “engaged in self-injurious
behaviors since the prior shift." She banged her
head on the wall for the first 30 minutes of the
next shift.

1107/21: Client #2 was hitting her head against a !
cement wall and tile floor. She "expressed | PY \ = Yarc \~e. AL
| wanting to officially say goodbye to Grandma in | H

the attempt of taking her life."

1/10/21: Client #3 was expressing suicidal
ideation and engaged in headbanging behavior. i
She “attempted to jump in front of multiple cars" '
with the intention of being hit.
4/11/21: Client #3 “attempted to enter the road in |
| an attempt to be struck by a car. The client was
| IVC'd. i
1/11/21: Client #2 also attempted to run into i
traffic. i
1/43/21: Client #2 banged her head on the road i
and later banged her head on a brick wall and hit i
her head with closed fists. j
1/14/21: Client #2 walked off campus and sat in
the middle of the road. Construction workers t
“stopped the flow of traffic to prevent the client
from getting hurt." Staff mentioned calling the
police due to it being a safety concem. The client
ran back to campus and engaged in headbanging
behaviors. 1
14/21; Client #2 expressed suicidal ideation of
wanting to walk into traffic to potentially be hit and
was again sitting in the middle of the road.
1/17/21: Client #2 was intensely hitting her head
against the wall with increased severity and
punching herself in the face.

1/18/21: Client #2 barricaded herself in her room
Division of Health Service Regulation
STATE FORM om LHPP11 continuation sheet 9 of 124

PRINTED: 03/09/2021
FORM APPROVED

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1} PROVIDER/SUPPLIER/CUIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

c
02/18/2021

MHLO11-204 8. WING

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

882 ELIADA HOME ROAD

Cc E
CUMMINGS COTTAG ASHEVILLE, NG 28806

cles
4) 1D SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION {EACH
PREFIX | {EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVE ACTION SHOULD BE CROSS-

TAG REGULATORY OR LSC IDENTIFYING INFORMATION) | taG REFERENCED TO THE APPROPRIATE OATE

DEFICIENCY)

Continued From page 9

| while intensely headbanging. She also began

| Tunning towards the road while another peer was
“off task."

1/18/21: Client #3 stated her intent to die in the
toad and began sprinting towards the road; |
1/24/21: Client #3 attempted to run into the road,
broke tlie off the floor and scratched herself and
began headbanging with moderate severity and
was hitting herself in the face.

1/28/21: Client #2 was headbanging with
increased intensity and speed. PK
1/29/21: Client #3 "wanted to kill herself by

standing in the road with the intent to get killed by

traffic." Client placed herself “at immediate and | O. Vase ~a ek.
imminent risk of being struck by a vehicle." i
1/29/21: Client #2 made repeated attempts to run
into the road and into traffic stating that she t
wanted to get hit by 2 car. The client “actually
laid in the road for a few minutes."

1/31/21: Client #2 moved towards the road in an
| attempt to get hit by a car.
| 2/4/21; Client #2 pushed past staff several times
to get to the road. The client wanted "to get hit by
a car.”

; 2/6/21: Client #1 hit her head numerous times
against a metal door and also banged her head i
against the cement ground. |
2/11/21: Client#1 was "violently hitting her head
on the ground." She also hit and bit herself.
2/12/21: Client #4 during a "dally" body
assessment, the nurse noted numerous
superficial cuts on her arm.

2/12/21: Client #2 pushed against staff and
attempted to go towards the road and also

! engaged in headbanging. j
-18 clients (Client #1, Client #2, Client #3, FC #5,
FC #6, FC #7, NAC #8, NAC #10, NAC #11, NAC | i
#13, NAC #16, NAC #17, NAC #18, NAC #20, |
| NAC #21, NAC #22, NAC #24, and NAC #25)

eloped from the facility 105+ times either by H
_ — ee _ =

Bivision of Heatth Service Regulation
STATE FORM ee00 LHPP14 Ifcontinuation sheet 10 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (1) PROVIDER/SUPPLIERICLIA.
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:.

(X3) DATE SURVEY
COMPLETED

c
02/18/2021

B. WING

MHL011-204

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

882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

CUMMINGS COTTAGE

(4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH
PREFIX (EACH DEFICIENCY MUST 8E PRECEDED BY FULL PREFIX CORRECTIVEACTION SHOULD BE CROSS- COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

Continued From page 10

climbing out of their windows, pushing past staff

| and/or running out of the cottage doors. In some

| instances, clients remained off campus for

several hours at a time. Numerous reports
indicated clients had run to various restaurants,

; grocery stores, a pharmacy, and the local sheriff's
department, all of which were located off a local 5
| lane highway.

-Based on the number of incidents, it could not be
| determined if all of the reports had been |
_ incorporated into the Incident Response

Improvement System (IRIS). PK \

Review on 1/14/21 of a Local Police Department
Computer Aided Dispatch (CAD) report of
responses to Eliada Homes, inc. for the period of
1/1/20-1/12/21 revealed:
-Civil disturbance on 5/20/20, 9/13/20, 9/23/20 |
and 10/30/20,
-Dornestic disturbance on 10/30/20.
-Business breaking and entering in progress on
9/7/20.
-Police assistance required on 12/18/20 and
1/1/20.
-Simple assault on 3/2/20, 5/19/20, 9/8/20 and
9/15/20.
-Missing juvenite on 3/18/20 x 4, 8/14/20 x 2,
8/30/20 x 1, 9/7/20 x 1, 9/8/20 x 3, 9/9/20 x 6, and
9/20/20 x 4, ,
-Locate missing person on 9/9/20 x 1.

| -Suicide overdose on 2/25/20 and 11/23/20.

i
I
|
;

Review on 2/1/21 of reports received from the

| Local Police Department for the period of

| 111/20-1/12/21 revealed:

| -8/11/20 Assault Inficting Serious Injury. NAC #21
| attempted to drown Staff #2 in the campus |
| swimming pool by pushing him under water while

| striking him in the face and jaw with a closed fist
Division of Health Service Regulation

STATE FORM nse LHPP41 Weontinuation sheat 11 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (41) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER;

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

c
Ba WING ere 02/18/2024

MHLO011.204

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

CUMMINGS COTTAGE

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

DEFICIENCY)

| Continued From page 11

7-8 times. NAC #21 attempted to hold Staff #2
under water 4 times during the struggle. Staff #2
was in fear of his life and felt like he had a |
| concussion. Staff #3 found Staff #2 “laying on the
ground with his eyes open shaking like if he was
in shock ...he began to regain consciousness ...” '
Staff #2 went to urgent care.
-9/7/20 Assault on a Female. NAC #29 assaulted |
NAC #20.
-9/8/20 Simple Assault. A staff member reported
that she had been assaulted by NAC #20 on i
7/18/20. She was thrown against the bathroom
| door and then diagnosed with a hemiated disc.
-9/8/20 Simple Assault. The Interim Residential
Director reported NAC #20 bit his teft upper arm | |
causing a puncture wound with bruising. NAC #20 | | |
also broke into a building that she did not have |
permission to access and the interim Residential 1 |
| Director wanted to pursue charges. ' |

+12 client elopements in which staff filed a |

missing juvenile report with the police as listed
below: i
9/8/20 at approximately 8:00 pm, 3 clients (FC
#7, NAC #20, and a client from a sister facility)
left campus. Staff attempted to follow them in a i
car. Staff lost sight of the clients as they took off i
running into an apartment complex located on a

local 5 lane highway. | |
9/9/20 at approximately 3:30 am, 2 clients (FC #7 | |
and a client from a sister facility) left campus.
Staff attempted to follow in a car. At 3:40 am, the ‘ |
clients ran into an apartment complex located on j
a local 5 lane highway.
9/9/20 at approximately 3:00 pm, 4 clients (FC i
#7, NAC #20, NAC #25 and a client from a sister |
facility) walked off campus towards a local city i
street.
9/20/20 at approximately 7:22 pm, 4 clients (FC i
#6, FC #7 and 2 clients from a sister facility) ran i
from the facility and “scattered in different |
Division of Health Service Regulation

STATE FORM eae LHPP411 Hfcontinuation sheet 12 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation
‘STATEMENT OF DEFICIENCIES (0X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

Cc
62/48/2021

MHLO11-204 B. WING

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

CUMMINGS COTTAGE

(4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH

PREFIX (EACH DEFICIENCY MUST 8 PRECEDED BY FULL PREFIX CORRECTIVE ACTION SHOULD BE CROSS- COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE pate

DEFICIENCY)

Continued From page 12

to ! Finding #2:
| directions.”

| Finding #2: 1.11.21: Surveyor 1. “Please use the encrypted!

The facility's quality assurance and quality mall Hin ibelow! to send jie Pal
improvement activities failed to adopt standards locumentation regarding clients in

| to improve client care.
discussed on the phone.”

1
| interview on 1/8/21 and 1/14/21 with the Interim

Residential Director revealed: The surveyors requested any PQI reports

| “Staff were required to report a client's sexual regarding inappropriate touch between

| allegations to Perfomance Quality Improvement 10.30.20 and 1.21.21 that were investigated.
(PQ. Eliada did not have any reports of
-For example, if a "peer smacked another peer's inappropriate during that time frame.
butt" then staff were to document it, inform their Poaes CO0’s response “I do not have any reports of
Supervisor and report it to PGI.

-PQI would conduct an internal investigation.

} -PQI would interview clients and staff and “pull
video" when needed to determine what level of
| action would be taken, such as moving

i 2, inappropriate touch for that time period.”

a | ‘3 ¢\ t \ However, four Internal Investigations were
conducted prior to the date range the

bedrooms, or setting structured boundaries. i su tveyors requested for allegations of

-In extreme cases, clients would be relocated. | inappropriate contact.

-In relation to questions regarding sexual ! i

allegation reports for Client #1, FC #5, FC #6 or 4.20.20 report of consensual sexual contact— |
i FC #7, he stated the following: lpeer to peer |
| The first week of October 2020, Client #1 entered

a peer's room at night. 9.21.20 report of unwanted Inappropriate

Staff found Client #1 in the peer’s room and

reported the incident to Pal jcontact — off campus — unknown adult to

| "The disclosure of [Client #1's] sexual behaviors ptudent

| goes back to her entering the room."

He was working the night FC #8 returned to | 10.21.20 report of unwanted tauch - peer to
campus and reported to the Therapist about peer
“sexual touching.”
“That would count as a supervisor being aware.” 10.22.20 report of consensual inappropriate

. ontact - peer to peer.
| Interview on 1/11/21, 1/19/21 and 1/27/21 with the

| COO revealed:

-Any sexual behaviors with clients were
immediately reported to PQI.

-Any allegations of sexually inappropriate
Division of Health Service Regulation

STATE FORM 6293 LHPP 44 Wcontinuation sheet 13 of 124

fee attached documents.

PRINTED: 03/09/2021
FORM APPROVED

Division of Health Service Regulation

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

c
02/18/2021

MHLO11-204 B. WING

NAME OF PROVIDER OR SUPPLIER. STREETADDRESS, CITY, STATE, ZIP CODE
$82 ELIADA HOME ROAD
ASHEVILLE, NC 28806

(%4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (EACH

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

,
V 105; Continued From page 13 Vv 105

CUMMINGS COTTAGE

|
touching would immediately require clients to be :

“called in", parents to be notified and asked if they
want to take further action.

-Most of the time sexual acts would be reported
to the Department of Social Services (DSS).

-She stated "They (DSS) say they can't do

| anything about it." |

| -The PQI process had no issues. i The Internal Investigation of the 10.30.20

| -Video footage was usually kept for 30 days. incident was sent to the surveyors on 1.29.21

i Video footage of the 7/26/20 Incident in which jas requested. The recommendation for that

| FC#5's face turned blue was not available. . q ° . i
-Video footage of the hours tong 10/30/20 jpAqes incident was documented in the report, as well
incident in which the locat police department a las agency follow up meeting addressing
responded to a Civil Disturbance call on campus i~27 preventative measure for future events.

was not available, rtrsel
-When she was asked to provide a copy of the Q|
Policy and Documentation of Qi meetings for the
past year, including meeting minutes and any
documents reviewed, she stated "What do you
mean Qi minutes? | may not have

bee attached.

The surveyors requested Q| minutes. COO
jasked for a description of the desired content

documentation, we meet weekly, but I'm not sure H f the minutes they were requesting. Ina
if | can printit. I'l see what | can find." phone conversation, the COO explained to both;
tarveyors that there were several meetings

Interview on 2/17/21 with the CEO revealed: | fadluding: sell ;

-"[COO] is in charge of PQI, but | am significantly i hat PAY holds including; Safety Committee, |
involved. 1 sit on several PQI| teams and | am Client Rights, Peer Review, Student Council, POI
actively engaged. | get all PQ! emails.” | weekly meeting. Also explained, was that our |
-The licensee would be posting an advertisement IPQI weekly meetings were focused on our EHR
for a PQ! Director. i

|
The Clinical Director was involved with PQ! by perade.
| participating in referral meetings to review | . .
applications of referred clients, the Client Rights (On 2.3.21: Surveyors informed the COO that
| Committee, and the Outcome and Measures | there was a new complaint on Lions and
; Committee. {Cummings cottages. They requested a list of

- Senior Leadership consisted of the CEO, COO,
Clinical Director, Human Resources Director, i
Finance Director, and the Development Director.
-In response to who was ultimately responsible | 1.1.20 to 12.31.20.
| for the PQI plan and making corrections to the
Plan of Protection, the CEO stated "[surveyor], !
Division of Health Service Regulation

‘STATE FORM one LHPP11 Weontinuation shoot 14 of 124

restrictive interventions, Seclusion, Serious
Injuries, suicide attempts and deaths from

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation
‘STATEMENT OF DEFIGIENCIES (1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED
Cc

MHLO11-204 B.WING 02/18/2021

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

882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

“HD; _ SUMMARY STATEMENT OF DEFICIENCIES iD PROVIDER'S PLAN OF CORRECTION (EACH ar)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVEACTION SHOULD BE CROSS- | COMPLETE
TAG REGULATORY OR LSG IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

CUMMINGS COTTAGE

mail sent from surveyors 2.3.21 - “The below
information will be needed by 5:00 PM

tomorrow, 2/4/21. We will need reports with
etails for any of these occurrences. The same

¥ 105] Continued From page 14

| the buck stops with me ...I will be ultimately
responsible. | can manage this."

Review on 1/5/21 of Eliada Homes, Inc. jate range as above applies.

' Restrictive Intervention Policy dated 10/31/94 and |

i ine Lahore inane ast nodes mui Restrictive Intervention Reports i
-"Restrictive Intervention incident reports must be H

reviewed by the supervisor/OP ( Gacined seclusion (forgot to mention this one on the

| Professional) within 72 hours after use of phone)

! restrictive intervention. The QP/Supervisor is erious injuries, including the treatment

responsible fer assuring appropriate follow ; rovided

through and debriefing with the client, staff, and
| the client's legal guardian.”

: -"Restrictive Intervention incidents will be ;
reviewed by the JAC (intervention Advisory
Committee) at quarterly meetings. This /
committee will include professionals who are not |
directly invoived in the treatment of the clients |
and who have training and expertise in the use of i
restrictive interventions. Quality Management will ! |
make periodic reports on the use of restrictive
interventions to EHI's (Eliada Homes,
Incorporated) Board of Trustees.” ' i
-"Quality Management will review and analyze
data on restrictive interventions quarterly to
monitor effectiveness and trends, and to identify
corrective actions necessary. Quality
Management will review the use of restrictive
interventions to detect any unusual pattems, and
will work with program leadership to make
corrections as needed. Findings will be reported
to Senior Leadership."

uicide attempts
Deaths” |

Review on 2/1/21 of the undated PQI Plan for the
facility revealed:
-a goal to evaluate the effectiveness and {
efficiency of services provide. t
~a goal to determine whether services meet '
| pre-determined expectations about quality and
{ outcomes.
Division of Health Service Regulation
STATE FORM aoe LHPP11 If dontinuation sheet 15 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(3) DATE SURVEY
COMPLETED

Cc
02/18/2021

MHLO11-204 B. WING

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD

ASHEVILLE, NC 28806

CUMMINGS COTTAGE

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

REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

TAG

Continued From page 15

-a goal to correct any observed deficiencies
through an established improvement process. |
-an objective to facilitate agency and program

j improvement to ensure that services are
available, timely, effective, safe, efficient, caring
and respectful. i
-an objective to develop and maintain an efficient
and effective system of data collection and
management.

-an objective to measure and evaluate program
outcomes. Poe \leo IAnclhe &
| -The CEO had agency-wide leadership to

improve agency organization and program
performance and ensures compliance with laws,
regulations, rules and standards that govern the
agency's services.

-The CEO provided oversight of the PQI Plan,
fisk management processes, program evaluation |
and data management.

-Agency staff assigned to PQI include the Chief
Operations Officer (COO), Business Analyst,

| Agency Trainer and Risk Reduction Manager, i
and Data Collection and Outcomes Consultant.
-Various PQI committees were made up of |
program leadership staff.

~The Client Rights Committee and Intervention
Advisory Committee [|AC] were two of those
committees. |

Review on 1/29/21 of the facility's undated
Internal Investigations Policy revealed:

-In order for students to be able to concentrate on |
their treatment and education, they must feel safe
and protected.

-In order for staff to be able to focus on the care,
treatment and education of students, they must
feel safe and protected.

~"... injuries, emergencies, and incidents resulting
in the potential for harm are taken very seriously.
These types of events warrant a timely, thorough,
Division of Health Service Regulation

STATE FORM 08 LHPP11 If continuation sheet 16 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES ——_—‘|_- (XT) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

c
02/18/2021

MHLG11-204 berteainal

NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

CUMMINGS COTTAGE

SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH 06)

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

V 105; Continued From page 16 V 105

and objective internal investigation ...All
evenis/incidents requiring an Internal

| Investigation require the immediate notification of
the Executive Director, Chief Operations Officer,
and Human Resources Director. The Executive
Director, Chief Operations Officer and Human

; Resources Director will determine if the
investigation will be conducted by the PQI |
| (Performance Quality Improvement) Department

| -4) A format Internal Investigation must be i
| conducted should any of the following occur: | \
i Allegation or complaint of abuse or neglect.
| Major injury to student resulting in EMT response, |
| emergency treatment, and/or physician

| intervention

| Allegation or complaint of sexual contact between
| students |
; Missing child ; '
| Significant property destruction

| Stolen property

; Discovery of illegal contraband (i.e. illegal
' substance, weapon, etc.) !
| Significant program disruption (i.e. group | H
| violence, students left unattended, etc.)

i
i
Review of an email on 1/11/21 from the DHSR

| surveyor to the Chief Operations Officer dated

| 4/11/21 revealed:

-A request to send any PQ! documentation

; regarding Client #1, FC #5, FC #6 and FC #7 "as
| discussed on the phone.”

|
|
|

Review of an email on 1/11/21 from the Chief j i
Operations Officer to the DHSR surveyor dated Addressed above.
| 1/11/21 revealed: {
| -In response to a request for all PQI {
! documentation relevant to internal investigations !
| involving Client #1, FC #5, FC #6 and FC #7 "I do ! |
| not have any reports of inappropriate touch for | | |
Division of Health Service Regulation ~
STATE FORM ones LHPP 11 ff continuation sheet 17 of 124

PRINTED: 03/09/2021
FORM APPROVED

Division of Health Service Regulation

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

(X2) MULTIPLE CONSTRUCTION
A BUILDING:

(X3) DATE SURVEY
COMPLETED

Cc
02/18/2021

MHLO11-204 B. WING

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

CUMMINGS COTTAGE

(x4) 1D ‘SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH

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

DEFICIENCY)

Continued From page 17

that time period." .

; Review of an email on 1/27/21 from DHSR
| surveyor to the Chief Operations Officer dated |
| 1/27/21 revealed: i
i -Requests were made for the following |
; documents: |
| Records Retention Policy for Video Footage
| Quality Improvement Policy Documentation of
all Quality Improvement Meetings from January i i
2020 to present date (including meeting i
minutes and any documents reviewed during
meetings)

Review on 1/28/21 of documents reviewed by
PQI for the period of 1/1/20 - 12/31/20 revealed:
-There were a total of 5 documents reviewed for
Cummings Cottage.

: -A PQI Report Form dated 9/21/20 summarized
an incident in which FC#6 eloped from campus ! 1
and alleged she had been inappropriately {
touched in her private area while off campus. 1
Allegations of clients from another cottage getting |
| into a vehicle of someone in the community were ' i
_ included in the report. |
| -An Incident Investigation Team Documentation |
1 form dated 10/21/20 in which a staff member |
used non-compliant TCI holds during a restrictive
intervention. 1
-2 PQI Report Forms dated 10/30/20 and 1 PQ!
Report Form dated 11/2/20 summarized an
incident which occurred over several hours on |
10/30/20 involving clients from two cottages,

| members of the community and the local police
| department.
I

| Review on 2/1/21 and 2/2/21 of Client Rights
: Committee minutes for the period of 1/1/20 - |
| 12/31/20 revealed: !
| -Meeting minutes dated 2/13/20 included the
Division of Health Service Regulation

STATE FORM oom LHPP11 Hfeontinuation sheet 18 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES: {%1) PROVIDER/SUPPLIERICLIA (42) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED

Cc
MHLO11-204 B. WING 02/18/2021

NAME OF PROVIDER OR SUPPLIER: STREETADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

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

CUMMINGS COTTAGE

Continued From page 18

following:

Staff injuries had significantly increased.

Trends indicated runaways occurred on first shift

or at shift change. |

Trends indicated staff debriefings were

incomplete. {

-Data reviewed during the 2/13/20 meeting

included the following:

There were 87 reported staff injuries at Eliada

during the 2019 calendar year.

Incident Totals at Eliada for the 2019 calendar “~

year included: poate
-337 restrictive interventions. V2 |G Yoele &
-212 reports of physical aggression.
-30 reports of property damage. |
-143 runaways. |
-8 reported suicidal behaviors.

| -127 self-injury reports. |

| -53 reports of sexualized behaviors. |

-40 consumer injuries.

-157 medication errors.

| -136 other/illegal behaviors.

i -257 search and seizure reports.

! -14 allegation reports.

| ~3 reports of use/distribution of illegal

substances.

-1 suspension from services.

Graphs which displayed restrictive interventions

; by the day of the week and by shift.

-There was no documentation of recommended

strategies to respond to self-injurious and

dangerous behaviors or to improve client care.

-Meeting minutes dated 6/4/20 included the

following: H

There were more restrictive interventions than i

last year.

Staff were still using phrases that were non-TCl

(Therapeutic Crisis Intervention) compliant.

| Trends, recommendations, and risks/concems for |

runaways were left blank.

Division of Health Service Reguiation

STATE FORM 6088 LHPP11 HWcontinuation sheet 19 of 124

PRINTED: 03/09/2021
FORM APPROVED

Division of Health Service Regulation

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

Cc
02/48/2021

MHLO11-204 B. WING

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

882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

; CUMMINGS COTTAGE

(X4)1D ‘SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH 8)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVE ACTION SHOULD BE CROSS- COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

| Continued From page 19
AAbvessed we \ayeru—

| Trends indicated that staff did not document that |

| nursing was notified to assess the client after docs

suicidal and self-injurious behaviors had i

occurred.

Risks/concems that staff did not cali guardians

“soon enough" after a client was missing from

campus.

Detailed documentation was not always listed

when the Clinician debriefed with clients.

-Data reviewed during the 6/4/20 meeting

included the following:

| There were 38 reported staff Injuries at Eliada

| from January 2020 - March 2020. i

: Incident totals at Eliada for the period of January |
2020-March 2020 included: i !

| -110 restrictive interventions. i
' ~64 reports of physical aggression.
i -15 incidents of property damage. |
-34 runaways. i i
' -4 reported suicidal behaviors.
i -67 self-injury reports. |
j -31 reports of sexualized behaviors. i /
i -25 consumer injuries.
: -23 medication errors. |
: -65 cther/illegal behaviors. i
; -57 search and seizure reports.

-12 allegation reports.

-4 reports of use/distribution of illegal
substances.

-2 suspension from services.
Graphs which displayed restrictive interventians : |
i by the day of the week, by shift and by student. j
-There was no documentation of recommended |
| strategies to respond to self-injurious and \

; dangerous behaviors or to improve client care.
| -There were no meeting minutes provided for
9/24/20, however data reports included the |
following:
; There were 26 reported staff injuries at Eliada | H

| from Aprit 2020 - June 2020, 15 of which were |
i .___- —: ===
Division of Health Service Regulation
STATE FORM e608 LHPP11 if continuation sheet 20 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation
‘STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/GLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(K3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

Cc
02/18/2021

MHLO11-204 8. WING

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

882 ELIADA HOME ROAD

CUMMINGS COTTAGE
S ASHEVILLE, NC 28806

4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH 8)

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

DEFICIENCY)

Continued From page 20

| Feported to worker's compensation and 2 of which
required medical attention. |
incident totals at Eliada for the period of April i
i 2020-June 2020 included: |
i _ -78 restrictive interventions. |
t -42 reports of physical aggression.

i -20 incidents of property damage.
i -32 runaways.

| -0 reported suicidal behaviors.

' ~64 self-injury reports.

: -7 reports of sexualized behaviors. |
i

i

-7 consumer injuries.

-14 medication errors.

~6¢4 other/illegal behaviors.
-25 search and seizure reporis. i
-7 allegation reports.

/ -1 report of use/distribution of illegal

; Substances.

: -0 suspension from services.

| Achart which indicated the number of Cummings
_ Cottage clients who had RI's and the number of

: RI's they were involved in as follows:

-January 2020: 35 R's involving a total of 4

| clients. ;
| -February 2020: 13 Ri's involving a total of 7

clients. ;

-March 2020: 13 RI's invoiving a total of 2 t
| clients. ; ; ; i he agency has now adopted the addition of
amar 1 2020: 13 Ris involving a total of 5 | isa components to the client rights meeting |
| -May 2020: 15 R's involving a total of 6 | genda. Effective March 2021
| clients. This information is not documented in the
; -June 2020: 10 Ri's involving a total of 4 j client rights meeting minutes, it is however
cients. ocumented in MDT with the doctor, cottage

Graphs which displayed restrictive interventions i
by day of the week, by shift, by student, by sex,
tace and ethnicity.

-There was no documentation of recommended

| strategies to respond to self-injurious and
dangerous behaviers or to improve client care.
Division of Heaith Service Reguiation

STATE FORM - LHPP11 ff continuation sheet 21 of 124

jocumented in personnel files. There are
xamples of this throughout the documents
submitted.

= minutes, individual coaching with staff

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES, <1} PROVIDER/SUPPLIERICLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

MHLO11-204 5. WING

CUMMINGS COTTAGE

(%4) 1D SUMMARY STATEMENT OF DEFICIENCIES iD

REGULATORY OR LSC IDENTIFYING INFORMATION) TAG

Continued From page 21

This deficiency is cross referenced into 10A
NCAC 27G.1901 Scope (V314) for a Type AJ rule
violation for serious harm and neglect and must
be corrected with 23 days.

V 108; 27G .0203 Privileging/Training Professionals Vv 109

10A NCAC 27G .0203 COMPETENCIES OF
QUALIFIED PROFESSIONALS AND
ASSOCIATE PROFESSIONALS

(a) There shall be no privileging requirements for
qualified professionals or associate professionals.

professionals shall demonstrate knowledge, skills
and abilities required by the population served. ( DY
(c) At such time as a competency-based
employment system is established by rulemaking,
then qualified professionals and associate
professionals shall demonstrate competence.

(d) Competence shall be demonstrated by
exhibiting core skills including:

(1) technical knowledge;

(2) cultural awareness;

(3) analytical skills;

(4) decision-making;

{5) interpersonal skills;

(6) communication skills; and

(7) _ clinical skills,

(e) Qualified professionals as specified in 10A
NCAC 27G .0104 (18)(a) are deemed to have
met the requirements of the competency-based
employment system in the State Plan for i
MH/DD/SAS.

(f) The governing body for each facility shall
develop and implement policies and procedures
for the initiation of an individualized supervision
; plan upon hiring each associate professional.
(g) The associate professional shall be

Division of Health Service Regutation
STATE FORM eeea

{X2) MULTIPLE CONSTRUCTION:
A. BUILDING:

PREFIX | (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVE ACTION SHOULD BE CROSS-

(b) Qualified professionals and associate Fe “(>

PRINTED: 03/09/2021
FORM APPROVED

c

(X3) DATE SURVEY
COMPLETED

02/18/2021

NAME OF PROVIDER OR SUPPLIER. STREET ADDRESS, CITY, STATE. ZIP CODE
882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

PROVIDER'S PLAN OF CORRECTION (EACH

REFERENCED TO THE APPROPRIATE.
DEFICIENCY)

6.2021; Case managers and Ciinicians were
etained in writing PCPs and goal setting, Case
[Managers wilt continue to reevaluate ICPM’s

an internal crisis document that is updated
frequentty), Crisis Plans, and Treatment Plans to
identify documentation of alternative strategies
jand assure that they are individualized for each
ktudent. Eliada has partnered with Six Core and
BBI to provide additional training in writing
individualized Treatment Plans. Date to be
determined i

Six Core Initiative and BB! have also agreed to
retrain our staff on alternative approaches to
Restrictive Intervention and a retraining of
Restrictive Interventions. Dates to be
determined

Additionally all residential staff will receive a 2
day resillancy training to assist them and the i
Students

110A NCAC 27G .0203 the agency has added
ithin the job description the inclusion of the

emia core competencies Effective 3/15/21

jand will modify all job descriptions affected.

Attached is the agency credentialing form, used
{to qualify OPs, in addition to supervision forms
that are utilized per state requirement
dependent upon degree, and qualifications.
Supervision plans are in place for ail required
taff. This is monitored by the HR department
Cech year.

COMPLETE

LHPP11 Wfcontinuation sheet 22 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES. (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION {X3) DATE SURVEY
AND PLAN OF GORRECTION IDENTIFICATION NUMBER: AMBUMIDING: COMPLETED

Cc
MHLO11-204 B.WING 02/48/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

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

CUMMINGS COTTAGE

: Continued From page 22

supervised by a qualified professional with the i |
population served for the period of time as
specified in Rule .0104 of this Subchapter.

This Rule is not met as evidenced by:

Based on record reviews and interviews, the

| facility failed to ensure that 1 of 1 audited

: Qualified Professionals (Residential
Clinician/Licensed Professional) demonstrated
the knowledge, skills and abilities required by the
population served. The findings are:

Refer to Tag V112 for additional information. |

Review on 1/22/21 of the record for the

Residential Clinician/Licensed Professional

revealed:

-Date of Hire: 6/25/18.

-Date of Separation: 12/2020.
-Title/Position: Residential Clinician/Licensed |

Professional.

-Job Description was signed 2/18/19 and included

the following:

Provide clinical supervision and oversight of the

treatment milieu.

Compiete monthly PCP's (Person Centered

Ptans)/Comprehensive Crisis Plans.

Facilitate and/or participate in Child and Family

Team meetings.

Interview on 1/19/21 with the Residential
Clinician/Licensed Professional revealed: |
-Client treatment plans were updated monthly. j
| ‘She encouraged staff to let her know "if things
Division of Health Service Regulation

STATE FORM eco LHPP11 continuation sheet 23 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation

‘STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (62) MULTIPLE CONSTRUCTION
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

(X3) DATE SURVEY
COMPLETED

c
02/18/2021

MHLO011-204 8. WING

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELt{ADA HOME ROAD

CUMMINGS COTTAGE ASHEVILLE, NC 28806

(4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL | PREFIX CORRECTIVE ACTION SHOULD BE CROSS-
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE
DEFICIENCY)

Vv 109 i Continued From page 23

weren't working.” I
-She stated, "You can change the treatment plan
all day, but that doesn't mean the student is going |
to participate." |

The following examples are self-injurious and.
dangerous behaviors documented by the facility. |
There was no documentation of development and |

! implementation of strategies to deal with these OQ
; behaviors in client treatment plans: Each of these items are addressed in later |
: -Client #1: after repeated self-harming behaviors ADS ; . . .
| such as headbanging, hitting self in the head, hair j_ \2s ipages with supporting documentation
| pulling and scratching self from 10/2/20 through |
2/6/21. i

-Client #2: after engaging in self-harming
behaviors such as headbanging for several hours
on 11/7/20 and continued instances of
headbanging behaviors, assaultive behaviors and
suicide attempts by running into traffic 11/7/20
through 2/12/21.

-Client #3:after repeated self-harming behaviors, Kj KA

assaultive behaviors, property destruction,
running behaviors, and attempts of walking into
traffic with the intent of being struck by a vehicle
from 1/6/21 through 1/29/21.

-Former Client (FC) #5: after numerous running
behaviors, self-harming with glass and wrapping
items around her neck, assaultive behaviors, and
property destruction from 3/18/20 through i

7/24/20.

-FC #6: after multiple occurrences of attempting
to self-harm with sharps and headbanging,
assaultive behaviors, and/or running into traffic H i
from 10/2/20 through 11/1/20.

~FC #7: after climbing on top of a roof, tying a
wire around his neck and attempting to jump off
the roof, and after multiple occurrences of
stealing staff keys and radios, eloping from
campus 9/8/20 from 8:05 pm - 1:30 am and

| 9/9/20 from 3:20 am - 7:15 am and 9/20/20 from
Division of Health Service Regulation
STATE FORM awe LHPP11 H continuation sheet 24 of 124

iD |
PREFIX |
TAG

v nial

LL ———
Division of Health Service Regulation

STATE FORM

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(QG) PROVIDER/SUPPLIERICLIA
IOENTIFICATION NUMBER:

MHLO41-204

B. WING

STREET ADDRESS, CITY, STATE, ZIP CODE

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED:
FORM

882 ELIADA HOME ROAD

CUMMINGS COTTA
e ee ASHEVILLE, NC 28806

SUMMARY STATEMENT OF DEFICIENCIES 1D

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

Continued From page 24

7:27pm ~ 1:00 am all of which staff filed a missing
person's report and client was retumed to
campus by the local police department.

This deficiency is cross referenced into 10A
NCAC 27G.1901 Scope (V314) for a Type A1 rule
violation for serious harm and neglect and must

| be corrected with 23 days.

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

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

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

(d) The plan shall include:

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

(2) strategies;

(3) staff responsible;

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

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

(6) written consent or agreement by the client or
responsible party, or a written statement by the
provider stating why such consent could not be
obtained.

Vii2

eae

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

REFERENCED TO THE APPROPRIATE
DEFICIENCY)

fevecac 276.0205 Assessment and
reatment/Habilitation or Service Plan

iThe agency acknowledges that within this section the]
interventions do not include individualized |
information. This was reviewed by the CEO with the
{CD to instruct the clinicians to add individualized
ktrategies that speak to the behaviors within the
udent section as well as PRTF staff section. Upon
Crvat of student. While there are other sections
that are highly Individualized this section was not.
(Moving forward, PCPs completed will demonstrate
individualized components of behaviors upon entry :
in addition to the other standard responses below. \
|This was implemented 2/12 and will be inspected by
new PQI Director and CEO each month

If continuation

LHPP14

(X3) DATE SURVEY
COMPLETED

Cc
02/18/2021

03/09/2021
APPROVED

&s)
COMPLETE
DATE

sheet 25 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation

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

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A BUILDING:

Cc
02/18/2021

MHLO041-204 8. WING

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD

ASHEVILLE, NC 28806

CUMMINGS COTTAGE

SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH

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

i Continued From page 25

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

| facility failed to develop and implement goals and | |
strategies to address the treatment needs for 3 of ! I
i 4 audited current clients (Client #1, Client #2,

‘ and Client #3) and 3 of 3 audited Former Clients
| (FC #5, FC #6, and FC

| #7). The findings are:

Review on 2/15/21 of Eliada Homes, Inc.

Psychiatric Residential Treatment Facility (PRTF)

| Restrictive Intervention Policy/Procedure
Attachment A dated 5/2016 revealed:

| - "Based on the client's medical and treatment

| history, presenting problems, and the crisis plan

in their PCP (Person-Centered Profile), an !

Individual Crisis Management Plan (ICMP) is

developed at admission for each client. The

| ICMP includes the fatlowing:

| 1. Safety concernsAvamings (medical, physical,

| Medication, abuse history).

| 2. Current issues and potential triggers.

! 3. High risk behaviors.

| 4, Intervention strategies for each stage of a i |

| crisis including identified behaviors and preferred

| strategies.

I 5. The identified restraint hold to utilize with the

! client, and the dangerous, aggressive, or

| self-injurious behaviors necessitating restrictive

| intervention after all less restrictive interventions

are ineffective to maintain safety for the client and

| others.”

i | -"The [CMP is reviewed anc revised as needed

i { after an incident of restrictive intervention, duri

| weekly team meetings, during each monthly i

Division of Health Service Regulation

STATE FORM 5390 LHPP11 If continuation sheet 26 of 124

PRINTED: 03/09/2021
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

Cc
02/18/2021

MHL011-204 B. WING

NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE

882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

(x4ayip | ‘SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (EACH
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVE ACTION SHOULD BE CROSS- COMPLETE
TAS REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

CUMMINGS COTTAGE

; Continued From page 26

| clinical case review, and at monthly child and
; family team meetings.”

1 -"The RN (Registered Nurse) on site contacts the
Medical Director for orders, consultation and/or

1 determination of follow up medical care when any |
1 of the following occur: | | H
(a) Restrictive intervention exceeds agency,
| State, and national standards for duration

| (>) Restrictive intervention involves repetitive and i
| severe head banging

! (c) Restrictive intervention involves significant
! seltinjurious behaviors

| (d) Restrictive intervention involves other
significant health or safety concerns."

i

i Review on 12/10/20 of facility support/intervention
| strategies that were part of all client Treatment

| Plans revealed:

"Student -

-Will participate in assessments to help with
treatment planning and identification of strengths,
triggers, and preferred coping skills. Participate I
in individual, family (if applicable), and group
therapies. Attend and participate in Child and
family Team Meetings. Work with staff on

; Support and safety planning. Participate in
academics. Follow basic expectations of the |
program.

Family -

-Will attend and participate in monthly Child and
Family Team Meetings and collaborate with the |
team. Attend family therapy twice per months, or

as clinically recommended, and work on

treatment goals during phone conversations.

Assist student with skills ieamed during

; therapeutic leave. Follow recommendations '
regarding therapeutic passes.

-PRTF - '
-Wili provide weekiy individuai therapy/ family
therapy at a minimum twice per month, group
Division of Health Service Regulation

STATE FORM ‘809 LHPP11 Hcontinuation sheet 27 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of: Health Service Regulation
‘STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

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

c
B. WING 02/18/2021

MHL011-204

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD

ASHEVILLE, NC 28806

CUMMINGS COTTAGE

(4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH

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

DEFICIENCY)

Continued From page 27

therapy. Provide 24-hour supervision to ensure

| safety. Provide trauma informed therapeutic and

| mindfulness practices such as meditation, yoga,

creative modalities, use of sensory ites, '

animal/equine therapy to increase student's ability

| to self soothe and regulate emotions. Provide |

| recreation and exercise opportunities such as

basketball, football, swimming (seasonal) biking, i

skateboarding, use of exercise room/gym. |

Provide therapeutic daily schedule/routine to |

1 Feduce arousal leveis, and prepare students for

transitions. Establish clear rules and

| expectations in the cottage and during academic

blocks. Teach and encourage student to use

' self-regulation skills to increase ability of safely {

| managing triggers and emotions. Remind
student of both positive and negative

{ consequences for actions and how actions affect

| others. Role model appropriate behavior and

; Provide learning opportunities. Provide positive

attention for desired responses. Provide

opportunities for education on nutrition. i |

| Coordinate care among ongoing tx (treatment)

| providers, including discharge and aftercare

i services.

| Psychiatrist (PRTF) -

i -Provide psychiatric assessment, i

| psychoeducation, monitor the efficacy and side

| effects of medications, and consult with

| guardianfamily/team.” {

| Review on 12/22/20 and 12/31/20 of Client #1's i
record revealed:
| -Date of Admission: 8/6/20.
| Age: 15.
: Diagnoses: Autism Spectrum Disorder; Anxiety
Disorder; Depression; Attention Deficit
| Hyperactivity Disorder. 1
_ -Psychiatric Assessment dated 7/8/20 indicated:
| Tecurrent hospitalizations, a recent suicide
Division of Health Service Regulation
STATE FORM eee LHPP11 H continuation sheet 28 cf 124

PRINTED: 03/09/2021
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

Cc
02/18/2021

MHLO11-204 B. WING

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD

CUMMINGS COTTAGE ASHEVILLE, NC 28806

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

v112 | Continued From page 28

! attempt, a long history of self-injurious behaviors, i
| childhood adversity, possible fesbian, gay,
i bisexual, transgendered (LGBT) status and a
| probable family history of mood disorders; during
| inpatient hospitalization, client attempted to harm i
; herself with multiple objects in the room which i
} eventually required the client to have all objects |
| temoved from the room except for a mattress on !
| the floor; On 6/25/20 the client reported
F increasing suicidal thoughts and tried to strangle
herself with hospital scrubs, she reportedly turned
blue and "a code was called which required
bagging before she stabilized." |

Review on 12/31/20 of Client #1's treatment plan
dated 7/15/20 with update/revision dates of
8/20/20; 9/21/20 and 10/21/20 revealed:
-On 7/15/20 the client had the following goals: '
Will develop & utilize effective coping skills to | |
decrease suicidal ideations as evidence by |
developing safety plan and identifying triggers
75% of the time. !
Will increase communication skills to increase !
positive interactions with family members as i
evidenced by expressing thoughts and feelings H
and having conversations with family without
being disrespectful or yelling 80% of the time.
Will improve positive peer interactions as i
evidenced by engaging with peers in prosocial
; activities 3 out of 5 times a day. i
| -Updates included the following: |
; Facility support/intervention strategies were
j | integrated into client's plan on 8/20/20. i
H | A progress note added on 8/20/20 indicated:
| Client "expressed that she has nothing to work on i
| while at Eliada and does not have any treatment
goals. Her child and family team has agreed to
let her settle in more to the unit before revising
| her goais." | |
lA progress note added on 9/21/20 indicated: i
Division of Health Service Regulation
STATE FORM aoe LHPPT1 ‘continuation sheet 29 of 124

PRINTED: 03/09/2021
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
¢

MHL011-204 B. WING ___ 02/18/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD

CUMMINGS COTTAGE ASHEVILLE, NC 28808

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

DEFICIENCY)

: Continued From page 28

Client “has had a few incidents since last review
Aprogress note added on 10/21/20 indicated:
Client "has been struggling over the past review
period ...has openly stated that she wants to go to
a higher levet of care...is frequenily invading
others' boundaries...” Client significantly bit a staff
member and walks out of the program "almost
daily."

-There were no specific goals or intervention |
strategies to address client's elopements,
headbanging, diting herself to draw biood,
scratching words into her arm with sharps, or
punching and biting staff.

Review on 1/29/21 of the Individual Crisis
Management Plan (ICMP) for Client #1 dated
12/2/20 revealed:

: -It contained the name of a direct care staff
member who was listed as an advocate.
-The document did not contain any signatures. |
~Pre-crisis strategies: "giving her a task, providing |
her choices/options, 1:1 proactive checkins and
physical support (side hugs and hand holding).
Appeal to her creativity, not responding to shock
value commentary. Directly ask her plan and
prepare to support, drawing, art projects,
distraction: ask random questions, appeal to her
interests, providing her socially appropriate
suggestions for getting her needs met."
-Triggering strategies: "have someone be with
her, 1:1 staff support, reminders or goals/
motivator.”

-Escalation strategies: "separating from her
peers/removing audience. 1:1 support. Firm voice
tone and expectations, proactive management of
room and person as to prevent hoarding of
sharps: proximity, mange environment, keep
communicating and providing verbal support."
-Outburst strategies: There was no
Division of Health Service Regulation

STATE FORM eso LHPP11 feontinuation sheet 20 of 124

PRINTED: 03/09/2021
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:

(XS) DATE SURVEY
COMPLETED

c
02/18/2021

MHL011-204 B. WING

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

882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

CUMMINGS COTTAGE

(4a) 1D SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (EACH 6)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVEACTION SHOULD BE CROSS- COMPLETE
REGULATORY OR LSC IDENTIFYING INFORMATION) REFERENCED TO THE APPROPRIATE DATE
“DEFICIENCY)

Continued From page 30

documentation.
-Recovery strategies: "motivational interviewing,
focusing on what she does care about, herself
interests and how her choices are creating a
negative effect on her life."

Review on 2/8/21-2/10/21 and 2/15/21 of the K D>

facility PRTF Incident Reports and PRTF

Restrictive Intervention Reports for Client #1 No- \2. | Atteci <a
revealed:

-10/15/20 Client #1 inappropriately exited the
cottage several times throughout the shift. Client
#1 engaged in headbanging behaviors and hit
herself in the head with closed fists.

-11/7/20 Client #1 walked out the side door of the
cottage, picked up a rock, postured at staff and
raised her arm in an attempt to hit staff in the i i
head with the rock.

-11/8/20 Client #1 left the cottage and wandered
around outside for approximately 1 1/2 hours.
Client #1 re-entered the cottage and vigorously
banged her head against a concrete wall and also
struck herseif in the head with a closed fist.
-11/11/20 Client #1 lunged at a peer and bit the
right breast of a staff member.

-11/19/20 Client #1 inappropriately exited the {
cottage. Client #1 was transitioned back inside
I and began to bang her forehead against the wall |
; and punch herself in the head.
-11/21/20 Client #1 banged her head on the wall i
and punched herself in the head with her fists. |
-11/27/20 Client #1 engaged in headbanging t
behaviors, punched herself in the head and bit
staff.

~12/25/20 Client #1 hit her arms against the bed, H
aggressively scratched at her arms, and pulled at \
her hair. Client #1 also engaged in headbanging
behavior which increased in frequency and |
| intensity.

-1/2/21 Staff noticed scratches on Client #1's
Division of Health Service Regulation
STATE FORM eee LHPP411 If continuation sheet 31 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

Cc
02/18/2021

MHLO11-204 bectebalieal

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD

CUMMINGS COTTAGE
ASHEVILLE, NC 28806

4) ID SUMMARY STATEMENT OF DEFICIENCIES iD PROVIDER'S PLAN OF CORRECTION (EACH 5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVE ACTION SHOULD BE GROSS- COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

Continued From page 31

; arm during a routine check and Client #1
admitted that she had self-harmed. | i
-1/14/21 Client#1 used a small piece of glass to
scratch the word “yes" into her left upper arm.
Later that same day, Client #1 banged her head
against the floor and then complained of
dizziness and nausea. i
-1/17/21 Client #1 chewed on the inside of her i
cheek until it bled.

-2/6/21 Client #1 hit her head against the metal
door of the laundry room numerous times,
banged her head against the cement ground and
bit a staff member's hand.

-2/7/21 Client #1 infringed "upon staffs physical |
boundaries” and urinated on herself.
-2/9/21 Client #1 engaged in headbanging
behaviors. | i
' -2/10/21 Client #1 bit her inner forearm "to the
point it drew blood." Client #1 informed staff that { i |
she did not want to return home because her
Grandfather beats her on a weekly basis until she j |
is bruised.

-2/11/21 Client #1 was violently hitting her head
on the ground, hit staff with a closed fist and bit
: more than one staff member on their arms. Client !
#1 also bit her own arm and hit herself. |

Interview on 12/9/21 with Client #1 revealed:
-She grabbed a staff member by the hair. Hl

| -She bit a staff member.
i -She stated, "I was panicking and didn't know
what to do."

Review on 2/16/21 of Client #2's record revealed:
| -Date of Admission: 10/28/20.

-Age: 12.

-Diagnoses: Disruptive Mood Dysregulation
Disorder; Major Depressive Disorder, Recurrent,
Unspecified.

-Comprehensive Clinical Assessment dated
Division of Healtn Service Reguiation

STATE FORM es08 LHPP11 H continuation sheet 32 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A, BUILDING:

(X3) DATE SURVEY
COMPLETED

c
02/48/2024

B. WING

MHLO11-204

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

882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (EACH

GUMMINGS COTTAGE

4) 1D

PREFIX (EACH DEFICIENCY MUST BE PRECEDED 8 FULL PREFIX CORRECTIVE ACTION SHOULD BE CROSS- COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) 1 TAG REFERENCED TO THE APPROPRIATE. BATE.
DEFICIENCY)
V 112; Continued From page 32

8/11/20 with an addendum dated 2/10/21
indicated: she was living at home with
grandmother and receiving intensive in home | |
services; it became apparent that she needed a

higher level of care along with more supervision | Q\

|
and further evaluation to best support her needs; 1 = Us [Supped PA 3 3 —-S3S |
i

| client has an impairment in speech, socialization,
impulse control, and affect regulation; There is
extensive history of mental health and substance
use disorders, along with multiple deaths by
suicide and drug overdose in the family. Ctient
has a history of self-injurious behaviors and
suicide attempts. She can be very hostile and |
aggressive both verbally and physically. She has
hit, pushed, and shoved her Grandmother and
other neighborhood children.

Review on 2/16/21 of Client #2's treatment plan
dated 11/3/20 with update/revision dates of
11/30/20, 12/28/20 and 1/27/21 revealed: H
-On 11/3/20: :
| Facility support/intervention strategies were |
integrated into client's plan. I i
Client had the following goal: Will demonstrate an j
improvement in symptoms as evidenced by
(AEB) monthly decrease in incidents, increase in
use of positive self-talk & reframing of automatic ' i}
negative thinking to increase self-worth and |
positive affect, increase In communicating i |
thoughts and feelings to decrease self-harm, | |
increase in participation & efforts to repair & t
maintain positive relationship with Grandma, |
increase in exchanging high risk coping strategies H
with coping skills which promote long term health
and safety. i
-Updates included the following: |
A progress note added on 11/3/20 indicated:
Client “has struggled with self-injurious behaviors
: since getting to Eliada Homes...
| A progress note added on 11/30/20 indicated:
Division of Health Service Regulation
STATE FORM 9899 LHPP411 'f continuation sheet 33 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

QX2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

c
02/18/2021

B. WING

MHLO11-204 —_—,

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

882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

CUMMINGS COTTAGE

(4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (EACH 5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVE ACTION SHOULD BE CROSS- ‘COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE OATE

DEFICIENCY)

Continued From page 33

| Client "has struggled with impulse control, peer
| relations and self-harm this review period. She
has had numerous incidents of self-ham ...The
main avenue for self-harm is headbanging and
Superficial scratching to her arms with her nails

A progress note added on 12/28/20 indicated:
Client " ...went from daily incidents and a lot of

’ restrictive interventions to only a handful ...”
-There were no specific goals or intervention
strategies to address client's attempts to run into i
traffic, laying in the road, headbanging, punching
herself and her peers, barricading herself in her
room, and eloping from the cottage.

Review on 2/16/21 of ICMP for Client #2 dated
2/10/21 revealed:

| -It contained the name of a direct care staff
member who was listed as an advocate,

-The document did not contain any signatures.
-Pre-crisis strategies: "providing options, giving
hurdle help, providing time and space when she
is conflicted in what to do, Providing her the time i
and space to advocate for her needs when ;
Proximity, give her a project, invite her to join in
activities. Be honest and direct; speak to me with
a respectful; moderate voice-tone. Give me
physical space. Explain to me what is going on.
Utilize humor and exploring her interests.
Running on the treadmill can be helpful. Explain
reasons behind expectations. Structured fitness
activities are helpful, as is time outside. Skills
streaming.”

-Triggering strategies: “Switching out with
unprefered staff, distraction and redirection with !
conversation and activities, reading her journal, |
painting, art projects, poetry. Disengaging.

! Explaining expectations, options and outcomes
and allowing her space to make a choice.

| Proximity, manage the environment.bi lateral
Division of Health Service Regulation

STATE FORM a8 LHPP11 continuation sheet 34 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

{X2) MULTIPLE CONSTRUCTION
A, BUILDING:

(3) DATE SURVEY
COMPLETED

Cc
02/18/2021

B. WING

MHLO11-204

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

(4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (EACH 8)

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

DEFICIENCY)

CUMMINGS COTTAGE

Continued From page 34

tapping, physical touch."
-Escalation strategies: " Switching out with |
unprefered staff, distraction and redirection with

| Conversation and activities, reading her journal,

| painting, art projects, poetry. Disengaging.
Expiaining expectations, options and outcomes
and allowing her space to make a choice.
Proximity, manage the environment.bi lateral
tapping, physical touch."

-Outburst strategies: "verbal disengagement,
silent proximity, maintaining expectations."
-Recovery strategies: "providing visuals, making a
written visual plan, reading to her, helping her
joumal, coaching in processing. preferred staff, i
female staff, using art to help her process and
communicate her emotions. Removing her from
the environment where the incident occurred.
providing visuals, making a written visual plan,
teading to her, helping her journal, coaching in
processing. validating feelings of retuming and
being around non-preferred peer, positive

| feedback, real talk, caring gesture, Hurdle help.”

Review on 2/8/21-2/10/21 and 2/15/21 of the
facility PRTF incident reports and PRTF
Restrictive Intervention Reports for Client #2
revealed:

-11/7/20 Client #2 scratched at her hands, hit her
head with closed fists and banged her head
against a flagpole and a brick wall. Nursing staff {
completed a neurological check and then Client
#2 began headbanging again. She also scratched
her arms and legs and smacked and "kneed"
herself in the head, Client #2 got a nosebleed.
-11/11/20 Client #2 "hammer punched" a peer in
the head.

-12/7/20 Client #2 banged her head on the floor
with increased intensity and vomited in her
mouth.

~12/20/20 Client #2 attempted to self-injure
Division of Health Service Regulation

STATE FORM one LHPP11 H continuation sheet 35 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regutation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

Cc
02/18/2021

MHL011-204 B. WING _

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

882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

CUMMINGS COTTAGE

(xa) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH 5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVEACTION SHOULD BE CROSS- COMPLETE
TAS REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)
V 112 | Continued From page 35 v112

herself by banging her head on her wall "for an
extended period of time."

-12/25/20 Client #2 hit herself in the head with a
closed fist and hit her head with increasing
intensity against the bed, her knee, staff's elbow,
and the floor.

-12/31/20 Client #2 fell to the ground and cried
out in pain while attempting to catch a football.
Client #2 expressed that she "felt something pop
in her knee." She had previously injured her knee
and was prescribed crutches and had refused to
use them. Client #2 received ice for her knee and
staff set the firm expectation to use crutches for
the remainder of the day.

-1/3/21 Client #2 engaged in self-injurious
behaviors. There were no further details
documented about the incident.

~1/6/21 Client #2 engaged in self-injurious
behaviors "since the prior shift." Client #2 banged
her head on the wall for the first 30 minutes of the
encoming shift.

-1/7/21 Client #2 hit her head against a cement
wall and tile floor and "expressed wanting to
Officially say goodbye to Grandma in the attempt
of taking her life."

~1/10/21 Client #2 banged her head against trees |
and a fence and then engaged in headbanging

| behavior outside of the cafeteria. Later in the

evening, Client #2 headbanged in her room and

also used her knees and fists to hit herself in the

head.

~1/11/21 Client #2 attempted to run into traffic.

-1/13/21 Client #2 banged her head on the road |
and then a few hours later, she banged her head

on a brick wall and hit herseif in the head with

closed fists.

-1/14/21 Client #2 attempted to take "the central

board" from staff, then walked off campus and sat

down in the middle of the road. Construction
workers stopped the flow of traffic to prevent
Division of Health Service Regulation

STATE FORM eee LHPP11 Weontinuation sheet 36 of 124

PRINTED: 03/09/2021
FORM APPROVED

Division of Health Service Re

gulation

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X2) MULTIPLE CONSTRUCTION
A, BUILDING:

(X3) DATE SURVEY
COMPLETED

c
02/18/2021

MHLO11-204 B.WING__

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

882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

CUMMINGS COTTAGE

(4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH 5)

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

DEFICIENCY)

Vv 112 | Continued From page 36 vi1i2

Client #2 from getting hurt. Staff informed Client
#2 they were going to call the police due to her
holding up traffic and it being a safety concern.

| Client#2 returned to campus and then engaged
in headbanging behavior.

-1/14/21 In the evening, Client #2 left the cottage
in another attempt to access the road. Client #2
expressed suicidal ideation and the desire "walk

| out into oncoming traffic to potentially be hit.”
-1/16/21 Client #2 engaged in "moderate
headbanging." Client #2 banged her head on the
wall and on the floor. She complained of a
headache and refused to allow the Registered
Nurse (RN) to check her head for an injury.
-1/17/21 Client #2 intensely hit her head against
the wall with increased severity and punched
herself in the face,

-1118/21 Client #2 barricaded herself in her room
and intensely banged her head. Client #2
continued the self-injurious behaviors once staff
got inside the room. Then Client #2 exited the
cottage and ran towards the road.

-1/21/21 Client #2 barricaded herself in her room
and engaged in headbanging. Client #2 then left |
the cottage and approached the road,
-1/25/21 Client #2 engaged in moderate i
headbanging behaviors.

-1/28/21 Client #2 was headbanging with
increased intensity and speed and became
aggressive towards staff.

-1/29/21 Client #2 inappropriately exited the i i
cottage and made repeated attempts to run into
the road and into traffic "so a car could hit her.” |
Client #2 actually laid in the road for a few
minutes. |
~1/31/21 Staff tried to prevent Client #2 from ;
feaving through the front door of the cottage.
Client #2 walked out the side door and "moved
towards the road in an attempt to get hit by a car.”
-2/4/21 Client #2 pushed past staff several times
Division of Heaith Service Regulation
STATE FORM 8099 LHPP11 If continuation sheet 37 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation

‘STATEMENT OF DEFICIENCIES (41) PROVIDER/SUPPLIERICLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(3) DATE SURVEY
COMPLETED

Cc
02/48/2021

MHL011-204 B. WING

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

882 ELIADA HOME ROAD

ASHEVILLE, NC 28806

oxayiD SUMMARY STATEMENT OF DEFICIENCIES iD PROVIDER'S PLAN OF CORRECTION (EACH 5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVEACTION SHOULD BE CROSS- COMPLETE

TAG REGULATORY OR LSG (DENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE. DATE
DEFICIENCY)

V 112) Continued From page 37 v112

| to get to the road. Client #2 wanted "to get hit by
| a car." She also engaged in headbanging

| behaviors.

| -2/8/21 Client #2 reported that she vomited her
medication about 10 minutes after taking them.
-2/9/21 Client #2 was hitting the wall and

| knocking "her good knee" into it. She also lightly
tapped her head against the wall.

-2/10/21 Client #2 ran down the parking lot j
towards another building on campus and
attempted to crawl through the bushes to get into
a "memorial" and exited the bushes and went into
a "bog field."

2/12/20 Client #2 pushed against staff and
attempted to go towards the road. Client #2
engaged in headbanging behaviors and
attempted to self-harm hy scratching her wrist. |

CUMMINGS COTTAGE .

Review on 2/16/21 of Client #3's record revealed:
-Date of Admission: 12/22/20.

~-Age: 14, |
-Diagnoses: Attention Deficit Hyperactivity
| Disorder; Major Depressive Disorder, Recurrent, 1
| Moderate: Post-Traumatic Stress Disorder
(PTSD), Chronic; Mathematics Disorder;
Personality Disorder, Unspecified.
~Comprehensive Clinical Assessment dated
11/10/20 with an addendum dated 2/2/21

; indicated: Client was bom biologically female and
has expressed a desire to be male; has alleged
being sexually assaulted by at least six
individuals; sexual abuse and physical abuse
Started at age 2; he engages in high-risk
behaviors; required hospitalization several times
in the past 6 months; due to substance use,
Coercion of younger peers, and sexual behaviors
it is advised that the client have only supervised
use of technology, that he be supervised at alll
times (exception of bathroom/other private
locations), that he not be place in a home with
Division of Health Service Regulation
STATE FORM ease LHPP11 Hf continuation shaet 38 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES Q(1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

{%3) DATE SURVEY
COMPLETED

Cc
02/18/2021

MHLO11-204 B. WING

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

882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

CUMMINGS COTTAGE

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

DEFICIENCY)

Continued From page 38

impressionable children, and that treatment team
members check for self-harm periodically, that
drug screens be conducted regularly, and other
forms of communication be monitored; his history
of suicidal tendencies and potential harm to self
and/or others is a highly significant concern; it is.
strongly recommended that a safety plan be
developed and implemented in the event he
exhibits thoughts, wishes, intent or attempt to
ham self or others.

Review on 2/16/21 of Client #3's treatment plan
dated 10/6/20 with update/revision dates of
10/26/20, 11/23/20, 1/8/21 and 2/5/21 revealed:
-On 11/23/20:

Facility support/intervention strategies were
integrated into client's plan.

Client had the following goal: Will maintain safety
for herself and others AEB Following all basic,
community, and safety expectations in and
outside of the cottage as evidenced by
completing no more than one community values

; check-in form a week; checking-in with staff, or
clinician, or using preferred coping strategies
when she/he identifies as blue, yellow, or red on
the zones of regulation at least twice a day
following daily review, during a transition, or any
other time necessary to maintain emotional
regulation; participating in all individual (at least
1x a week) and group therapy (at least 3x a
week) as well as all child and family team
meetings (1x a week); respecting the boundaries
of peers and staff as evidenced by no instances
of a boundary pian; Verbal and physical
aggression, maintaining appropriate boundaries
with staff and peers AEB no instances of verbal or
physical aggression.

-Updates included the following:

On 1/8/21 the following goal was added: "Will
show an increase in ability to manage symptoms.
Division of Health Service Regulation

STATE FORM e280 LHPP11 If continuation sheet 39 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service R
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

gulation

(<1) PROVIDER/SUPPLIER/CLIA
(IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A, BUILDING: __

03) DATE SURVEY
COMPLETED

Cc
02/18/2021

B. WING

MHL011-204

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ASHEVILLE, NC 28806
(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES iD

CUMMINGS COTTAGE

PROVIDER'S PLAN OF CORRECTION (EACH “9
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVE ACTION SHOULD BE CROSS- COMPLETE
TAG REGULATORY OR LSC IDENTIFYING. INFORMATION) TAG REFERENCED TO THE APPROPRIATE

DEFICIENCY)

V 112! Continued From page 39

| AEB increase in ability to manage symptoms of
anger by communicating with staff when he
enters the yellow zone prior to entering the red
zone, increase in ability manage symptoms | t
related to PTSD by participating in eye movement
desensitization and reprocessing (EMDR)

sessions, increase in ability to manage symptoms va j
related to oppositional defiant disorder (ODD) by i
following expectations and responding to | -J / ANacwnee '

directives from staff, increase personal insights |
into triggers and awareness of what yellow and !
red zones look like for him individually by creating
@ personal support plan, increase ability to
manage anger AEB no more than 2 instances of

| walking out of the cvitage and/or property |
destruction per week." 1
A progress note was added on 1/8/21 which
indicated: Client "is struggling with anger on a ! i
daily basis. We have seen self-injurious behavior | i
in the form of headbanging and scratching
themselves with fingemails or erasers ..."

A progress note was added on 2/5/21: Client "has
struggled with normal programming scheduling.
They have amassed numerous incident reports in
the form of aggression, eloping from campus, .
suicidal ideation, unsafe behavior and putting
themselves in danger. [Client] has also been in
over 8 restrictive interventions due to unsafe i }
behavior, aggression towards staff and i
attempting to place themselves in unsafe |
conditions specifically trying to step into traffic. |
[Clien{} has struggled with going to school and is
currently failing classes due to unexcused

absences ...at this time there is little engagement

with therapy or working on their trauma."

-There were no specific goals or intervention

strategies to address client's elopements, |
headbanging, cutting herself, hitting herself,

walking into traffic, attempting to jump in front of
multiple cars, punching, biting and cutting staff,
Division of Health Service Regulation

STATE FORM ad LHPP11 Mf continuation sheet 40 of 124

PRINTED: 03/09/2021
FORM APPROVED

‘STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X17) PROVIDER/SUPPLIER/CLIA.
IDENTIFICATION NUMBER:

(<2) MULTIPLE CONSTRUCTION
A. BUILDING:

(3) DATE SURVEY
COMPLETED

c
B. WING ____ 02/19/2021
STREETAODRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

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

DEFICIENCY)
V 112! Continued From page 40

attempts to steal staff's keys and radios, and
Property destruction.

MHL011-204

NAME OF PROVIDER OR SUPPLIER

CUMMINGS COTTAGE

Review on 2/16/21 of the ICMP for Client #3

dated 2/10/21 revealed:

-It contained the name of a direct care staff

| Member who was listed as an advocate.

-The document did not contain any signatures.

-Pre-crisis strategies: “Invite to engage, role '

| model engagement, humor, physical activities lv
(Football & Soccer) Proximity, Humor, K

prompting/invitations to join. | “LY | Othachee |

-Triggering strategies: "Humor, real talk,

distraction, remove the audience, change the

environment, strategic proximity, validating

feelings.”

-Escalation strategies: “Provided with a physical ' |

outlet, proximity, time, real talk, manage the

environment, point to progress."

-Outburst strategies: “Do not use humor, firm

expectations, silent proximity and minimal verbal

engagement, reminders of his goal to remain in

the program."

-Recovery strategies: "Staff support (try to avoid

preferred staff), open ended questions."

Review on 2/8/21-2/10/21 and 2/15/21 of the |
facility PRTF Incident Reports and PRTF
Restrictive Intervention Reports for Client #3
revealed:

-1/1/21 Staff found metal in Client #3's room and |
her arm was bleeding from self-harming.

| 71/3/21 Client #3 verbalized suicidal ideation and
began headbanging in her room. Client #3 :
Punched a mirror several times and left the
cottage and made multiple suicidal ideation
comments. Client #3 also disclosed that she had
been sexually assaulted in ail of her past
placements.

-1/5/21 Client #3 picked at scabs on her hand
Division of Health Service Regulation
STATE FORM sean LHPP11 H continuation shest 41 of 124

PRINTED: 03/09/2021
FORM APPROVED

Division of Health Service Regulation

‘STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(41) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

Cc
02/18/2021

MHLO11-204 B. WING

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
382 ELIADA HOME ROAD

ASHEVILLE, NC 28806

CUMMINGS COTTAGE

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

DEFICIENCY)

Continued From page 41

until they bled. Client #3 hit herself in the face
several times and tapped her head on the patio
fence.

-1/6/21 Client #3 engaged in headbanging
behavior, threw items at staff, inappropriately
exited the cottage and attempted to
inappropriately enter the administration building.
Client #3 "continued her attempts to engage in z
| unsafe behavior" and attempted to walk into S- \
traffic.

-1/10/21 Client #3 was expressing suicidal
ideation, engaged in headbanging behavior, i
attempted to enter the road with the intention of
being hit by a car and attempted to jump in front
of muitipie cars. Client #3 struck staff with a
closed fist and bit staff. One staff member had
bite marks on both hands and nail marks on one
hand, another staff member had bite marks to
their knuckle and thumb and swelling to their left
ankle from being kicked.

-1/11/21 Client #3 continually expressed suicidal
ideation, pushed against staff and dug their nails
into staffs hand. Client #3 attempted to enter the
Toad in an attempt to be struck by a car. One staff
member received scratches to his hands, another
staff member received scratches to his right
hand. Client #3 was involuntarily committed i
(IVC'd) due to suicidal ideation and attempting to
get into traffic; |
-1/15/21 Staff tried to block Client #3 from
entering the road. Client #3 punched staff in
various areas. Staff were hit in the face, neck and
stomach.

1/17/21 Client #3 engaged in headbanging
behavior.

-1/18/21 Client #3 stated their intent to die in the '
road and began sprinting towards the road. i
-1/22/2' Client #3 exited the cottage and staff |
blocked Client #3 from going off campus. Client
#3 became physically aggressive, pushed against
Division of Health Service Regulation

STATE FORM 9889 LHPP11 H continuation sheet 42 of 124

aArMNacd—~ea, !

PRINTED: 03/09/2021
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

c
MHLO11-204 BAWING 02/18/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
862 ELIADA HOME ROAD

CUMMINGS COTTA
mi OTTAGE ASHEVILLE, NC 28806

(a ID | SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (EACH (x8)
PREFIX | (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVE ACTION SHOULD BE CROSS- COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DATE
! DEFICIENCY)
I -
V 142) Continued From page 42 V112

and attempted to punch staff, and attempted to
rip down a sign in front of the administration
building.

-1/24/21 Client #3 pushed, punched and bit staff
while trying to exit the side doors of the cottage.
Client #3 attempted to run into the road, used a '
Piece of plastic to cut a staff member's neck and
attempted to grab staff's radios and keys. Client 1
#8 lifted the carpet in their room to reveal tile i:
beneath, broke tile off the floor and scratched self !
with it and "wrote F**k youl ona staff's arm.” y

Client #3 began headbanging with moderate YW -f
severity and was hitting herself in the face. Client
#83 had mild bruising on their knuckles due to
punching a wall. A staff member was injured by
having their fingers caught in the door.

-1/26/21 Client #3 inappropriately exited the
cottage. I
-1/29/21 Client #3 engaged in several instances
of self-injurious behavior as evidenced by
attempts to head bang and cross the road
“placing self at immediate and imminent risk of |
being struck by a vehicle." Client #3 “wanted to
ill herself by standing in the road with the intent i
to get killed by traffic." Client #3 repeatedly
attempted to strike staff with a closed fist and |
kicked staff. i
-1/31/21 Client #3 walked out of the cottage and
began to walk off campus and pushed against

| Staff. Client #3 transitioned back to cottage and
“began to bang loudly in her room". She
attempted to leave the cottage multiple times and H
Staff biocked her from exiting. Client #3 began
i tearing posters off the wall, banging on windows i
and attempting to set off the fire alarm. Client #3
also demonstrated physical aggression. {
-2/1121 Client#3 walked down the road and j
almost walked off campus. |
-2/2/21 Client #3 inappropriately left the courtyard
and approached the road. Client #3 made suicidal
Division of Health Service Regulation

STATE FORM Lema LHPP41 Ifcontinuation shest 43 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Re
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

gulation

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

c
02/18/2021

B. WING

MHL011-204

NAME OF PROVIOER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882. ELIADA HOME ROAD
ASHEVILLE, NC 28806

CUMMINGS COTTAGE

SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (EACH (X5}
(EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVEACTION SHOULD BE CROSS- COMPLETE
REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

V 112) Continued From page 43

statements and staff blocked Client #3 from
getting off campus.

-2/5/21 Client #3 engaged in self-injurious
behavior. The report did not include details or a
summary of the incident.

Review on 9/8/20 of FC #5's record revealed:

| -Date of Admission: 2/25/20.

-Age: 13.

i -Diagnoses: Post Traumatic Stress Disorder;
Attention Deficit Hyperactivity Disorder,
Combined Type; Major Depressive Disorder,
Single Episode Moderate: Oppositional Defiant
Disorder;

-Discharge Date: 7/27/20.

-Comprehensive Clinical Assessment dated
2/12/20 indicated; Client had consistent conflict
and avoidance of adoptive Mother: verbal and
physical aggression towards adoptive Mother;
Consistent enuresis; defiance at home and
school settings; limited improvement after a year
of intensive in home services; will benefit from
ongoing individual group and family therapy to
support identification of challenges that impact
her relationship with her Mother, as well as build
positive relationships to challenge her mistrust
and difficulty connecting with others who hold
expectations of her.

Review on 9/17/20 of FC#5's treatment plan
dated 1/17/20 with update/revision dates of
2/11/20, 3/9/20, 4/9/20, 5/8/20, 5/27/20, 7/7/20
and 7/20/20 revealed:

-Facility support/intervention Strategies were
integrated into client's plan on 1/17/20 while client
| was in a sister facility,

| -On 2/11/20 client had the following goals: |
Will demonstrate an improvement in
post-traumatic stress symptoms AEB decreased
avoidance behaviors, decreased irritability, and
Division of Health Service Regulation

STATE FORM 8088 LHPP11 {f continuation sheet 44 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Heaith Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
‘AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

{X3) DATE SURVEY
COMPLETED

c
02/18/2021

MHL011-204 B. WING

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

(X4) 1D SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (EACH 5)

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

DEFICIENCY)

CUMMINGS COTTAGE

Continued From page 44

{ elimination of angry outbursts.

Will demonstrate an improvement in symptoms of
attentional difficulties AEB enhanced
concentration, decreased restlessness and
fidgetiness, and increase in following directions.
-On 3/9/20 the above goals were discontinued
and the following goal was added:

Will demonstrate an improvement of symptoms
AEB an increase in accepting responsibility for
high tisk, or aggressive reactions to stimuli,
increase in honesty with self, or others, increase
in ability to meet the need for attention without
engaging in self-harm, or aggression, increase in
ability to self-support and self-regulate emotions
when in a negative space, increase in ability to i
temain focused and engaged in conversations
and structured activities.

-Updates included the following:

A progress note added on 3/9/20 indicated: Client
“struggled at first to adjust to the new unit but has H
been able to adhere to a majority of rules and
expectations. A Child Family Team (CFT)
meeting was held on 3/9/20 to discuss progress
and symptoms and to better identify goals for her
to work on while in Cummings Cottage. i
A progress note added on 4/9/20 indicated: Client
"was engaging in run behaviors and consistently
reporting self-harm but did not have visible marks
progress note added on 5/8/20 indicated: Client |
“has had a mostly regressive review period. She
has run consistently ...has hada few instances of
verbal aggressions in which she threatens to fight |
peers ...continues to threaten self-harm ..."

A progress note added on 5/27/20 indicated:
Ctient has been accepted to a locked PRTF.

| “Her team felt the transition was necessary due to
continued running behaviors, especially in the i
evening." Client is waiting for her transition date
to be set.

Oivision of Health Service Regulation
STATE FORM 6208 LHPP11 H continuation sheet 45 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation

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

(03) DATE SURVEY
COMPLETED

(42) MULTIPLE CONSTRUCTION
A, BUILDING:

c
02/18/2021

B. WING

MHL011-204

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD

CUMMINGS COTTAGI
mi = ASHEVILLE, NC 28806

X4} 1D SUMMARY STATEMENT OF DEFICIENCIES: ID PROVIDER'S PLAN OF CORRECTION (EACH (6)
PREFIX (EACH DEFICIENCY MUST SE PRECEDED BY FULL | PREFIX CORRECTIVEACTION SHOULD BE CROSS- COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE OATE

DEFICIENCY)

Continued From page 45

A progress note added on 7/7/20 indicated: “It
has been almost 60 days since the teams initial
recommendation of Locked PRTF ...The team

i feels [client] no longer meets criteria for a locked
/ unit..."

A progress note added on 7/20/20 indicated: H '
Client "has demonstrated regressive behaviors,
| which have continued for several weeks, The {

f
Clinical team determined that she again qualified
| for a lacked PRTF due te continued running A 6 Supp” +s Pr ¢ \ &
behaviors, during which she often picks up items I-V) uE-B)
from the ground to use for self-harm or to
threaten staff ..."

| -There were no specific intervention strategies to
: address client's repeated elopemenis, physical \
aggression towards staff, tying items around her
neck in repeated attempts to choke herself, and
cutting herself with numerous sharp objects. | |

Review on 1/29/21 of the ICMP for FC #5 dated
6/17/20 revealed:

-It contained the name of a direct care staff
member who was listed as an advocate.

-It contained the name of another direct care staff
member who was listed as a co-advocate.

-The document did not contain any signatures.

| -Pre-crisis strategies: "Hold firm expectations,
kind but firm, hold accountable, caring gestures,
cleaning projects. Validation. Positive reframing.”
-Triggering strategies: "time and space, firm but

| kind accountability, clear expectations, reframe {
reality.”

-Escalation strategies: “time and space, firm but
| kind accountability, clear expectations, reframe |
reality.”

Outburst strategies: There was no
documentation.

Recovery strategies: There was no
documentation.

Division of Health Service Regulation
STATE FORM wm LHPP14 H continuation sheet 46 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation

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

(X2) MULTIPLE CONSTRUCTION
A, BUILDING:

(X3) DATE SURVEY
COMPLETED

c
02/18/2021

B, WING

MHL011-204

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

CUMMINGS COTTAGE

84) 1D SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (EACH 25)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVE ACTION SHOULD BE CROSS- COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION} TAG REFERENCED TO THE APPROPRIATE SATE

DEFICIENCY)

V 112; Continued From page 46
Review on 2/8/21-2/10/21 and 2/15/21 of the

facility PRTF Incident Reports and PRTF
Restrictive Intervention Reports for FC #5
revealed:

-3/19/20 FC #5 ran from the cottage, punched
and hit staff.

-3/22/20 FC #5 ran out of the cottage towards a
peer that was engaged in a restrictive
intervention. When FC #5 was unable to reach
her peer, FC #5 ran towards the comfield.
-3/24/20 FC #5 was hyper focused on a peer that
was being restrained the courtyard. FC #5
inappropriately exited the cottage and attempted
to get close to her peer who was being
restrained. FC #5 then ran towards the horse
Pasture and continued to nun back and forth on
the road. Several hours later, FC #5 pushed
against staff, ran out of the cottage and into the
courtyard. FC #5 attempted to leave the courtyard
multipie times.

-3/26/20 FC #5 left the cottage inappropriately to
join a peer from another cottage in “monopolizing
the courtyard."

-4/21/20 FC #5 exited the cottage after she saw a
peer walk out of the cottage. Fc #5 proceeded to
tun. FC #5 returned to the cottage after the
common area closed and charged at staff who
were in her doorway. FC #5 kept grabbing staff to
get past them, thinking that another staff member
was "managing" her bedroom.

-4/22/20 FC #5 saw horses run through the
courtyard. She screamed and sprinted out of the
cottage. A peer aggressively followed FC #5 and
threatened her with physical harm. Staff removed
the peer as FC #5 walked barefoot to the animal
barn. FC #5 attempted to pick up sharps but was
unsuccessful. FC #5 returned to the cottage and
became escalated when she realized "her room

; had been managed”. FC #5 attempted to exit the

Cottage again by pushing against staff and trying
Division of Health Service Regulation

STATE FORM cena LHPP11 if continuation sheet 47 of 124

PRINTED: 03/09/2021
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:

(3) DATE SURVEY
COMPLETED

Cc
02/18/2021

MHLO11-204 B. WING

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

CUMMINGS COTTAGE

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

DEFICIENCY)

Continued From page 47

to pull staff's fingers off the door: FC #5 began to
swing at staff. Staff informed the guardian that FC
#5 had briefly left campus.

-4/25/20 FC #5 hit staff with a large stick and
attempted to run off-campus towards the road.
After retuming to the cottage, FC #5 pushed
against staff in an attempt to leave her room to go
outside.

4/27/20 FC #5 pushed against staff and kept
trying to get past them to run away.

-4/28/20 FC #5 ran out of the cottage and upon

; feturning, FC #5 ran back out of the cottage after
@ peer from a sister facility ran outside. FC #5
made verbal threats to the peer and pushed
against staff who were trying to prevent her from
engaging with the peer.

-4/30/20 FC #5 was fixated on her off-task peers
in the courtyard. FC #5 ran out of the cottage and
placed herself ‘in the middle of chaos where staff
were hit with sticks". FC #5 began sprinting in an |
attempt to run off campus. |
-5/11/20 FC #5 ran out of the cottage twice.
~5/12/20 FC #5 attempted to run out of the
cottage. Staff attempted to prevent FC #5 from
exiting and she ran down the opposite hallway | |
and exited the cottage.
-5/16/20 FC #5 kicked a hole in the closet of her t
toom. FC #5 ran out of the cottage after seeing a j

peer run out the door,

-7/6/20 FC #5 attempted to run towards the |
woods off-campus and began to hit staff with a
stick. Staff received scratches to their left arm.
-7/12/20 FC #5 grabbed a stick and threatened to 1
hit staff. FC #5 grabbed some string and began to
tie it around her neck. RN noted FC #5 "reports
her neck hurts and that it is hard to breathe (yet
student had just ran at full speed away trom staff
and returned without difficulty)." FC #5's neck was
slightly red from where she wrapped a cord
around it. FC #5 would not let RN assess closely.
Division of Health Service Regulation

STATE FORM saan LHPP14 W continuation sheet 48 of 124

PRINTED: 03/09/2021

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES: {X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
c
MHLO11-204 B.WING 02/18/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZiP CODE

882 ELIADA HOME ROAD
ASHEVILLE, NC 28806
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH

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

pp DEFICIENCY)
Vv 112] Continued From page 48

-7/13/20 FC #5 ran out of the cottage towards a
window that she knew had been broken and she
managed to get a handful of broken glass from
the ground. FC #5 walked around the weight bam
and picked up several items that she could use to
self-harm (a bungee cord and a sharp piece of
wood). FC #5 choked herself with the bungee
cord after wrapping it around her neck twice. She
punched staff and tried to push past them to
cross the road when cars were going by. RN
noted FC #5's "neck has small red areas on it
from wrapping cord around it yesterday.”
-7114/20 FC #5 walked off-campus towards
partment buildings while holding a stick. FC #5
had been off task and outside of the cottage for 3
hours. Upon returning, FC #5 attempted to exit
the cettage again by pushing past staff snd
punching staff in the stomach.

-7/26/20 FC #5 punched and kicked staff. FC #5
attempted "to choke herself several times with
various things found on campus" including a rope
and haybale ties. FC #5 was in possession of
various pieces of glass and a tree limb. Staff
stated, "this made them feel unsafe so they kept
their distance except when she was.
self-harming.” RN was notified that FC #5
“seemed to faint as she fell fo the ground” but
staff asked nursing not to come when FC #5
stood up. RN noted FC #5 made superficial cuts
on arms and forearms with glass. One staff

| Member was punched in the back 10 times and
two staff members were kicked in the legs
several times.

| -7/26/20 Later in the evening, FC #5 exited the
cottage and was able to find items to tie around
her neck (hay barrels with long rope attached to
them, maintenance equipment, and a rope horse
lead). FC #5 wrapped a hay barrel cord around
her neck and asked for help when it became
Stuck and it resulted in her face turning blue.
Division of Health Service Regulation

STATE FORM 6200 LHPP11 H continuation sheet 49 of 124

CUMMINGS COTTAGE

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation

‘STATEMENT OF DEFICIENCIES (41) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X3) DATE SURVEY
COMPLETED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

Cc
02/18/2021

MHLO11-204 B. WING

NAME OF PROVIDER OR SUPPLIER STREET ADORESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

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

DEFICIENCY)

CUMMINGS COTTAGE

PREFIX
TAG

i Continued From page 49

| Video recording was performed per facility
protocol.

interview on 9/17/20 with the Legal Guardian for |
FC #5 revealed:
-Eliada Home kept allowing FC #5 to leave |
campus.

-They were not providing safety.

-She stated, "I wanted to keep [FC #5] on facility

| grounds because they say once a child leaves the
| facility that they can't touch them.”

~FC #5 picked up a bottle from the street, broke it
and cut herself with it.

-She was concerned about blood borne
pathogens and germs.

-She was informed by the Residential Clinician
that the facility "would staff better” and would usc
testraints to prevent FC #5 from leaving campus.
-The staff were informed of this "but never
executed the plan."

-Eliada staff do not review all of the documents
that are provided to them.

-Staff seemed unaware of FC #5's behaviors.
-She stated, "They claimed that they changed
their procedures and that they no longer used
restraints, but they have documentation stating
restraints may be used. They should have used
them. It was more dangerous to allow [FC #5] to
run off campus into a busy street with traffic and |
objects with which she could cut herself ...Even
though they don't use restraints anymore, they

| told me they would, but they didn't ...[FC #5]

' picked up twine from hay bales which shouldn't
be on campus. They claimed she got it off the
side of the road. It puts a child's life at risk ...] saw
an area where [FC #5] rubbed the twine against
her neck causing a rope burn ...\Why didn't they
use interventions? They should eliminate t
dangers"
-FC #5 eloped from campus and went to the |

Division of Health Service Regulation
STATE FORM 6e08 LHPP11 If continuation sheet 50 of 124

PRINTED: 03/09/2021
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

c
02/18/2021

MHLO11-204 B. WING

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD

ASHEVILLE, NC 28806

CUMMINGS COTTAGE

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

DEFICIENCY)

Continued From page 50

Sheriff's Department which is located off
Leicester Highway.

Interview on 9/17/20 with the Post Adoption
Specialist for FC #5 revealed:

FC #5 "was in an extremely dangerous situation j
and the higher ups at Eliada agreed. They

claimed they would intervene." [This is inaccurate, Client 2 has the [Q of 81
-FC.#65 had an intelligence quotient of 81 and . .
needed to be supervised. with Autism.

| -She stated, "Eliada cut and pasted
documentations. We were unable to determine
which parts were true about [FC #5] and which
parts were copied and pasted from another
child's documentation.”

-She had a conference call on 6/22/20 with the
Residential Clinician, the Case Manager and the
Legal Guardian for FC #5.

-The Residential Clinician was advocating for
frontline staff to intervene with [FC #5] in order to
keep her on the facility grounds,

-She stated, "They (facility staff) claimed [FC #5]
didn't try to hurt herself, but she cut herself with
glass and was able to put a rope around her
neck. They didn't intervene. | don't agree with
physical intervention, but they didn’t have eyes on
her ...[FC#5] has high end attention seeking
behaviors, but they need to do their job. [The
Residential Clinician] was advocating for staff
intervention on 6/22/20, and then on 7/6/20 we
had a follow up meeting and we questioned them
; about why they never intervened, but they didn't
have an answer. Everybody knew what the plan
was, but they didn't follow the plan.”

-FC #5 ran to the "police annex off the highway" 3
| different times.

Interview on 9/17/20 with a Sergeant from the
local Sheriff's Department revealed:

~A child from Eliada Group Home showed up at
Division of Health Service Regulation

STATE FORM aaa LHPP11 tfcontinuation sheet 51 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation

‘STATEMENT OF DEFICIENCIES (41) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(%2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

c
02/18/2021

MHL011-204 8. WING

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD

COTTAGE
CUMMINGS AG! ASHEVILLE, NC 28806

(x4) 1D ‘SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION(EACH os)

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

DEFICIENCY)

Continued From page 51

the police station 3 different times. 1
-The child claimed other kids at the home were
picking on her.

-Group home staff were present with the child
each time she came to the police station.
-The first time that she came to the police station, i
she was sent to the hospital.

-The other times, she returned to Eliada Home.
-Emergency Medical Services (EMS) were called
each time she arrived because she had an injury.
-She stated, "She had cuts that didn't appear i
deep, but I'm not medical and | wanted to ensure
she was evaluated, so | am required to call EMS.” i
-The last time the child came to the police station, |
she learned she was transferring to another
residential facility.

(Correction: The student when going to the

Observation an 1/44/21 from 11:36 am to 11:40 sherriff office, would walk beside our horse

am of Leicester Highway discussed in interviews

with the Legal Guardian and the Pest Adoption pasture, through cross a 2 lane small road,
pei Walt Je 1 {ross through the apartment complex and
| -The Highway had five lanes for traffic F 5 A |
| There wore fwo lanes of trafife flowing East he sheriff's office was right past there in a
“There were two tanes of traffic flowing West hopping center on the same side ofthe |
-There was one turn lane treet. She was not crossing Leicester \

“The posted spocd mit was 45 miles per hour | highway which is a much busier road.
Review on 12/22/20 & 12/31/20 of FC #6's record
revealed: |
-Date of Admission: 9/9/20. i
-Age: 14. |
-Diagnoses: Post Traumatic Stress Disorder;
Disruptive Mood Dysregulation Order.
-Discharge Date: 11/10/20.

-Comprehensive Clinical Assessment dated
10/7/20 with an addendum dated 11/5/20
indicated: Client was born with a farge amount of
cocaine in her system; was adopted by her

| current parent; has a strained relationship with

| her adoptive Mother; has been in several foster
Division of Health Service Regulation

STATE FORM ome LHPP11 continuation sheet 52 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation
‘STATEMENT OF DEFICIENCIES 041) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A, BUILDING:

(X3) DATE SURVEY
COMPLETED

c
02/18/2021

MHLO11-204 5. WING

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

882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

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

CUMMINGS COTTAGE

Continued From page 52

homes in the last year; struggles to discuss her
trauma while leaming to effectively regulate her
emotions; her adoptive parents had a difficult
separation and divorce which cause strain; has a
history of trying to cut herself with items; has
required multiple hospitalizations for regulation. |

Review on 12/31/20 of FC #6's treatment plan . ]

dated 8/25/20 with update/revision dates of a

9/24/20 and 10/23/20 revealed: \-yo Pe
+ -On 8/25/20:

Facility supportintervention strategies were
integrated into client's plan.

Client had the following goal: Wil! dersonstrate an
improvement in post-traumatic stress symptoms 1
: AEB an increase in age-appropriate behaviors, a
decrease in irritability, and elimination of angry
outbursts.

-Updates included the following:

A progress note added on 9/24/20 indicated:

Client “appears to have moved out of a

honeymoon phase pretty quickly and has had

issues aligning with peers that negatively

influence her. Of the approx 2 weeks she has

been at Eliada she has struggled with running
behaviors and instigative /aggressive behaviors

towards staff and peers.”

A progress note added on 10/23/20 indicated:

Client "has continued in similar vein from the last

review period into this one. [Client] inappropriately
leaves the cottage when angry or flooded with

emotions and attempts to get others involved in

her off task behaviors. She has shown

self-injurious behavior in the form of finding

sharps and cutting, and headbanging. She has

| done significant property destruction on campus |
as well in the form of broken windows ...At this

time we are looking at a locked unit lateral

| transition ..."

-There were no specific goals or intervention
Dhision of Health Service Regulation

STATE FORM a9 LHPP11 Hf continuation sheet 53 of 124

PRINTED: 03/09/2021
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

c
MHLO011-204 B. WING 02/18/2021

NAME OF PROVIDER OR SUPPLIER, STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

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

CUMMINGS COTTAGE

V 112) Continued From page 53 v112

| strategies to address client's sexualized
| behaviors, elopements, headbanging, stealing
| staff's radios and keys, property destruction,
hitting, punching, kicking and biting staff,
repeated attempts to strangle herself and
| attempts to be struck by traffic.
|
Review on 1/29/21 of the ICMP for FC #6 dated
| 10/14/20 revealed:
i -lt contained the name of a direct care staff !
| member who was listed as an advocate. j
-The document did not contain any signatures.
-Pre-crisis strategies: "positive encouragement,
invite her te join, help her label feelings and
| process them, give her options of things can do,
do her hair. Give her a project."
-Triggering strategies: "help her label emotions
and identify the need not being met, connect peer
acceptance to positive coping strategies.
Providing her with strategies to make a
correction, reminding her she has choices.”
| -Escalation strategies: "remove the audience, |
separate from peers, less verbal interaction more
proximity.” |
-Outburst strategies: "proximity, manage the
environment, remove audience, redirection with
proximity, harm reduction (headboards, familiar
staff)."
~Recovery strategies: "Staff supported LS} (Life
Space Interview), assist her in giving language to |
connect thoughts feelings and behaviors, use
: visual prompts to assist in communicating and
processing, assisting in processing potential i
choices and outcomes.”

| Review on 2/8/21 -2/10/21 and 2/15/21 of the
facility PRTF Incident Reports and PRTF
Restrictive Intervention Reports for FC #6
revealed:

-$/14/20 A peer waiked behind FC #6 and
Division of Health Service Regulation

STATE FORM sse8 LHPP11 If continuation sheet 54 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (41) PROVIDER/SUPPLIER/CLIA (42) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A BUILDING:

c
MHL011-204 B. WANG 02/19/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

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

CUMMINGS COTTAGE

Continued From page 54

“shoved her head down," then began “swinging
on her." FC #6 was hit in the head once by the
peer.

-9/14/20 Staff chased FC #6 as she ran outside
of the cottage and off-campus to a local store. FC
#6 entered the store and came back out shortly
after. FC #6 returned to campus and again ran
Out the side door of the cottage as a peer ran out
the other side door. FC #6 climbed a fence and
jumped into the swimming pool which was closed.
FC #6 “had been attacked by a peer multiple
times within 48 hours..."

9/21/20 FC #6 exited the cottage through a side
door after a peer exited through a window, FC #8
aggressively hit staff and obtained a staff radio.
Staff chased FC #6 across the courtyard and
attempted to block her from running towards the
toad. FC #6 and her peer left campus.

-9/23/20 FC #6 threw a container of hair product
at the wall and banged her fists on the door and
windows of the cottage. FC #6 proceeded to
‘scratch her arm up and down with a comb FC #6
engaged in headbanging behavior and was
physically aggressive with staff while exiting the
cottage.

-9/27/20 FC #6 exited cottage and ran off
campus. Staff continually communicated with the
supervisor by radio "due to lack of additional staff
following”. FC #6 reached Leicester Highway and
threw 10 apples at staff and on apple hit an
oncoming car. FC #6 then tore down letters of a
restaurant's message board. She returned to
campus and threw liquids, cups and brushes at
staff, ripped up all of the Halloween decorations
and again ran out of the cottage. FC #6 began to
head bang and lunged at, hit and bit staff. FC #6
grabbed a piece of wood and rocks and
scratched herself in the throat and arms. FC #6
also attempted to choke herself,

9/28/20 FC #6 exited the cottage, flipped over
Division of Health Service Regulation

STATE FORM ed LHPP4t if continuation sheet 55 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(3) DATE SURVEY
COMPLETED

c
02/18/2021

MHLO11-204 8. WING

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

882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

CUMMINGS COTTAGE

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

DEFICIENCY)

; Continued From page 55

patio tables and had a physical altercation with a
peer. FC #6 was hyper-focused on an ambulance
coming for a peer in a sister facility. FC #6 picked
up a chair, threatened staff with it and used it to
smash a window in the chapel. FC #6 engaged in
sexualized behavior and "made out" with a peer.
FC #6 picked up glass and tried to cut herself
with it and expressed "heavy suicidal ideation”.
She also punched, slapped & kicked staff.
-9/29/20 FC #6 exited cottage and walked around
the courtyard looking for pieces of glass. FC #6
had a physical altercation with a peer. FC #6
began to “severely head bang" and also became
aggressive with staff.

-10/2/20 FC #6 began to scratch her wrists with
an “object” in her pocket. FC #6 attempted to
jump in front of cars that were passing by and
stated she wanted to be run over. FC #8
attempted to bang her head on different objects,
climbed into a sand truck behind the cottage and i
began to jump the fence surrounding the horse i
| pasture. FC #6 attempted to pass sharps toa
peer, punched and hit staff and began to choke

| herself with her sleeves and a hoodie. FC #6
made "continued attempts to strangle herself as
well as head bang."

-10/3/20 FC #6 inappropriately exited the cottage
and joined a peer at the "boarded up window" of
the chapel. FC #6 picked up a piece of glass and
| started to cut herself with it. FC #6 was.
transitioned back to the cottage. FC #6 exited the
cottage a second time and returned to the chapel
in search of glass to self-harm with. FC #6 was
transitioned back to the cottage and engaged in
headbanging behavior.

~10/4/20 FC #6 joined off-task peers from a sister
facility and walked around campus. Staff lost
eyesight of the clients from 3:54pm-3:56 pm. FC

| #6 and her peers jumped the fences and staff "let
them know when cars were approaching so they
Division of Health Service Regulation

STATE FORM a8 LHPP11 If continuation sheet 56 of 124

Division

of Health Service Regulation

STATEMENT OF DEFICIENCIES {X5) PROVIDER/SUPPLIER/CLIA

AND PLAN

NAME OF PROVIDER OR SUPPLIER,

OF CORRECTION IDENTIFICATION NUMBER:

MHLO11-204

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

B. WING

882 ELIADA HOME ROAD

CUMMINGS COTTAGE

PREFIX
TAG

vii2

ASHEVILLE, NC 28806

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

'
| Continued From page 56

could move to the side of the road". FC #6 and
her peers again jumped the fences into the horse
| pastures and one peer got injured. FC #6 began
to "make-out" with a peer and looked for glass
sharps. FC #6 and her peers obtained "a cart”

; and started to pull each other through the road.
-10/6/20 FC #6 ran up and down the halls of the
cottage and opened side doors to trigger the
alarm. FC #6 threw water on staff, pulled the fire
alarm and refused to leave the cottage. FC #6
re-entered the cottage and headbanged, bit staff
on the finger and continued to run up and down
the halls. FC #6 pulled the fire alarm again and
refused te leave the cottage. FC #6 continucd to
head bang and began to strike staff with closed
and opened fists.

-10/13/20 FC #6 walked out of the cottage,
re-entered and pulled the fire alarm. FC #6 exited
the cottage and waited for the firemen to do their
sweep. Upon re-entering the cottage, FC #6
proceeded to stand on the tables in the common
i area anc hit the lights above the table. She
headbanged against walls "continuously from
7:31 pm on". FC #6 ripped peers personal effects
from their bedroom doors and attempted to exit
the cottage several times but was blocked by
staff. FC #6 then became physically aggressive
with staff and she continued headbanging. FC #6
attempted to leave the cottage through a door
and through her window and when these options
were blocked, she began punching staff. RN
noted "injury to student (FC #6)" and that FC #6
“was intensely headbanging past baseline
behaviors.”

-10/18/20 FC #6 ran out the side door of the
cottage and stated "I'm gonna go kill myself." She
ran around the cottage and looked for sharps.

| Staff used their bodies to block FC #6 as she

: attempted to climb a staircase so she could jump
| Off the top. FC #6 hit staff muitiple times with

Division of Health Service Regulation
STATE FORM

PREFIX
TAG

LHPP11

STREET ADDRESS, CITY, STATE, ZIP CODE

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

DEFICIENCY)

[pees
vit2

PRINTED: 03/09/2021
FORM APPROVED

(3) DATE SURVEY
COMPLETED

Cc
02/18/2021

Ifcontinuation sheet §7 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Re;

STATEMENT OF. DEFICIENCIES
AND PLAN OF CORRECTION

(41) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(3) DATE SURVEY
COMPLETED

c
02/18/2021

MHL011-204 B. WING

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD

ASHEVILLE, NC 28806

CUMMINGS COTTAGE

SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH 65)
(EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVE ACTION SHOULD BE CROSS- COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

Vv 12 | Continued From page 57

closed fists.

-10/21/20 FC #6 had been running in and out of
the cottage throughout the shift. FC #6 began
banging on windows around the cottage and
Started to break the screen window into the
kitchen. FC #6 struck staff repeatedly with
opened and closed fists.

-10/29/20 FC #6 inappropriately exited the
cottage through a side door. FC #6 returned to
the cottage and exited the cottage through a side
door a second time. FC #6 walked over to the
chapel and began to peel tape off the windows.

! FC #6 entered the chapel, grabbed a chair and hit
the window. FC #6 ran to the outside of the
window and tried to obtain large pieces of glass.
FC #6 then entered the horse pasture and got
stuck by thoms.

| -10/30/20 FC #6 exited through the side door of

| the cottage and went to a sister facility and
engaged with a peer in the backyard. FC #6 and
her peers stole the keys to the tractor. FC #6 got
aggressive with community bystanders at the

corn maze. FC #6 flipped a table and yelled at
staff. Police were on campus. FC #6 joined her
peer and talked to the police. FC #6 and her peer
then left campus. Staff lost eyesight of FC #6 and
her peer from 6:24pm-6:26pm. "This incident and
the greater context of it lasted for several |
hours...”

-11/1/20FC #6 began to bang her head on the wall
and walked out of the cottage. FC #6 ran around
the cottage and through the courtyard. FC

#6 tried to kick in the window on the porch of the
cottage and hit staff on the head with an open
palm. FC #6 continued to head bang on various
surfaces of the porch, or in the courtyard. FC #6
ran up and down the road towards cars yelling
"please hit me". Staff managed the environment
by directing traffic. FC #6 continued to lay in the H
middie of the road. Staff expiained to FC #6 “that

Division of Health Service Regulation
STATE FORM bans, LHPP11 If continuation sheet 58 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Re

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(41) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

c
02/18/2021

MHLO11-204 8. WING

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZiP CODE
882 ELIADA HOME ROAD

ASHEVILLE, NC 28806

CUMMINGS COTTAGE

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES: PROVIDER'S PLAN OF CORRECTION (EACH

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

DEFICIENCY)

Continued From page 58

the people in the car would more than likely stop
before they hit her’. FC #6 began to run towards.
the bystanders in the corn maze. As FC #6
walked back towards the cottage, staff noted she
was running into traffic. FC #6 was pushing

, through staff and she was getting” too close to a
car." Staff informed the guardian of the incident
and “ the prolonged intensity of it' and that FC #6
was attempting to "lay down in front of moving
cars and was backing up traffic." FC #6 was
NC'd .

Review on 1/29/21 of a Performance Quality
improvement (PQ!) Report Forra for FC #6 dated
9/21/20 revealed:

-On 9/21/20 FC #6 returned from an elopement
and reported to the nurse "she had been
inappropriately touched in her private area while
off campus." FC #6 would not give details and
later stated that she just said this to take the

| focus off her elopement from campus.

-Peers reported "getting into a car of someone in
the community.”

-The Clinician was informed of the incident and
was encouraged to address it in therapy.
-Guardians were informed of the allegation. |

Interview on 1/4/21 with the Legal Guardian for

FC #6 revealed:

-FC #6 was "fighting a lot, pulling the fire alarm i |

and going into a corn field and being involved with |

other girls” that resided in the group home.

-FC #6 had a self-harming incident every day

while at the facility.

-She stated, "| wanted her at a different facility

where she couldn't self-harm."

-FC #6 was able to repeatedly leave campus

while residing at the facility.

| -FC #6 was sent to the hospital the first week of
November 2020 for headbanging, breaking glass

Division of Health Service Regulation

STATE FORM sa00 LHPP11 W continuation sheet 59 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (M1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

{X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

c
02/18/2021

MHLO11-204 B. WING

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD

ASHEVILLE, NC 28806

CUMMINGS COTTAGE

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

TAG REGULATORY OR LSC IDENTIFYING INFORMATION) | Tas REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

Continued From page 59

and cutting herself.
-FC #6 was transferred to a locked PRTF and
has only been involved in 2 incidents there.

| Interview on 1/7/21 with FC #8 revealed:

-She did not feel safe at Cummings Cottage.

-Other clients tried to physically attack her.

-She stated "Kids left the cottage whenever they

wanted to. | left too..."

-Whenever she left, she was followed by staif "for

a while."

-Staff stopped following clients after a certain

distance, or length of time.

-She stated, "i was touched by a peer; don't know

the number of times; it happened more than

once; | let them touch me; it happened with me

and severai other peers; we weren't wearing any

clothes; we took our clothes off and touched each

other; staff weren't around; we would go to a

church, or storage place away from campus; it

was always unlocked ..."

-Clients mixed with the public all the time at the |
|
|

com maze. ;
-If someone wanted to hurt themselves, items
were available on campus,

-It was easy to get out of the cottage and run. i
-She saw a female trying to jump off the roof of a
building at the facility. i
~She stated, "There's no consequences for :
running away, or for hitting someone, or any bad
behaviors." j

Review on 12/11/20 & 1/4/21 of FC #7’'s record
revealed:

-Date of Admission: 8/5/20.

-Age: 16.

| -Diagnoses: Oppositional Defiant Disorder, j
Moderate; Major Depressive Disorder, Moderate;
Alcohol Use Disorder; Cannabis Use Disorder. \
_ it -Discharge Date: 11/20/20. |
Division of Health Service Regulation

STATE FORM ese LHPP11 continuation sheet 60 of 124

(x4) ID
PREFIX
TAG

Division of Health Service Reg

STATEMENT OF DEFICIENCIES.
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(Xt) PROVIDER/SUPPLIERICLIA,
IDENTIFICATION NUMBER:

WMHLO11-204

CUMMINGS COTTAGE

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

| Continued From page 66
|

-Gomprehensive Clinical Assessment dated
7/24/20 with an addendum dated 10/21/20
indicated: Client was experiencing anger
outbursts (non-violent) and struggles with impulse
control; his behaviors escalated over time to
extremely risky. He experiences suicidal thought
patterns; feelings of hopelessness, guilt and
shame; Has a history of running away from home,
engaging in risky behavior such as using
substances and risky sexualized behavior
(meeting up with men); a cycle of acute inpatient

| Stays in the last 7 months; Went to the
Emergency Room (ER) after attempting suicide
and inpatient hospitalization followed; He still has
urges to run in the community, to self-harm and
has suicidal thoughis.

Review on 12/31/20 of FC #7’'s treatment plan
dated 7/18/20 with update/revision dates of
8/17/20, 9/18/20 and 10/20/20 revealed:

-On 8/17/20:

Facility supportfintervention strategies were
integrated into client's plan.

Client had the following goal: Will demonstrate an
improvement of symptoms AEB increase in
exchanging high risk coping strategies with
behaviors which support self-worth and
self-confidence, increase in honesty with self and
others, increase in independence AEB a
consistent ability to motivate, regulate, and
support self, increase in participation and focus
during academics or other less preferred
activities.

| -Updates included the following:

A progress note added on 9/18/20 indicated: For
a few weeks, client engaged “negatively with off
task peers which resulted in elopement,
monopolizing areas on campus and refusing to
work towards goals ..."

A progress note added on 10/20/20 indicated:

Division of Health Service Regulation

STATE FORM

A. BUILDING:

B. WING

STREET ADDRESS, CITY, STATE, ZIP CODE

882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

ID
PREFIX
TAG

Is

(X2} MULTIPLE CONSTRUCTION

PRINTED: 03/09/2021
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

c
02/18/2021

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

REFERENCED TO THE APPROPRIATE. DATE
DEFICIENCY)

LHPP11 if continuation sheet 61 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (Xa) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED

c
MHL011-204 we a 02/18/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

(44) 1D ‘SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL CORRECTIVE ACTIGN SHOULD BE CROSS-

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

CUMMINGS COTTAGE

Continued From page 64

Client "has had a challenging review period.

| Towards the beginning of this review period, [FC
#7] was running almost every day, and joining up
with peers from his program and other programs
and causing chaos around campus and off
campus. [FC #7] entered into a manic state
multiple times during these elopements as
evidenced by his extreme risk taking behavior

| and a notable shift in personality as noticed by
staff. [FC #7] became aggressive on multiple
occasions resulting in the need for restrictive 1
intervention on one occasion. [FC #7] also
demonstrated significant remorse during this
time, so much that he attempted to jump off a roof
to hang himself. [FC #7] required hospitalization
during this time to help him stabilize and ensure
he was appropriate to retum to this program with
ail of the safety concerns he had presented ..."
-There were no specific goals or intervention

i strategies to address client's sexualized
behaviors, elopements, substance use behaviors, i
property damage, stealing staff's keys, attempts
to jump off the roof of a building, and physical

| assaults on staff.

Review on 1/29/21 of the ICMP for FC #7 dated
11/4/20 revealed:

-It contained the name of a direct care staff |
member who was listed as an advocate.

-The document did not contain any signatures,
-Pre-crisis strategies: "engage In meaningful
tasks like handing out dinner, helping fold
laundry, use humor, engage in his self interests,
encourage his GED studies. give him a
task/project, talk about his interests. Keep him
distracted with tasks and activities, physical
activity, encouraging new interests." 1
-Triggering strategies: "Proactive check-ins, real
| talk, remind him of his impact on others, giving

Division of Health Service Regulation
STATE FORM 809 LHPP11 If continuation sheet 62 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (Xt) PROVIDER/SUPPLIERICLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

c
02/18/2021

MHLO011-204 B. WING

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

CUMMINGS COTTAGE

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

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

DEFICIENCY)

¥ 112! Continued From page 62

Space to make choices, encourage empathy and
compassion. Validate, provide grace and |
compassion, reflect his feelings and needs and
allow him space to make a choice. Distraction, i ;
Physical activity. Limiting stimulation and

setting boundaries with physical proximity rather
than verbatizing.”

-Outburst strategies: "back up in protective
stance, same as escalation.” ; '
-Recovery strategies: "separate, 1:1, phone call, !
will process with involved staff.”

audience." | i
-Escalation strategies: “redirection, proximity, |
manage the environment, short term goals with a — !
plan to keep him distracted. Distraction, timit Due, ter Pescs (e3 -Lo
stimuli in environment, mange the environment, \ !
!

17

t

i : !
Review on 2/8/21-2/10/21 and 2/15/21 of the ! Doc i
facility PRTF Incident Reports and PRTF iBi~
Restrictive Intervention Reports for FC #7 t
revealed: B le
-8/11/20 A peer jumped in the pool and
proceeded to hit FC #7 twice and kick him. The
peer attempted to keep FC #7 under the water. i
Staff safely removed FC #7 from the pool. i i
-9/13/20 FC #7 engaged in repeated unsafe i i
behaviors for days (running off-campus and
potentially engaging in sexual acts with a peer).
FC #7 instigated sister facilities by banging on
windows, kicking and punching doors. FC #7
stole a set of keys from staff with the intent to
unlock a sister facility on campus.
-9/21/20 FC #7 destroyed the couches, ripped up |
a table, hit staff multiple times and engaged in
intense headbanging on the front porch from H
2:15pm-2:28pm. FC #7 was "still self-harming
when 2nd shift ended”. At 7:40 pm FC #7 climbed
onto the roof “for the second time" and tied wire H
around his neck and attempted to leap off the
i building. Staff pulled FC #7 from the edge of the
Division of Health Service Regulation
STATE FORM as LHPP11 H continuation sheet 63 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (41) PROVIDER/SUPPLIERICLIA
‘AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A, BUILDING:

(3) DATE SURVEY
COMPLETED

Cc
02/18/2021

B. WING

MHL011-204

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

882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (EACH 0x5)

PREFIX {EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVEACTION SHOULD BE GROSS- COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE. DATE

DEFICIENCY)

CUMMINGS COTTAGE

Continued From page 63 v112

roof and removed the wire from his neck. FC #7
was “taken to the hospital due to increased
suicidal ideation and attempts, as well as
increased and intensive headbanging."
-10/30/20 FC #7 inappropriately exited the i
| cottage through a side door with a peer. FC #7

| climbed the gate of a sister facility in an attempt

| to have another student join them. FC #7 and his
Peers approached a tractor that had members of
the community (including toddlers) on the trailer.
FC #7 gained possession of the tractor ignition

keys and gave them to a peer to put in her bra. 1 Rees
| FC #7 had a verbal altercation with a bystander
| and then grabbed a can of beer and began Bl ~ BE

| drinking it rapidly. FC #7 sprinted towards the
bystander and threw the remainder of the beer on
the bystander, along with the accompanying
bystanders in the vicinity. FC #7 ran up the hill
towards a sister facility and began to remove long
fence stakes and successfully gained possession !
ofa fence stake. FC #7 transitioned back to the
cottage and quickly ran back to the "off task
peers." FC #7 charged towards a bystander when
they threatened to "break his neck if he were to
come near their child." FC #7 transitioned back to
the cottage. FC #7 exited the cottage again and
Te-joined 2 off-task peers and a nurse who was
conducting routine rounds between cottages. FC
#7 grabbed a container of pills from the nurse's
pocket and ran towards the corn maze. FC #7
stated he took one of the pills. Staff transitioned
FC #7 back to the cottage and he repeatedly
exited and entered the cottage. FC #7 continually
attempted to exit the cottage through his window
and the door. FC #7 began to demonstrate signs
of returning back to baseline and he again exited
the cottage inappropriately and re-joined 2 off
task peers in front of a sister facility. FC #7

; attempted to keep the front door of the sister
facility opened as staff transitioned a peer back
Division of Health Service Regulation

STATE FORM 9699 LHPP11 Ifcontinuation sheet 64 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X83) DATE SURVEY
COMPLETED

Cc
02/18/2021

B. WING

MHLO11-204

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

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

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVE ACTION SHOULD 8E CROSS- ‘COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE. DATE

DEFICIENCY)

CUMMINGS COTTAGE

Continued From page 64

| inside. FC #7 then attempted to leave campus.
FC #7 was IVC'd due to his extreme behaviors.

-Numerous efforts were made 12/11/20-1/4/21 to
' interview the Legal Guardian for FC #7. The !
Legal Guardian for FC #7 did not retum calls.

Interview on 1/5/21 with Staff #1 revealed:

-Staff used foam headboards to try to protect
clients that were engaging in headbanging
behaviors.

-If staff were unableto use the headboard then
the client would be placed in an RI.

-Staff were not permitted to utilize RI's on clients
that were off campus.

-If'a client exhibited dangerous behaviors while
they were off campus, then staff would call the
local police department for assistance.

-The facility had an expectation for clients not to
interact with the public at the corn maze.

-There were no physical barriers to prevent
clients from entering the corn maze.

-He stated, "We try to verbally redirect clients but
if it's not effective, like we saw this year with the
com maze, then it's a problem."

-The facility had a group of clients that needed a
higher level of care than what the facility could
provide.

-Staff can handle 1 or 2 client's "going off task.”
-The facility had groups of 3-5 clients at a time
that were engaging in aggressive, or dangerous
behaviors.

-He stated, "The kids we are accepting and the
process for accepting needs changed ...we need
to change the baseline of behaviors that we
accept. We can't take high acuity kids without a
means to maintain milieu. Cummings is unlocked
...The locked PRTF has the ability to intervene

| with higher acuity kids because whenever they
get escalated, they are at icast contained to a
Division of Health Service Regulation

STATE FORM ea09 LHPP11 If continuation sheet 65 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA
AND PLAN OF CORRECTION (IDENTIFICATION NUMBER:

(42) MULTIPLE CONSTRUCTION
A. BUILDING: n

(X3) DATE SURVEY
COMPLETED

Cc
02/18/2021

B. WING

MHL011-204

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

882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

CUMMINGS COTTAGE

(41D ‘SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (EACH os)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVEACTION SHOULD BE CROSS- COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

Continued From page 65

safer environment within the cottage. Ifa kid is

escalating at Cummings Cottage, they usually run

out of the cottage ... Cummings Cottage has more

elopements."

-Radios only worked up to a certain distance off

\ campus.

-Staff were expected to carry their personal cell

phones for emergency use.

-He stated, "Lots of staff felt burned out ... People
were exhausted and in turn, that affects the kids.”

Interview on 1/5/21 with Staff #2 revealed:
-If.a client ran, staff did not restrain them
anymore unless they believed the client would |
harm or kill themselves. !
-Once a client was off campus, staff could not |
touch them in any way unless the circumstances
were extreme.

-He stated, "| had to intervene once. | lifted a
student up over a guardrail that was off a highway i
a few months ago.”

-Staff were given radios to keep in
communication with one ancther. | i
-The radios did not work well and did not always
keep a signal off campus.

-Employees did not always have their cell phones i
with them because if they were damaged during
an incident with a client, Eliada would not replace
the cost.

-The local police department would not usually
pick up a client without an IVC (Involuntary
Commitment).

-He stated, " ...we take kids with behaviors that
are too high acuity, We can't support them. My
last few months here have been terrible ... The
admission process needs to be overhauled. We
can't manage the behaviors ... They can't keep
staff here ...it's high tumover ...It's sink or swim
and most staff aren't prepared ... "

-Clients banged their heads on the wall until they
Division of Heatth Service Regulation

STATE FORM 7. LHPP11 If continuation sheet 66 of 124

PRINTED: 03/09/2021
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:

{X2) DATE SURVEY
COMPLETED

Cc
02/18/2021

B. WING:

MHLO11-204

NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE

882 ELIADA HOME ROAD

CUMMINGS TAGE ASHEVILLE, NC 28808

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (EACH (XS)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVEACTION SHOULD BE CROSS- COMPLETE
TAG REGULATORY OR L&C IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE CATE

DEFICIENCY)

Continued From page 66

needed hospitalization.

-He knew that "corn maze guests” were assaulted
by clients.

-Staff were not supposed to restrain clients in
front of a quest, or off campus.

Clients were able to obtain sharps and other
contraband on and off campus.

-Staff were "wildly inconsistent’ with conducting
Toom searches.

-The clients learned there were no consequences
to their behaviors.

Clients "can assault someone and the next day
is a brand new day and everything starts fresh as
if nothing happened and they do it again.”

Interview on 1/4/21 with Staff # 3 revealed:
-The cottages should have more staff.

-The general public were allowed to attend the
com maze which increased safety issues.
-Clients were not supposed to interact with the
public at the corn maze.

-The com maze was large and if several clients
ran into the maze it would not be safe for staff to
follow. !
-There have been high acuity clients at the facility i
which were hard to manage. t
| -itwas an unsafe situation when client behaviors
| escalated.

Interview on 1/19/21 with the Residential
Clinician/Licensed Professional revealed:

-She stated, " ...not every client is the right fit for
an unlocked unit. They might look right on paper.
Eliada tries to give everyone an opportunity.”
-She was frustrated with the facility for accepting
clients with running behaviors.

-Numerous staff members expressed their
concerns about clients to senior leadership.

-The facility accepted a client that “ran from DSS.
(Department of Social Services) during transport
Division of Health Service Regulation

STATE FORM 6200 LHPP14 ifeontinuation sheet 67 of 124

L

PRINTED: 03/09/2021
* FORM APPROVED
Division of Health Service R

‘STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X2) MULTIPLE CONSTRUCTION

ABUILDING:

(1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

(X3) DATE SURVEY
COMPLETED

c

B. WING ________ 02/48/2021

MHL011-204

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD

ASHEVILLE, NC 28806

CUMMINGS COTTAGE

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

KID.
PREFIX
TAG

| Continued From page 67

| to Eliada ..potice had to bring her to campus ..."
and upon arrival to campus she ingested
medications.

-There was a student going to the police ona
regular basis, with superficial cuts from self-harm.
-Emergency Medical Services (EMS) would show
up at the police station and state "there's no injury
here.”

-She stated, “Passive self-harm works for the
student to get attention when they want it and if
we respond by placing her in an RI (restrictive
intervention) it would be destructive."

-Clients "have gotten off campus and have
attempted dangerous things.”

-The facility needed to place "the right individuals
| in the unit” and not place clients with a history of

: elopements in an unlocked cottage. -

-If a client has not had a history of running and
they see another client continually eloping then
they might try it too.

-She stated, "Cummings Cottage was a great
step down for kids coming from a locked unit, to
transition and demonstrate that they are ready to
go home. It’s not the best for students that are
having increased behaviors and are headed for a
locked PRTF. If they are going up levels in care
then definitely not Cummings Cottage. Same

| with lateral moves from PRTF to PRTF, it wasn't
the right fit since Cummings is unlocked.”

| Treatment plans were updated monthly.

| Interview on 1/8/21 and 1/14/21 with the Interim
Residential Director revealed:

-He was "filling in” for the Residential Director
while she was out on maternity leave.
-Cummings Cottage was an-unlocked PRTF.
-Prior to admission, client referrals were screened
and the facility “could eliminate” clients for
admission “based on clear red flags if they had a
history of behaviors that we wouldn't be able to
Division of Health Service Regulation

STATE FORM ses LHPP11 Icontinuation sheet 68 of 124

Division of Health Service Regulation

TAG

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

Division of Health Service Regulation

STATE FORM

(X1) PROVIDER/SUPPLIERICLIA
(DENTIFICATION NUMBER:

MHL011-204

CUMMINGS COTTAGE

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

Continued From page 68

manage."

-He stated, "| don't feel we admit students that we
can't support. We admit students that are likely
to be successful here.”

-The facility no longer admitted clients with
“significant running behaviors.”

-He stated, "When a student has running
behaviors, we set up a safety plan and eventually
refer them out if it continues. We haven't really
had significant issues like that since [FC #5]."
-FC #6 had "a skew of incidents like that and
was placed elsewhere.”

-The facility had "zero tolerance for headbanging
which results in restrictive intervention almost
immediately.”

-If a client was cutting, staff would strictly ensure
the bedrooms were searched and kept safe.

-If a client had repeated self-harm behaviors, the
facility could order staff “to have eyes on them at
all times."

-He stated, “For significant headbanging, we will
IVC. Same with suicide attempts. If it was
serious, we would seek hospitalization for
stabilization."

Interview on 1/11/21 with the COO revealed:
-She was aware of the number of elopements
from the cottage.

-The facility has had no elopements since "that
group" of clients (FC #5, FC #6, and FC#7) were
discharged.

-Client behaviors were "staffed multiple times with
senior leadership, the doctor, and nursing.”

-She stated, "We tried to prevent the
headbanging as much as possible with the
equipment we have and with our bodies. The
cutting is staffed and case management
discussed it weekly."

-After the "large incident 10/30/20" there was a
meeting called with management to address the

STREETADDRESS, CITY, STATE, ZIP CODE

882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

PRINTED: 03/09/2021
FORM APPROVED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

{(X3) DATE SURVEY
COMPLETED

Cc
02/18/2021

B. WING.

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

DEFICIENCY)

PREFIX
TAG

LHPP11 If continuation sheel 69 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (M1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

c
02/18/2021

MHLO11-204 B. WING

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

CUMMINGS COTTAGE

(%4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH X65)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVE ACTION SHOULD BE CROSS- COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

Continued From page 69

behaviors.

-She stated, “Every time we figured out what

; worked with them then something else would

happen ...”

-The Clinician/Therapist was responsible for

updating the treatment plans.

-She believed the treatment plans were being

| updated.

-ICMP's were updated in the cottages and used

by staff to “help kids in crisis.” Docs
; \-& GQ Wreve ds

Interview on 2/16/21 with the Chief Executive

Officer (CEO), the COO, and the Clinical Director

revealed:

-CGEO stated, "We are taking in the highest acuity

clients. We are being forced by the LME (Local

Management Entity) to take them. I'm reaching

out to them. We have new behaviors every day |

and the treatment plan needs to be signed by the !

+} parent, so are you suggesting that we need to

update the treatment plan every day? There's

documentation on the CFT minutes and I'll just

use those for my appeal.”

This deficiency is cross referenced into 10A
NCAC 27G.1901 Scope (V314) fora Type A1 rule I
violation for serious harm and neglect and must ( j
be corrected with 23 days.

i 110A NCAC 27G.0209 (e) Medication Storage |
V 120) 27G .0209 (E) Medication Requirements v 120 'V120); A locked medication storage tote was
purchased and has been consistently used to
transport medication on campus and between
buildings. Medication is locked in the tote as
soon as it is handed to the Nurse during Intake.
(A) in a securely locked cabinet in a clean, Anytime medication is transported on campus,

well-lighted, ventilated room be! n 59 degrees tt is locked in the tote and does not leave the
and 86 degrees Fahrenheit; nurse until the medication is locked in the

medication cart. This was completed prier to

10A NCAC 27G .0209 MEDICATION
REQUIREMENTS

(e) Medication Storage:

(1) Alt medication shall be stored:

Division of Health Service Regulation
STATE FORM 8200 LHPP11 Htcontinuation sheet 70 of 124

PRINTED: 03/09/2021
FORM APPROVED

Division of Health Service Regulation

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

{X3) DATE SURVEY
COMPLETED

iej
02/18/2021

MHLO11-204 B. WING .

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

882 ELIADA HOME ROAD
ASHEVILLE, NC 28306

CUMMINGS COTTAGE

4) ID SUMMARY STATEMENT OF DEFICIENCIES ‘D PROVIDER'S PLAN OF CORRECTION (EACH %8)
PREFIX (EAGH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVE ACTION SHOULD BE CROSS- COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

2/18 exit interview

Continued From page 70

(B) in a refrigerator, if required, between 36
degrees and 46 degrees Fahrenheit. If the
refrigerator is used for food items, medications
shall be kept in a separate, locked compartment
or container;

(C) separately for each client;

(D) separately for extemal and internal use; i
{E) In a secure manner if approved by a physician
for a client to self-medicate.

| (2) Each facility that maintains stocks of

j controlled substances shail be currently
registered under the North Carolina Controlled
Substances Act, G.S. 90, Article 5, including any
subsequent amendments.

This Rule is not met as evidenced by: Based on
record reviews and interviews the facility failed to
store all medication in a securely locked cabinet
affecting 1 of 3 audited Former Clients (FC#7).
The findings are:

Review on 12/11/20 & 1/4/21 of FC #7's record
revealed:

-Date of Admission: 8/5/20. i
-Age: 16.

-Diagnoses: Oppositional Defiant Disorder,
Moderate; Major Depressive Disorder, Moderate;
Alcohol Use Disorder; Cannabis Use Disorder.
-Discharge Date: 11/20/20.

Review on 12/11/20 of a PRTF (Psychiatric
Residential Treatment Facility) Restrictive
Intervention Report for FC #7 dated 10/30/20
revealed:

-A nurse was conducting routine rounds between
cottages.

Division of Health Service Regulation
STATE FORM ena LHPP1 feontinuation sheet 71 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERCLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(42) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

c
02/18/2021

MHL011.204 B. WING

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

882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (EACH

CUMMINGS COTTAGE

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

V 120! Continued From page 71

| -Staff observed FC#7 grab a container of pills
from the nurses pocket and run towards the corn
maze.

_ -FC#7 informed staff that he took one of the pills.

Review on 1/14/21 of an email dated 10/31/20 at
5:30 pm from the Nurse Manager to the nurse
who worked the evening of the incident revealed:
-"Could you provide me further clarification
regarding this situation with [FC#7} yesterday
evening? [FC#7] grabbed 4 container of pills from
the Nurses pocket and ran towards the corn
maze [FC#7] states he took one of the pills.”

Review on 1/14/21 of an email dated 10/31/20 at
8:04 pm from the nurse who worked the evening
of the incident to the Nurse Manager revealed:

- "Sure, he came up to me right before | was
about to walk into the back of [another cottage],
had a short conversation with me, then reached
into my scrub pocket and pulled out a bottle of
pills (it was a bottle of Zoloft for the new student)
and took of sprinting towards the spider web.

| [Interim Residential Director] ran right after him

| and had the bottle back within 15 seconds I'd say.
No one visualized him open the bottle or take any
pills (we all had eyes on him the entire incident),
and | truly don't believe he would have had
enough time to do so while he was running full
Sprint. | never saw his arms or hands doing
anything that looked like opening the bottle. As
soon as we got the bottle back, we all agreed that
it did not seem like he had done anything other
than run with it and give it back immediately.”

Interview on 1/11/21 with the Chief Operations
Officer (COO) revealed: |
-Medications are always administered inside of
the cottage.

-The only time medications are outside of the |
Division of Health Service Regulation

STATE FORM eaee LHPP11 ff continuation sheet 72 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation
‘STATEMENT OF DEFICIENCIES (41} PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED
Cc

MHL011-204 B.WING 02/48/2021

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

882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

CUMMINGS COTTAGE

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

V 120] Continued From page 72 Vv 120

cottage is during the admission process.
-Nurses would carry medications for newly
admitted clients across campus to the cottage.
-After the incident on 10/30/20, the process was
changed.

-Nursing staff now use a locked box to transport
medications to the cottage.

Interview on 1/14/21 with the Nurse Manager

revealed:

-She was not working curing the incident

10/30/20.

-The nurse that had the medications in her pocket

was no longer employed by the facility.

-It was likely that the nurse on shift during the

10/30/20 incident had client medications in her

pocket because she had a lot of items to carry.

-When a client is admitted to the facility:

Nursing staff meet the client and guardian at the {

intake office and verify the client's prescription

medication bottles.

Pills are not counted unless there are controlled

| medications.

Nursing staff take the medications to the nursing

| office which is centrally located on campus and :

the medications are reviewed by the doctor.

Nursing staff take the medications to the

residential cottage once doctor's orders are

received.

-The walk from the nursing office to the cottage is

not a long distance. | |

-Medications were transported to the cottage at

night while the clients were asleep.

-If a medication was needed right away, then it

would be transported during the day.

-If a client had more than 1 or 2 medications, then i

nursing staff would carry the medications in a

personal belongings bag, or in a bag from the i

pharmacy.
_ There was a plan in place for the facility to a I

Division of Health Service Regulation

STATE FORM bad LHPP41 'f continuation sheet 73 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

c

MHL011-204 B. WING 02/18/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD

ASHEVILLE, NC 28806

CUMMINGS COTTAGE

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

Continued From page 73

t purchase a locked box.
! -Nursing staff never received a locked box to
transport client medications across campus.

This deficiency is cross referenced into 10A

: NCAG 27G.1901 Scope (V314) for a Type A1 rule
| violation for serious harm and neglect and must
be corrected with 23 days.

Vv 314)

27G .1901 Psych Res. Tx. Facility - Scope

410A NCAC 27G .1901 SCOPE

(a) The rules in this Section apply to psychiatric
residential treatment facilities (PRTF)s.

(b) APRTF is one that provides care for children
or adolescents who have mental illness or
substance abuse/dependency in a non-acute
inpatient setting.

(c) The PRTF shall provide a structured living
environment for children or adolescents who-do

| not meet criteria for acute inpatient care, but do
require supervision and specialized interventions
on a 24-hour basis.

(d) Therapeutic interventions shall address
functional deficits associated with the child or
adolescent's diagnosis and include psychiatric
treatment and specialized substance abuse and
mental health therapeutic care. These
therapeutic interventions and services shall be
designed to address the treatment needs
necessary to facilitate a move to a less intensive
community setting.

| (e) The PRTF shall serve children or adolescents
: for whom removal from home or a
community-based residential setting is essential
to facilitate treatment.

(f) The PRTF shall coordinate with other
individuals and agencies within the child or
adolescent's catchment area.

V314

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

10A NCAC 27G .1901

SCOPE

7G .1901 Psych Res. Tx. Facility - Scope

ithin scope, the facility acknowledges
[that due to the number of other findings,
scope is cited as an overall deficiency.
Within scope The DRNC item has been
laddressed and corrected, the medication
error has also been corrected (meds are
now transported in a locked box)Trainings |
have begun with more to complete to
ddress findings, policies have been
lupdated and attached to this, hundreds of
pages of documentation of strategies
hanged for students following events and
Inew behaviors, Restrictive Intervention
“other hold” language being discontinued
jand the name of the TCI authorized non RI
hold has been replaced, training occurred
3/17, all residential staff being recertified
in RI on 3/21

Division of Health Service Regulation

STATE FORM LHPP11 continuation sheet 74 of 124

STATEMENT '

NAME OF PR‘

(X4) ID
PREFIX —
TAG

|
{

i

Division of Healt
STATE FORM

Division of Health Service Regulation

AND PLAN OF CORRECTION

OF DEFICIENCIES: (X1) PROVIDER/SUPPLIER/CLIA

IDENTIFICATION NUMBER:

MHL011-204

OVIDER OR SUPPLIER

CUMMINGS COTTAGE

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

Continued From page 74

(g) The PRTF shall be accredited through one of
the following; Joint Commission on Accreditation
of Healthcare Organizations; the Commission on
Accreditation of Rehabilitation Facilities; the
Council on. Accreditation or other national
accrediting bodies as set forth in the Division of
Medical Assistance Clinical Policy Number 8D-1,
Psychiatric Residential Treatment Facility,
including subsequent amendments and editions.

A copy of Clinical Policy Number 8D-1 is available
at no cosi from ihe Division of Medicai Assistance
website at http:/Avww.dhhs.state.nc.us/dma/,

This Rule is not met as evidenced by: Based on
ftecord reviews, observation and interviews, the
facility failed to provide supervision and
therapeutic interventions to address the functional
deficits and acute needs in a structured
environment. The findings are:

CROSS REFERENCE: 10A NCAC 27G.0201
Governing Body Policies (V105). Based on record
reviews and interviews the governing body failed
to ensure their incident reporting system was
followed and failed to implement policies to
assure their operational and programmatic
performance was meeting applicable standards
of practice.

CROSS REFERENCE: 10A NCAC 276.0203
Competencies of Qualified Professionals and
Associate Professionals (V109). Based on record
reviews and interviews, the facility failed to
ensure that 1 of 1 Qualified Professionals

STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

PRINTED: 03/09/2021
FORM APPROVED

(%8) DATE SURVEY
COMPLETED

‘(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

Cc
02/18/2021

B. WING

PROVIDER'S PLAN OF CORRECTION (EACH

PREFIX CORRECTIVEACTION SHOULD BE CROSS-
TAG REFERENCED TO THE APPROPRIATE, CATE
DEFICIENCY)

ross Reference: 104 27G .0201 Governing Body
‘alicies (V105) : Within this rule, the Facility was
bed with poor Performance and Quality
mprovement oversight to management of
documents. The Facility has developed a procedure
hat outlines where review and modification of
Soren strategies to address the student’s current
behaviors between biweekly CFT meetings and
Imonthly PCP review is located. The review and
iModification of strategies will continue to be
included in Multidiscipfinary Team (MDT), weekly
{Clinical Case Review (CCR), nightly nursing reports,
Maily updates, and shift notes as well as the
lebriefing incident reports. The new Performance
fand Quality Improvement Director and the
Performance and Quality Improvement coordinator
will conduct quarterly audits to ensure updates are
pice within one or all of these documents. The

V314

policies requested during the complaint survey were
mission Criteria Policy Restrictive Intervention
Policy Intake Admission PolicyThe Restrictive
Intervention policy was revised to clarify that
— Facility strives to have an RN present
hroughout the Restrictive Intervention, emergency
Lituations occur in which a student's safety is in
imminent danger,and restrictive interventions are
immediately necessary to prevent further harm. In
nemergency situation, where a student’s health or
insite is at risk, staff certified in TCI and CPR have|
jalways monitored the restrictive intervention until
jan RN arrives which is in compliance with DHSR rule
(LOA NCAC 27E .0104:The language in our restrictive
intervention policy was revised to clarify that an RN
is not required to be present before a restrictive
intervention is initiated but are required to monitor
the studenit’s vitals and mental health within one
hour of a restrictive intervention.

Ith Service Regulation

head LHPP11 continuation sheet 75 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (41) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED

c
MHL011-204 8. WING 02/18/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

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

CUMMINGS COTTAGE

Continued From page 75 vata liada revised our Behavior Support and

| icy in mid- F r
(Residential Clinician/Licensed Professional) anagement Policy in m ct 2020 to re ect ou
| demonstrated the knowledge, skills and abilities idecision not to use seclusion as a behavior
required by the population served. Imanagement intervention. Eliada revised our

Intake/Admission Policy to reflect the use of
pre-placement interviews or visits of students
and their families as part of our referral and

CROSS REFERENCE: 10A NCAC 227G.0205
Assessment and Treatment/Habilitation or Service
Plan (V112). Based on record reviews,

| observation and interviews, the facility failed to admission process. Also added to the policy is
develop and implement goals and strategies to |the Admission assessments conducted by the |

| address the treatment needs for 3 of 4 audited IRN and Intake staff.

; Current clients (Client #1, Client #2, and Client #3)

| and 3 of 3 audited Former Clients (FC #5, FC #6, CROSS REFERENCE: 10A NCAC 27G.0203

| and FC #7). Competencies of Qualified Professionals and

\Associate Professionals (V109). 10A NCAC 27G

GROSS REFERENCE: 10A NCAC 276.0209 (e) 0203 the Facility has added within the job

Medication Storage (V120): Based on record ly iption the inclusi f th ired
reviews and interviews the facility failed to store escription the inclusion of the required core
all medication in a securely locked cabinet competencies Effective 3/15/21 Attached is the
affecting 1 of 3 audited Former Clients (FC#7). Facility credentialing form, used to qualify QPs,
| in addition to supervision forms that are
GROSS REFERENCE: 10A NCAC 27G.1902 (e) | lutilized per state requirement dependent upon
Staff (V315). Based on record reviews and P = 4 . P P
interviews, the facility failed to provide 24 hour | pegree, and qualifications. The core |
on-site coverage by a registered nurse (RN) competencies are actually already listed on the

|

affecting 3 of 4 audited current clients (Client #1, back of these documents, The facility has an
| Client #2, and Client #3) and 3 of 3 audited — A oma

| Former Clients (FC #5, FC #6, and FC #7). individualized supervision plan for staff.

{ a a 5

Forms Attached and policy
CROSS REFERENCE: 10A NCAC 27D.0101 (c)

‘ Policy on Rights Restrictions and interventions CROSS REFERENCE: 10A NCAC 27G.02039 (e)

i (V500). Based on record reviews and interviews, Medication Storage (V120). A locked

‘ the facility failed to implement policy that identifies edication storage tote was purchased and has
any restrictive intervention (RI) that is prohibited | een consistently used to transport medication
from use within the facility affecting 2 of 4 audited n campus and between buildings. Medication is
current clients (Client #1 and Client #2) and 3 of 3 locked in the tote as soon as it is handed to the

| audited Former Clients (FC #5, FC #6 and FC urse during Intake. Anytime medication is
#7). ransported on campus, it is locked in the tote

ind does not leave the nurse until the

CROSS REFERENCE: 10ANCAC 270.0101 (f) edication is locked in the medication cart. This

Policy on Rights Restrictions and Interventions

Division of Health Service Regulation
STATE FORM 6009 LHPP11 if continuation sheet 76 of 124

PRINTED: 03/09/2021
FORM APPROVED

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES: (X1) PROVIDER/SUPPLIER/CLIA (2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED

Cc
MHLO11-204 B.WING 02/18/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
$82 ELIADA HOME ROAD

CUMMINGS COTTAGE
ASHEVILLE, NC 26506

ayo. | ‘SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH
PREFIX ! {EACH DEFICIENCY MUST BE PRECEDED BY FULL CORRECTIVE ACTION SHOULD BE CROSS-
TAG REGULATORY OR LSC IDENTIFYING INFORMATION} REFERENCED TO THE APPROPRIATE
DEFICIENCY)
_ ee |
V 314! Continued From page 76 aia CROSS REFERENCE: 10A NCAC 276.1902 (e)|
taff (V315Attached to the report are nursing
| (V501). Based on record reviews and interviews ‘imesheets to demonstrate coverage, We have not |
1 the facility failed to implement policies which been out of ratio within our nursing department.
| require a Registered Nurse (RN) to be physically ¢ Nurse manager has been here for 7 years and
Present to monitor restrictive interventions ''s), pares never in her time have we been out of nursing,
1 orders to be signed by a licensed practitioner, and ‘atio. In 2019 we received a DHSR waiver to 1
i client debriefings to be conducted. reduce from 2 nurses to I nurse due to the reduction|
aint in buildi d the cl imity of }
Origin | Review on 2/16/21 and 2/17/21 of the Plan of ae We cleo veccived this oatver tae dl G21
al pop . . taff. We also received this waiver for all of 2020
| Protection completed and signed by the Chief ut upon suspension, we were denied the waiver for
Executive Officer (CEO) and the Chief | Mere
; Operations Officer (COO) on 2/16/21 revealed: | #5 year.
nt ciate acon will the faciity take to ROSS REFERENCE: 10A NCAC 270.0101 (c)
| SOR NCAG27G G201 Governing Body Policies olicy on Rights Restrictions and |
‘ g y interventions (V500). the facility has included in

, (V105); Senior Leadership will immediately
assess our referral and admission criteria. Eliada
| will be assessing entrance criteria in addition to

| the state and federal required PRTF (Psychiatric
' Residential Treatment Facility) criteria as it
telates to admissions on this campus. Eliada will
move towards interviewing students and their |

revious identified section the policy regarding
he reporting of abuse and neglect. Restricted
Intervention Policy with attachment A&B to cover
all the information required is also included

jwithin the report. Addtionally, the facility has
ichanged toe Restrictive intervention policy to

: guardians prior to admission if student has a mirror state requirements which removes our
history of aggression, sexualized behavior, initial requirement for a nurse to be present upon
: absconding, and self-harm. Senior Leadership i initiation.
ill set up a meeting with contracted LME's (Local .
| Management Entity) and MCO's (Managed Care | HOA NCAC 27E .0102
| Organizations)to discuss their expectation and
| demand for Eliada to serve high acuity students. [This information is included within the new
| The agency will discuss the acuity of the students jrevised Restrictive Intervention Policy in
| Teferred to this campus while continuing to work padition to Attachment A or B with
| to partner with the state and LME/MCOs to. locuments re TCI and permitted and non
| Support these difficult to place youth in our | permitted holds.
| community.

40A NCAC 27G.0203 Competencies of Qualified
| Professionals and Associate Professionals

| (V109); The PQ! (Performance and Quality
Improvement) department and senior leadership
will review core competencies of QP and AP
within residential services. The PQ! department .
will review the core competencies with residential

Division of Health Service Regulation
STATE FORM 8698 LHPP11 If continuation sheet 77 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regutation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

003) DATE SURVEY
COMPLETED

Cc
02/48/2021

MHLO11-204 8. WING

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD

ASHEVILLE, NC 28806

CUMMINGS COTTAGE

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

DEFICIENCY} \

V 314| Continued From page 77 v314

leadership with a plan to review in team
meetings. The PQ! Department will retrain
clinicians, case managers and cottage
supervisors on documentation of updates to crisis
plans in addition to including team meeting
reports in submission to investigations regarding
strategies for students.

10A NCAC 27G.0209(e) Medication Storage
(V120); The medical storage tote was purchased
and has been consistently used to transport
medication, since the interview took place with
the lead nurse. | verified this with the lead nurse
this evening. |
10A NCAC 27G.0205 Assessment and
Treatment/Habititation or Service Plan (V112);
The PQI Department will retrain clinicians, case
Managers and cottage supervisors on
documentation of updates to crisis plans within
the PCP (Personal Care Plan) and in addition to
include team meeting reports in submission to
investigations regarding strategies for students.
140A NCAC 27D.0101() (f) Policy on Rights
Restrictions and Interventions (V500 & V501):
PQI will immediately set up a meeting with the
three agency TCI (Therapeutic Crisis
Intervention) trainers to discuss incident review,
incident documentation, nursing supervision,
debriefing for staff, and TCI retraining. Eliada will
Review language within Etiada Homes policies to
| assess what is physically possibie to manage
regarding response times of nursing. PQI and
Clinical Director will reevaluate ICPM's (Individual
Crisis Management Plans), Crisis Plans, and
Treatment Plans identify documentation of
alternative strategies and assure that they are
individualized for each student. We will also
modify language within PQI policy as it relates to |
restrictive interventions. j
140A NCAC 27G.1902(e) Staff (V315); Eliada
does have 24 hour on-site coverage by a
Division of Health Service Regulation

STATE FORM ana LHPP411 If continuation sheet 78 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation

‘STATEMENT OF DEFICIENCIES Xi} PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

c
02/18/2021

B. WING

PAHLO11-204

NAME OF PROVIDER OR SUPPLIER STREETAODRESS, CITY, STATE, ZIP CODE

882 ELIADA HOME ROAD

ie IN TTAGE
UMMINGS, CO ASHEVILLE, NC 28806

x4) 1D ‘SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION{EACH 5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVE ACTION SHOULD BE CROSS- COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

Continued From page 78

fegistered nurse. Eliada will meet with PQ! and
Lead Nurse to discuss TCI monitoring during
restrictive interventions.
410A NCAC 27G.1901 Scope (V314) for Type A1
Serious Harm and Neglect
| reached out to [contact] at Disability Rights to
get clarification on their expectations for reporting
| every restrictive Intervention. The agency will
work with Disability Rights and devise a plan to |
get into compliance with their requirements.
The agency wiii continue to work with the state
and LME/MCO team with six core on the use of
| restrictive interventions.
The agency will pull data on the number of
_ students during the past year requiring restrictive |
| interventions, compared to those that did not.
his information will be presented by the agency
| in the appeal of this finding.
The agency will ensure that all of Eliada Home
Policies are being followed as it relates to
restrictive interventions until they are updated and
approved Friday February 19, 2021. At which
time all staff will be notified and trained on |
changes.
Describe your plans to make sure the above
happens.
40A NCAC 27G. 0201 Governing Body Policies
(¥105) - [CEO] will be managing these phone
calls personally this week to discuss new
guidelines on accepting youth in cottages that are
referred with a history violent and aggressive i
behaviors.
10A NCAC 27G.0203 Competencies of Qualified i
Professionals and Associate Professionals
(v109);
Acore competency checklist will be presented by
residential leadership to each cottage supervisor
© The cottage supervisor will review the core
competency with all cottage staff and have ail
staff sign off on attendance at the training.
Division of Health Service Regulation
STATE FORM ad LHPP11 Hf continuation sheet 79 of 124

PRINTED: 03/09/2021
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

Cc
MHLO11-204 B. WING 02/18/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD

ASHEVILLE, NC 28806

CUMMINGS COTTAGE

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

V 314| Continued From page 79 v314

|
| o The Residential Director and PQI will inspect

| that this has occurred by reviewing sign in sheets
and training documents. This training is to be
completed by the first of March 2021.

| 10A NCAC 27G.0209(e) Medication Storage i
(¥120); The medical storage tote was purchased
and has been consistently used to transport
medication, since the interview took place with
the lead nurse. | verified this with the lead nurse
this evening.

{0A NCAC 27G.0205 Assessment and
Treatment/Habilitation or Service Plan (V112);
oA training checklist will be set up to include for
EAC Lions Assessment cottage to update the
crisis plan each CFT (Child and Family Team) if
new interventions are identified and update the
PCP the 2nd week of assessment. ,

| o PQI will be instructed to start including team
meeting minutes in investigation requests to

| demonstrate conversations of new strategies with I
youth.

© Residential Director and COO will inspect that
each of these trainings have occurred by the end
of the month of February 2021.

10A NCAC 27D.0101(c) (f) Policy on Rights '
Restrictions and Interventions (V500 & V501);
[COO] will immediately set up a meeting with the
three agency TCI trainers to discuss incident
review, incident documentation, nursing
supervision, debriefing for staff, and TCI
retraining. Senior leadership and PQI will meet

| 2/17/21 to review the above and make
recommended changes. This will be reviewed
with the executive committee of the board Friday
2/19/21

10A NCAG 27G.1902(e) Staff (V315); [COO] will
meet with PQI, TCI trainers and Nursing by the
end of the week.

10A NCAC 27G.1901 Scope (V314) for Type A1

| Serious Harm and Neglect [COO] will work with
Division of Health Service Regulation

STATE FORM 8200 LHPP11 Hoontinuation sheet 80 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation
‘STATEMENT OF. DEFICIENCIES: (X%1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER;

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

c
B. WING ______________ 02/18/2021

MHL011-204

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD

ASHEVILLE, NC 28806

CUMMINGS COTTAGE

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX GORRECTIVEACTION SHOULD BE CROSS- COMPLETE
TAG REGULATORY OR LSC iDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE OaTE

DEFICIENCY)

Continued From page 80

Disability Rights to come back into compliance.
Eliada will continue to work with the Six Core
Initiative Project to reduce Restrictive
interventions in PRTF.

COO and CEO will be monitoring all above steps
and participating in calls and conversations as it
relates to this serious compiaint. They will also
be responsible for pulling the data as it relates to
restrictive interventions, documentation of

| alternative strategies and the number of students
not invoived with restricted interventions.”

Review on 2/17/21 of the Addendum Plan of
Protection completed and signed by the COO on

| 9/16/21 revealed:

| -"What immediate action will the facility take to
ensure the safety of the consumers in your care?
10A NCAC 27G. 0201 Governing Body Policies
(V105); Tuesday, February 23, 2021, Senior
Leadership will assess our referral and admission
criteria. At this meeting, Senior Leadership will be
assessing entrance criteria in addition to the state
and federal required PRTF criteria as it relates to
admissions on this campus. Senior Leadership
will set up a meeting with contracted LME’s and
MCO's to discuss their expectation and demand
for Eliada to serve high acuity students. The
agency will discuss the acuity of the students
referred to this campus white continuing to work
to partner with the state and LME/MCOs to
support these difficult to place youth in our
community. As of Monday February 22, 2021,
Efiada will begin interviewing students and their
guardians prior to admission if student has a
history of aggression, sexualized behavior,
absconding, and self-harm. [COO] was in contact
with [contact] at Disability Rights February 16th
and this morning. [Contact] stated that sending
the printed IRIS reports from February 2020 to
February 2021 would bring Eliada back into
Division of Health Service Regulation

STATE FORM oan LHPP11 K continuation sheet 81 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation

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

(2) MULTIPLE CONSTRUCTION
A. BUILDING:

(3) DATE SURVEY
COMPLETED

Cc
02/18/2021

MHLO11-204 8. WING

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD

ASHEVILLE, NC 28806

CUMMINGS COTTAGE

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

Continued From page 81

compliance. Our Residential Administrative
Assistant will print the IRIS reports and [Finance
Director], will fax the reports to [Division of
Medical Assistance email] and [DRNC email].
Going forward, every IRIS report will

} automatically be sent to Disability Rights and
DMA by the person submitting the report in IRIS.
410A NCAC 27G.0203 Competencies of Qualified
Professionals and Associate Professionals

| (¥109); Senior Leadership, will review core
competencies of QP and AP within residentiai
services. [Agency Trainer] will review the core
competencies with residential leadership with a
plan to review in team meetings. [CEO! will
retrain clinicians, case managers and cottage |
supervisors on documentation of updates to crisis
plans and ICMP's after each serious incident.
[Agency Trainer] will retrain proper TCI holds in
Team Meetings beginning on February 24, 2021.
140A NCAC 27G.0209(e) Medication Storage
(V120); The medical storage tote was purchased {
a few weeks ago and has been consistently used
to transport medication on campus and between
buildings. Medication is locked in the tote as soon
as it is handed to the Nurse during Intake.
Anytime medication is transported on campus, it
is locked in the tote and does not leave the nurse
until the medication is locked in the medication
cart. |
10A NCAC 27G.0205 Assessment and
Treatment/Habilitation or Service Plan !
(V112);[CEO] will retrain clinicians, case

managers and cottage supervisors on

| documentation of updates to crisis plans within

| the PCP and in addition to include team meeting

reports in submission to investigations regarding i
| strategies for students. [Clinical Director] |
conducted a campus training for Case Managers
and Clinicians on writing PCP individualized
treatment goais 1/6/2021. [Risk Reduction
Division of Health Service Regulation

STATE FORM bea9 LHPP11 Hcontinuation sheat 82 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (3) DATE SURVEY

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

MIHLO11-204 B.WING 02/18/2021

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD

CUMMINGS COTTAGE
ASHEVILLE, NC 28806

‘SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (EACH 6)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVE ACTION SHOULD BE CROSS- COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DATE
| DEFICIENCY)
V314 Continued From page 82 v314

| Manager] will inspect the recent PCP's to assure
| that they are being updated regularly and contain
individualized goals.

140A NCAC 27D.0101(c) (f) Policy on Rights
Restrictions and Interventions (V500 & V501);
PQIis meeting with all four agency TCI trainers 1 |
February 18, 2021 to discuss incident review,
incident documentation, nursing supervision, 1
debriefing for staff, and TCI retraining. Eliada
reviewed the language within Eliada Homes
policies to reflect the TCL RIN expeciation for what
is possible to manage regarding response times
of nursing. We will also modify language within
PQ policy as it relates to restrictive interventions.
[CEO] will reevaluate (CPM's, Crisis Plans, and
Treatment Plans identify documentation of
alternative strategies and assure that they are
individualized for each student.

10A NCAC 27G.1902(e) Staff (V315); Eliada does
have 24 hour on-site coverage by a registered
nurse. Eliada will meet with PQ! and Lead Nurse
to discuss TCI monitoring during restrictive
interventions. Language was changed in the
procedures to reflect keeping students safe
before a nurse can arrive to the incident. The
Cottage Supervisor on site will monitor the
restrictive intervention until the nurse arrives.

140A NCAC 27G.1901 Scope (V314) for Type A1
Serious Harm and Neglect

[Contact] at Disabitity Rights clarified their
expectations for reporting every restrictive
intervention. This language was not included in
our policy, procedures, and attestations sent
previously. The agency is working with Disability
Rights and have devised a plan to get into
compliance with their requirements by Friday
February 19, 2020. The agency will continue to
work with the state and LVIE/MCO team with six
core on the use of restrictive interventions. The
agency wilt pull data on the number of students |
Division of Health Service Regulation
STATE FORM coms LHPP1t tf continuation sheet 83 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation

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

(%2} MULTIPLE CONSTRUCTION
A. BUILDING:

(%3) DATE SURVEY
COMPLETED

Cc
02/18/2021

B. WING

MHL011-204

NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE

882 ELIADA HOME ROAD

CUMMINGS COTTAGE ASHEVILLE, NG 28806

41D ‘SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (EACH 05)
PREFIX | (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIK CORRECTIVE ACTION SHOULD BE CROSS- COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

Continued From page 83

during the past year requiring restrictive
interventions, compared to those that did not.
This information will be presented by the agency
in the appeal of this finding. The agency will
ensure that all of Eliada Home Policies are being
followed as it relates to restrictive interventions

| until they are updated and approved Friday
February 19, 2021. At which time all staff will be
notified and trained on changes.

Describe your plans to make sure the above
happens.

10A NCAC 27G. 0201 Governing Body Policies
(V105) - [CEO] will be managing these phone
calls personally this week to discuss new
guidelines on accepting youth In cottages that are
referred with a history violent and aggressive
behaviors.

10A NCAG 27G.0203 Competencies of Qualified
Professionals and Associate Professionals
(V109):

Acore competency checklist will be presented by
| residential leadership to each cottage supervisor
o The cottage supervisor will review the core
competency with all cottage staff and have all
staff sign off on attendance at the training.
o The Residential Director and PQ! will inspect
that this has occurred by reviewing sign in sheets
and training documents. This training is to be
completed by the first of March 2021.

140A NCAC 27G.0209(e) Medication Storage
(V120); The medical storage tote was purchased
and has been consistently used to transport
medication, since the interview took place with
the lead nurse. | verified this with the lead nurse
this evening.

10A NCAC 27G.0205 Assessment and
Treatment/Habilitation or Service Plan (V112);

0 Atraining checklist will be set up to include for
[sister facility] to update the crisis plan each CFT
if new interventions are identified and update the

Division of Health Service Regulation
STATE FORM 6800 LHPP4141 if continuation shast 84 of 124

PRINTED: 03/09/2021
FORM APPROVED

Division of Health Service Regulation

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

(<2) MULTIPLE CONSTRUCTION
A, BUILDING:

(X3) DATE SURVEY
COMPLETED

c
02/18/2021

MHLO11-204 B. WING

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
$82 ELIADA HOME ROAD

CUMMINGS COTTAGE
ASHEVILLE, NC 28806

‘SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH 5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVE ACTION SHOULD BE CROSS- COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

;—_____—
Continued From page 84

V314

PCP the 2nd week of assessment.

© PQI will be instructed to start including team
meeting minutes in investigation requests to
demonstrate conversations of new strategies with i
youth. i !
o Residential Director and COO will inspect that
each of these trainings have occurred by the end

of the month of February 2021.

10A NCAG 27D.0101(c) (f) Policy on Rights Deo
i Restrictions and Interventions (V500 & V501); | \ Ardaenwe a w\ doc
| {COO} will immediatety set up 4 meeting with the ‘

three agency TCI trainers to discuss incident fo SS - S11

review, incident documentation, nursing
supervision, debriefing for staff, and TCI
retraining. Senior leadership and PQI will meet i
2/18/21 to review the above and make
recommended changes. This will be reviewed
with the executive committee of the board Friday |
219/21

140A NCAG 27G.1902(e) Staff (V315); [COO] will
meet with PQI, TCI trainers and Nursing by the
end of the week 2/19/2021. |
10A NCAG 27G.1901 Scope (V314) for Type A1 '
Serious Harm and Neglect [COO] will work with i
Disability Rights to come back into compliance by
Friday 2/19/2021. Eliada will continue to work with
the Six Core initiative Project to reduce
Restrictive interventions in PRTF. COO and CEO. {
will be monitoring all above steps and |
participating in calls and conversations as it |
relates to this serious complaint. They will also be |
responsible for pulling the data as it relates to i
restrictive interventions, documentation of
alternative strategies and the number of students
not involved with restricted interventions.”

Clients served by the facility have a range of
mental health diagnoses including but not limited
| to Autism Spectrum Disorder, Post Traumatic

| Stress Disorder, Major Depressive Disorder,
Division of Health Service Regulation

STATE FORM bined LHPP11 if continuation sheet 85 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES A) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED

c
Be WING er 02/18/2021
NAME OF PROVIDER OR SUPPLIER, STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

CUMMINGS COTTAGE

04) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVE ACTION SHOULD 8E CROSS- COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

Continued From page 85

Disruptive Mood Dysregulation Disorder,
Attention Deficit Hyperactivity Disorder,
Oppositional Defiant Disorder, and Substance
Use Disorder and range in age from 12-17 years.
The clients have histories of trauma, sexualized
behaviors, self-injurious behaviors, substance
abuse and suicide attempts. The facility failed to
provide a structured living environment with
supervision and also failed to provide services
designed to address the treatment needs of the
clients. This directly resulted in the use of
numerous restrictive interventions (RI's) and
multiple injuries to clients and staff. The lack of
appropriate supervision contributed to 18 clients
eloping from the facility 105+ times either by
climbing out of their windows, pushing past staff
and/or running out of the cottage doors. In some
instances, clients remained off campus for
several! hours at a time and there were 12

| incidents in which staff filed a missing person's
report with the police. Numerous clients engaged
in seiftharm behaviors which involved
headbanging, cutting themselves with sharps,
running into traffic, and attempting to choke
and/or drown themselves. Other incidents of |
concern include sexualized behaviors between
clients, a client obtaining and consuming beer at
a community function on campus, clients getting
into a car with a stranger during an off campus
elopement, a client using a piece of plastic to cut
a staff member's neck, clients obtaining staff

| radios and stealing staff's keys with the intent to
unlock a locked program on campus, a client
stealing keys to the ignition of a tractor that was
pulling adults and children from the community, a
client attempting to drown a staff member and in

| @ separate incident a client attempting to drown a
peer in the campus swimming pool. Additionaity,
there were 390 restrictive interventions (restraints
and/or seclusions) between Javiuary 1, 2020 to
Division of Heaith Service Regulation

STATE FORM ase LHPP11 H continuation sheet 86 of 124

PRINTED: 03/09/2021
- FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES 041) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X3) DATE SURVEY

(X2) MULTIPLE CONSTRUCTION
' . COMPLETED

A BUILDING:

ie}
02/18/2021

B. WING

MHLO011-204

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

882 ELIADA HOME ROAD

cUMMI COTTAGE
UMMINGS ASHEVILLE, NC 28806

4) ID i] SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (EACH (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED 8Y FULL PREFIX CORRECTIVE ACTION SHOULD BE CROSS- COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

Continued From page 86

February 12, 2021. Of this number, there were 18
times when multiple Ri’s were co-occurring at the
same time, or within a close time frame of one
another. The Registered Nurse (RN) was not
present to monitor client safety for all, or part of
166 RI's. Additionally, there were numerous R's in
which it could not be determined if the RN was
present due to insufficient documentation. Staff
frequently utilized techniques that were not
compliant with the RI training curriculum used by
the agency. The facility documented the use of
non-compliant physical holds and interventions 72
times. There were 69 injuries among 30 staff
members during the Ri's. Staff injuries included
but were not limited to staff having their hair !
pulled out, staff being bit, punched, kicked, and |
headbutted, along with staff being hit with and/or
stabbed with various objects. The facility's quality
assurance program failed to identify trends and
strategies that had a negative impact on client
care and outcomes. The facility gathered data
about the use of Ri's but failed to address the
extent of reliance on the use of restraints. The
facility did not comply with required reporting to
Disability Rights North Carolina (DRNC) for i
serious occurrences for the 2020 calendar year
and the first 6 weeks of 2021, limiting DRNC's
ability to have timely oversight of restraints, |
seclusions, serious injuries, and suicide attempts.

The failure of the facility to recognize the
significant treatment needs of the clients and |
adapt the therapeutic interventions to meet those
needs constitutes a Type A1 rule violation for
serious neglect and harm and must be corrected 1
within 23 days. An administrative penalty of 1
$6,000.00 is imposed. If the violation is not
corrected within 23 days, an additional
administrative penalty of $500.00 per day will be
imposed for each day the facility is out of

Division of Health Service Regulation
STATE FORM Goad LHPP11 ifeontinuation sheet 87 of 124

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES: (1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

MHL011-204

NAME OF PROVIDER OR SUPPLIER

CUMMINGS COTTAGE

41D ‘SUMMARY STATEMENT OF DEFICIENCIES
PREFIX | (EACH DEFICIENCY MUST BE PRECEDED BY FULL
Tas | REGULATORY OR LSC IDENTIFYING INFORMATION)
V314 I Continued From page 87
compliance beyond the 23rd day.
|
V 315, 27G .1902 Psych. Res. Tx. Facility - Staff

10A NCAC 27G .1902 STAFF

(a) Each facility shall be under the direction a
physician board-eligible or certified in child
psychiatry or a general psychiatrist with
experience in the treatment of children and

; adolescents with mentat illness.

| (b) Atali times, at least two direct care staff

| members shall be present with every six children
| or adolescents in each residentiat unit.

(c) Ifthe PRTF is hospital based, staff shall be

! specifically assigned to this facility, with

| responsibilities separate from those performed on
| 4n acute medical unit or other residential units.

| (J) A psychiatrist shatl provide weekly
consultation to review medications with each child
| or adolescent admitted to the facility.

(e) The PRTF shall provide 24 hour on-site
coverage by a registered nurse.

| This Rule is not met as evidenced by:

| Based on record reviews, the facility failed to

| provide 24 hour on-site coverage by a registered
: nurse (RN). The Findings are:

| Refer to Tag V112 for additional client information
| and V500 and V501 for additional information on
| Restrictive Interventions.

Interview on 1/14/21 with the Interim Residential
Director revealed:

Division of Health Service Regulation
STATE FORM

(2) MULTIPLE CONSTRUCTION
A, BUILDING: _

B. WING

iD
PREFIX
TAG

v314

V3I5

Tacs

8038

PRINTED: 03/09/2021
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

c
02/48/2021

STREET ADDRESS, CITY, STATE, ZIP CODE

882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

PROVIDER'S PLAN OF CORRECTION (EACH 4X5)
CORRECTIVE ACTION SHOULD BE CROSS- COMPLETE
REFERENCEDTO THE APPROPRIATE DATE

DEFICIENCY)

10A NCAC 27G .1902 STAFF

he Facility has maintained nursing coverage

ind ratio daily throughout the years. The
Facility received a waiver from DHSR in 2019
fand 2020 to reduce the number of nurses on
(campus from 2 to 1 on campus 24/7 365. The
\waiver noted that the nursing staff were
located in a space within 50 yards of the
furthest cottage and was able to meet the

eeds of the students on campus after the
Fein closed 3 level 3 cottages and 1 PRTF due
ito funding levels. Eliada remained in |
lcompliance with the terms of our waiver.

‘ttached you will find the time sheets for
farsi staff from January 2020 to present. We}
are happy to provide them further back as i

eeded. The Facility takes nursing coverage
ios seriously. Upon the reopening of the PRTF;
cottages the Facility will be back up to 2 nursing,
staff on site per shift 24/7 365.

| Dees svop pene |
143 ~3

i
I
H
|
i
|
!
|
i
i
!
|
|
!
|

LHPP11 \feonftinuation sheet 88 of 124

PRINTED: 03/09/2021
| FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (1) PROVIDER/SUPPLIER/CLIA
‘AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A, BUILDING:

(X3) DATE SURVEY
COMPLETED

c
02/48/2021

B. WING

MHILL011-204

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

882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

CUMMINGS COTTAGE

4 ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH 5)
PREFIX | (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVE ACTION SHOULD BE CROSS- | COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE. DATE

DEFICIENCY)

¥345/ Continued From page 88

-When he first started working for the facility there
was more nursing staff available.

-The facility has one RN for 3 cottages which
include "2 PRTF's (Psychiatric Residential
Treatment Facilities) and 1 Level Ill (Residential
Treatment Staff Secure for Children or
Adolescents)”

-He stated, "Staff have been coached to call RN if
it looks like RI (Restrictive Intervention) is going
to happen.”

Interview on 1/14/21 with the Nurse Manager
revealed:

-The campus was iarge and it took time for the
RN to get to the location of the RI. ;
-The R's usually happened so quickly that the

| RN didn't have time to respond.
| -She stated, " ...it's over before the nurse gets
there."

~The facility went from a ratio of "2 RN's on

campus to 1 RN at all times.”

-There was 1 RN for 24 beds. |

-There were an additional 10-12 clients on

campus attending an academy program during

school hours from 8:00 am - 2:30 pm.

-She stated "The Academy students don't request

a lot of our time but there's potential for being

pulled away ...staffing has been a challenge ...it's

hard since reducing our ratio ..."

-As the Nurse Manager, she worked from 8am -

5pm and was responsible for attending meetings,

assisting the doctor with client evaluations and

providing training to staff.

-She was not always available to assist the RN on
duty.

| Interview on 1/11/21, 1/19/21 and 1/27/21 with the
Chief Operations Officer (COO) reveated:

-RN's were stationed in a building across the
courtyard directly between two cottages.
Division of Health Service Regulation

STATE FORM e809 LHPP41 Wconfinuation sheet 89 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(%3) DATE SURVEY
COMPLETED

Cc
02/18/2021

MHLO11-204 8. WING

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA ROME ROAD

CUMMII OTTAGE
=< ¢ ASHEVILLE, NC 23806

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

DEFICIENCY)

| Continued From page 89

| -The nursing office, the gym and the kitchen were
located in the same building.

| -The nursing office was in between the gym and
the kitchen.

-The RN and Nurse Manager were on campus
during the day. [
-If necessary, the Nurse Manager "could be
called back in."

-She stated, "We never had to call the Nurse |
| Manager back though."

-An RI would have to be monitored by a Qualified
Professional (QP) if the RN was not available.
-She stated" ...but I'm not aware of any
circumstances where a nurse would not be able
to get there.”

-She stated, "It's not been reported to my
knowledge that we had 2 RI's at the same time.” |

; Interview on 2/16/21 with the Chief Executive
Officer (CEO), the COO, and the Clinical Director
revealed:

; -"....the team has a process that they will notify
the nurse but they can't stand there and wait for
her to arrive ..." \
-"There have been 1 or 2 times when the nurse
wasn't present for an Ri. It's happened once or :
twice that more than one intervention was going H '
on at the same time." |

| Review on 2/8/21-2/10/21 and 2/15/21 of facility i ; '
: PRTF Incident Reports dated 1/1/20-2/12/21 i
revealed: H i - Ree shes
- there were 18 times when multiple RI’s were ! \Ww sone S
co-occurring at the same time, or within a close My Glu dene wert |
time frame of one another as follows: |
ee err
1/22/20: Non-audited Client (NAC#10) and NAC MSs a

io Ca O~ ns aaa

| 5/11/20: FC #5 and NAG #21 were restrained

#13 were in restraints at the same time.
5/07/20: NAC #17 and NAC #18 were in
i
behind Bh OT, payes\-Z6
Division of Health Service Regulation
STATE FORM nea LHPP11 H continuation sheet 90 of 124

restraints at the same time.

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation
‘STATEMENT OF DEFICIENCIES (1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

c
02/48/2021

MHL011-204 B. WING

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 EWADA HOME ROAD
ASHEVILLE, NC 28806

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

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

CUMMINGS COTTAGE

| Continued From page 90

within 4 minutes of one another. |
5/16/20: NAC #18 and NAC #20 were restrained
within 1 minute of one another and FC #5 and
NAC #18 were in restraints at the same time. i
7/02/20: NAC #18 and NAC #20 were in
restraints at the same time.

7/12/20: NAC #18 and NAC #20 were in
restraints at the same time on two separate

; occasions.

7/14/20: NAC #18, NAC 420 and NAC #22 were
in restraints at the same time and NAC #24 was
placed in restraints 1 minute later. Additionally, 1
% hours ater FC #5 and NAC #24 were in
restraints at the same time. !
79/20: NAC #23 was placed in 14 R's in less {
than 2 hours. |
8/18/20: NAC #20 and NAC #22 were restrained
| Within 2 minutes of one another.

; 9/07/20: NAC #20 and NAC #25 were restrained
| within 15 minutes of one another. |
| 9/13/20: FC #7 and NAC #25 were in restraints at '
| the same time.

| 9/21/20: FC #6 and NAC #25 were restrained |
| within 2 minutes of one another in the |
morning. |
9/21/20: FC #6 and NAC #25 were in restraints at
the same time in the evening. Additionally, 23
minutes later FC #7 and NAC #25 were in
restraints at the same time.

10/30/20: FC #6 and FC #7 were in restraints at
the same time.

| 1177/2020: Client #1 and Client #2 were

| testrained within 21 minutes of one another.
11/11/20: Client #1 and Client #2 were in |
restraints at the same time.

118/21: Client #2 and Client #3 were in restraints
at the same time.

| -Additionally, there were 3 instances of
co-occurring RI's between both PRTF's as

follows:
Division of Health Service Regulation

STATE FORM e008 LHPP 14 Hf continuation sheet 91 of 124

;
|
|
i
I
|
i
i
i

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation
‘STATEMENT OF DEFICIENCIES (X4) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

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

c
8. WING —______-._______ 02/18/2021
STREET ADDRESS, CITY, STATE, ZIP CODE

882 ELIADA HOME ROAD
ASHEVILLE, NC 28606

MHL011-204

NAME OF PROVIDER OR SUPPLIER

CUMMINGS COTTAGE

(4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (EACH *6)

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

DEFICIENCY)

V 315! Continued From page 91

9/27/20: FC #6 was in a restraint from 5:21 pm to
5:23 pm and again from 5:30 pm to 5:31 pm,
while a client from another PRTF was in a
subsequent restraint from 5:06 pm to 5:50 pm.
10/4/20: FC #6 was in a restraint from 4:15 pm to
4:16 pm and again from 4:18 pm to 4:20 pm,
while a client from another PRTF was ina
subsequent restraint at 4:15 pm to 4:16 pm and
from 4:18 pm to 4:20 pm.

10/30/20: FC #7 was in a restraint from 5:27 pm
to 5:34 pm and again from 5:37 pm to 5:42 pm,
while a client from another PRTF was ina
subsequent restraint from 5:30 pm to 5:32 pm.

Review on 1/14/21 of the Cummings's Cottage
| Waiver Approval dated 8-26-20 revealed:
Waiver of Rule 10A NGAC 27G .1902 (e) /
provides the PRTF shall provide 24 hour on-site |
coverage by a registered nurse was granted a
waiver to use decreased nursing based on the
following criteria outlined in the Waiver Request
dated 7/1/2020:

“All nursing staff will have 24/7 on-call support
from a Lead Nurse/RN, Medical
Director/Psychiatrist, and a Physician Assistant.
"The PRTF program employs a radio
communication system that provides

continuous and immediate staff to staff contact
including nursing staff

24/7.

“  Eliada also ensures the safety of our
residents by providing crisis

management services that include a 24/7
licensed professional on-call, a

24/7 qualified professional on-call, a residential

| Program

manager/supervisor on site until 11pm, one NRC
support 5 days a week, a t
Lead NRC on weekends, and up to 20 residential
interns (college
Division of Health Service Regulation
STATE FORM e008 LHPP11 M continuation sheet 92 of 124

PRINTED: 03/09/2021
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

c
MHL011-204 B. WING 02/48/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD

ci S CO
UMMINGS COTTAGE ASHEVILLE, NC 28808

(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (EACH 065)
PREFIX (EACH DEFICIENCY MUST 8E PRECEDED BY FULL PREFIX CORRECTIVE ACTION SHOULD BE CROSS- COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 315| Continued From page 92 V¥ 315

| graduates) living on campus who can be
activated in the event of a crisis.

Interview on 1/14/21 at 2:07 PM with the Nurse
Manager revealed:

-The campus was large and it took time for the
RN to get to the location of the Restrictive
Intervention RI. 1
-The Rls usually happened so quickly that the RN
didn’t have time to respond.

-" it's over before the nurse gets there.”

-The facility went from a ratio of "2 RN's on
campus to 1 RN at all times."

-There is 1 RN for 24 beds. 1
-There were an additional 10-12 clients on
campus attending an academy program during
school hours from 8:00 am - 2:30 pm.

-"The Academy students don't request a lot of our
time but there's potential for being pulled away
...Staffing has been a challenge ...it's hard since
reducing our ratio ..." 1
-As the Nurse Manager, she worked from 8am -
5pm and was responsible for attending meetings,
assisting the doctor with client evaluations and
providing training to staff.

~She was not always available to assist the RN on t
duty. i

This deficiency is cross referenced into 10A
NCAC 27G.1901 Scope (V314) for a Type A1 rule
violation for serious harm and neglect and must
be corrected with 23 days.

V 500, 27D .0101(a-e) Client Rights - Policy on Rights Vv 500

10A NCAC 27D .0101 POLICY ON RIGHTS
RESTRICTIONS AND INTERVENTIONS

(a) The governing body shall develop policy that
; assures the implementation of G.S. 1220-59,

Division of Heaith Service Regulation
STATE FORM ons LHPP11 continuation sheet 93 of 124

PRINTED: 03/09/2021
FORM APPROVED

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (Xt) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

{X3) DATE SURVEY
COMPLETED

c
02/18/2024

MHL011-204 B. WING

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

682 ELIADA HOME ROAD
ASHEVILLE, NC 28806

CUMMINGS COTTAGE

4) 1D SUMMARY STATEMENT OF DEFICIENCIES: PROVIDER'S PLAN OF CORRECTION(EACH
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVE ACTION SHOULD BE CROSS- COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE OATE

| . DEFICIENCY)
V500| Continued From page 93 vs00 _{10A NCAC 27D .0103 POLICY ON RIGHTS
RESTRICTIONS AND INTERVENTIONS

G.S, 122C-65, and G.S. 1220-66.
(b) The governing body shall develop and a 7 ‘
| implement policy to assure that: L)Attached is the facility's policy on reporting
| () all instances of alleged or suspected fabuse and neglect. This is within the employee
; abuse, neglect or exploitation of clients are manual and is reviewed during the pre service

| reported to the County Department of Social and throughout the year in varying meetings.
Services as specified in G.S. 108A, Article 6 or

GS. 7A, Article 44; and
I

Attached admission nursing paperwork re
jabs to monitor medications as required this is
ompleted on every student entering the
‘campus and facility.

(2) procedures and safeguards are ‘
instituted in accordance with sound medical Yace $
practice when a medication that is known to
Present serious risk to the client is prescribed.
Particular attention shail be given to the use of
neuroleptic medications.

| (©) tn addition to those procedures prohibited in
| 10A NCAC 27E .0102(1), the governing body of
each facility shall develop and implement policy
| that identifies:

(1) any restrictive intervention that is

| prohibited from use within the facility; and

(2) in a 24-hour facility, the circumstances
under which staff are prohibited from restricting
the rights of a client.

(d) If the governing body allows the use of
restrictive interventions or if, in a 24-hour facility, LOA NCAC 27E .0102
the restrictions of client rights specified in G.S. wae
122C-62(b) and (d) are allowed, the policy shall [This information is included within the new
identify. evised Restrictive Intervention Policy in
(1) the permitted restrictive interventions or Ceidition to Attachment A or B

allowed restrictions;

(2) the individual responsible for informing
the client; and

(3) the due process procedures for an
involuntary client who refuses the use of
restrictive interventions.

| (€) tf restrictive interventions are allowed for use
| within the facility, the governing body shall
develop and implement policy that assures

; Compliance with Subchapter 27E, Section .0100,
Division of Health Senice Regulation
STATE FORM 5899 LHPP11 NW continuation sheet 94 of 124

|~3e

PRINTED: 03/09/2021
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:

(03) DATE SURVEY
COMPLETED

Cc
02/18/2021

MHLO11-204 B. WING

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ASHEVILLE, NC 26806

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION(EACH 5)

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

DEFICIENCY)

CUMMINGS COTTAGE

V 500! Continued From page 94

which includes:

{1} the designation of an individual, who

| has been trained and who has demonstrated
competence to use restrictive interventions, to
provide written authorization for the use of
restrictive interventions when the original order is
renewed for up to a total of 24 hours in

accordance with the time limits specified in 10A De va
NCAC 27E .0104(e)(10)(E); |
@ the designation of an individual to be 1-3

responsible for reviews of the use of restrictive
interventions; and

: B) the establishment of a process for
appeal for the resolution of any disagreement
over the pianned use of a restrictive intervention.

This Rule is not met as evidenced by:
Based on record reviews and interviews, the
facility failed to implement policy that identifies | \
any restrictive intervention (RI) that is prohibited i i
from use within the facility affecting 2 of 4 audited
current clients (Client #1 and Client #2) and 3 of 3
audited Former Clients (FC #5, FC #6 and FC

#7). The findings are:

Review to Tag V112 for additional client
information.

Review on 1/5/21 of Eliada Homes, Inc. H
Restrictive Intervention Policy dated 10/31/94 and
revised 1/21/02 revealed:
-"6. Training/Privileging
@) Staff must be trained in the appropriate

uses of restraint, seclusion and isolation time out
: procedures prior to their use with students. i

b) Staff must complete the crisis intervention i
| curriculum and pass written and practical

Division of Health Service Regulation
STATE FORM 2088 LHPP14 if continuation sheet 95 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (41) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

Q@) MULTIPLE CONSTRUCTION
A, BUILDING:

(X3) DATE SURVEY
(COMPLETED

Cc
02/18/2024

MHLO11-204 ———— |

NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, 2IP CODE

882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

CUMMINGS COTTAGE

(x9) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH
PREFIX {EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVE ACTION SHOULD BE CROSS-
TAG : REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE
DEFICIENCY)

Continued From page 95

examinations before being approved to

i administer physical restraints, Staff must ona
semi-annual basis demonstrate competencies in
the following: |
1. Techniques to identify staff and student
behavior that may trigger emergency Safety
situations. .

2. - The use of non-physical interventions to
Prevent emergency safety situations.

3. The safe use of restraint, seclusion, and time
out."

; Review on 2/15/21 of Eliada Homes, inc.

Restrictive Intervention Policy/Procedure

Attachment A dated 5/2016 revealed:

-"Eliada utilizes the Therapeutic Crisis

Intervention (TCi) model developed and managed

by Cornell University and approved by the NC |

| Division of Mental Health. i

-All PRTF (Psychiatric Residential Treatment |

Facility) staff must complete 28 hours of initial |

TCI training and must Pass written and practical | |

tests.

-All PRTF staff must be re-certified in TCl every 6

months.

-Refresher trainings are conducted quarterly or

iiore Gitén as needed.

-Eliada has an agency Trainer trained as a trainer |

of the TCI model. Eliada typically has 2-3 |

Program managers also trained as trainers in |

TCl. They complete a week long Train the Trainer |
i
i

certification and re-certification every two years.
-The TCI model utilizes 4 restraints: standing
restraint; seated restraint; small child restraint;
and supine restraint. |
| -The prone team restraint is not allowed."

Review on 2/8/21-2/10/21 and 2/1 5/21 of the
| facility PRTF Restrictive Intervention Report for

| Client #1 reveated: i
Division of Health Servior Regulation

STATE FORM based LHPP14 Hfeontinuation shest 96 of 124

|

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (44) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X83) DATE SURVEY
COMPLETED

Cc
02/48/2021

MHL011-204 8. WING

NAME OF PROVIDER OR SUPPLIER

STREET ADORESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

CUMMINGS COTTAGE

SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (EACH (%5)
(EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVEACTION SHOULD BE CROSS- COMPLETE.
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

| Continued From page 96

-11/11/20 staff "yolked the student by putting their
forearms under the student's armpits and holding
their arm across staff's body. Staff adjusted the
hold and move the student to the wall and
readjusted to lower the student again and
proceeded to brace the wall." from
5:47pm-6:08pm. The Registered Nurse (RN) |

| documented the entire Ri as a standing restraint Doc
which does not match the description

| documented by staff. Staff did not identify the |)
type of restraint they utilized.

-11/19/20 "staff initiated a standing restraint
against the back of her door at 9:56pm ... staff
transitioned the standing restraint to the wall
adjacent to her door due to staff conducting
checks"; staff released the restraint at 10:06 pm.
-11/21/21 due to client being on the floor, "staff
could not perform a proper TCI hold".
Other/physical hold for 30 minutes from
5:04pm-5:34pm.

-2/11/21 staff attempted to initiate "a restraint”,
struggled to secure "the hold", then reinitiated and
decided on a seated restraint; RN only
documented the seated restraint; RN noted client
bit her own arm, staff bit on right arm, staff bit on
left arm and staff bit on right arm |
-The techniques used were either non-TCl
compliant, or it could not be determined if the
techniques used were TC! compliant.

Review on 2/8/21-2/10/21 and 2/15/21 of the
facility PRTF Restrictive Intervention Report for
Client #2 revealed:

11/7/20 staff initiated an "other hold” from 8:10
pm - 8:13pm and initiated a supine restraint from
8:13pm - 8:22pm as a 3rd staff arrived.

-1/17/21 "Staff attempted multiple supines but
were unable to hold due to lack of compliance
with safety per lack of staff being unable to hold |
i legs and student's positioning against the wail.” !
Division of Health Service Regulation

STATE FORM seo LHPP14 Hfeontinuation sheet 97 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (<2) MULTIPLE CONSTRUCTION (%3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED

Cc
MHLO11-204 B.WING 02/18/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

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

CUMMINGS: COTTAGE

Vv 500! Continued From page 97 Vv 500

-1/28/21 staff "attempted to yoke [Client #2] at
7:34pm and released due to her being on the
ground." The RN documented the restraint as
other/physical hold for 1 minute.

-1/29/21 RN documented other/physical hold at
6:22 pm for t minute and other/physical hold at |
; 6:37 pm for 3 minutes

-The techniques used were either non-TCl
compliant, or it could not be determined if the
techniques used were TCI compliant.

Review on 2/8/21-2/10/21 and 2/15/21 of the

f
facility PRTF Restrictive Intervention Report for (oc. ,
| FC #5 revealed: Su ppsts purses AS-\
-3/22/20 Staff "initiated a restrictive intervention \

on [FC #5] but immediately released due to

| unsafe positioning as both staff and [FC #5] fell to
the ground.” RN documented other/physical hold |
for 1 minute. Client reported left ankle was kicked
during initiation of RI and complained of pain.
Ankle red with minimal swelling, ice applied.
-3/26/20 Staff initiated "a restraint" (no technique
or start/end time was documented) then staff |
moved onto the grass before initiating a Supine
Restraint.

-4/25/20 Staff initiated "a restrictive intervention"
at 8:30 pm and transitioned client fully inside of
her room and released due to poor positioning. |
RN documented the restraint as other/physical
hold for zero minutes.

-4/30/20 Staff utilized "an approach from behind"
and immediately released due to safety. RN
documented the restraint as other/physical hold
for 1 minute.

-5/11/20"A restrictive intervention" was initiated at
8:40 pm. The RN documented the RI as a
standing restraint for 1 minute. i
-5/12/20 Staff attempted to initiate a standing
restraint on client when she attempted to run out
of the cottage and released due to unsafe
Division of Health Service Regulation

STATE FORM ones LHPP11 lf continuation sheet 98 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation
‘STATEMENT OF DEFICIENCIES (<1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF GORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(83) DATE SURVEY
COMPLETED

c
02/18/2021

MHLO11-204 8. WING

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD

ASHEVILLE, NC 28806

CUMMINGS COTTAGE

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

DEFICIENCY)

\ Continued From page 98

positioning; Staff attempted to initiate another H
standing restraint and again released due to
unsafe positioning. RN documented |
other/physical hold at 9:34 pm for 1 minute for the |
first RI and standing restraint at 9:35 pm for 1
minute for the second RI. i
-5/16/20 Client was placed in" an other/hold that |
was an approach from behind"; RN documented |
other/physical hold at 8:00 pm for 1 minute.
-7/6/20 Staff initiated "a restrictive intervention in |
the yoke position. The student dropped her
weight and staff transitioned into a seated
restraint, which was not TCI compliant due to the
lack of a wall. Staff released the restrictive }
intervention due to the hold not being TCI
compliant.” RN documented Client complained of |
left arm discomfort and received tylenol and ice; |
Area of skin that was held was red from student
fighting Rl; A staff member received scratches to
left arm; RN documented the Ri as a seated
restraint for 2 minutes which does not match staff 1
documentation.

-7/13/20 RN documented other/physical hold for 1
minute at 5:23 pm. !
-7/26/20 RN documented other/physical hold at i
; 10:30 am for 1 minute, at 10:36 am for 1 minute,
and at 10:50 am for iminute.

-The techniques used were either non-TC!
compliant, or it could not be determined if the
techniques used were TC! compliant.

Review on 2/8/21-2/10/21 and 2/15/21 of the
facility PRTF Restrictive Intervention Report for
FC #6 revealed: .
| -9/21/20 RN documented other/physical hoid at
! 10:44 am for 1 minute, and at 10:45 am for 1
minute.
i

i

-10/4/20 Staff placed client in “other/physical hold"
at 4:15 pm and 4:18 pm. RN documented

| other/physical hold at 4:15 pm for 1 minute and at
Division of Health Service Reguiation

STATE FORM be99 LHPP14 Hicontinuation sheet 99 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (%1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

(X83) DATE SURVEY
COMPLETED

Cc
02/18/2021

MHLLO11-204 B. WING

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD

Cl INGS GC
unin OTTAGE ASHEVILLE, NC 28806

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

DEFICIENCY)

V 500! Continued From page 99

4:18 pm for 2 minutes.
-10/13/20 RN documented other/physical hold at
7:57 pm for 3 minutes.
-11/1/20 Staff noted the restraint "was |
non-compliant due to staff transitioning [FC #6} i
away from the com maze while in a standing

restraint.

; -The techniques used were non-TC! compliant. Boe

| Review on 2/8/21-2/10/21 and 2/15/21 of the ( Suppects \DO - yO)
facility PRTF Restrictive Intervention Report for

| FC #7 revealed:

~9/21/20 RN documented other/physical hold at
7:40 pm for 1 minute.

-10/30/20 he attempted to exit the cottage
through his window and staff used a "breaking up
@ altercation method to pull [FC #7] back to his
room.” This Ri was not documented by the RN.
FC #7 was involved in 5 additional RI's on this
date which were documented as compliant.
-The techniques used were either non-TC|

_ compliant, or it could not be determined if the
techniques used were TC] compliant.

Review on 2/8/21-2/10/21 and 2/15/21 of the
facility PRTF Restrictive Intervention Reports
from January 2020-December 2020 revealed:
-There were 52 non-TCl compliant “other/physical |
holds" utilized on 12 non-audited clients (NAC
#10, NAC #11, NAC #16, NAC #17, NAC #18,
NAC #19, NAC #20, NAC #21, NAC #22, NAC
#23, NAC #24, and NAC #25) as listed below:
1/28/20 at 7:50 pm other/physical hold x 1 minute
on non-audited client (NAC) #11.

2/7/20 at 10:16 am other/physical hold x 1 minute
on NAC #10.

2/9/20 at 5:38 pm other/physical hold x 1 minute
on NAC #10.

2/9/20 at 5:42 pm other/physical hold x 1 minute
on NAC #16.
Division of Health Service Regulation
STATE FORM e009 LHPP11 continuation sheet 100 of 124

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER.
MHL011-204

NAME OF PROVIDER OR SUPPLIER

CUMMINGS COTTAGE

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

V 500) Continued From page 100

2/28/20 at 4:51 pm other/physical hold x 1 minute

| on NAC #16.

| 3/3/20 at 2:43 pm other/physical hold x 3 minutes

on NAC #16.

3/4/20 at 7:47 pm other/physical hold x 1 minute

on NAC #16.

3/17/20 at 7:14 pm other/physical hold x zero

i minutes on NAC #16.

3/17/20 at 10:15 pm other/physical hald x 1

| minute on NAC #16.

1 4130/20 at 1:53 pm other/physical hold x zero

minutes on NAG #17.

5/4/20 at 12:08 pm other/physical hold x 1 minute

| on NAC #19.

5/7/20 at 5:45 pm other/physical hold x 1 minute

} on NAC #20.

5/16/20 at undocumented time other/physical

hold x (no end time) on NAC #20.

| 6/24/20 at 9:10 pm other/physical hold x 1 minute

on NAC #20.

6/24/20 at 9:18 pm other/physical hold x 1 minute

i on NAC #18.

| 6/24/20 at 9:20 pm other/physical hold x 5

| minutes on NAC #18.

6/25/20 at 8:15 pm other/physical hold x 1 minute

| on NAC #20.

| 7/2/20 at 12:52 pm other/physical hold x 1 minute

| on NAC #20.

| 7142/20 at 8:40 pm other/physical hold x 1 minute

i on NAC #18,

7/12/20 at 7:57 pm other/physical hold x 1 minute

_ on NAC #20.

7/12/20 at 8:39 pm other/physical hold x 1 minute

| on NAC #20.

| 7/14/20 at 8:28 pm other/physical hold x 1 minute

on NAG #20.

7/14/20 at 8:33 pm other/physical hold x 1 minute

| on NAC #22.

| 7/14/20 at 8:43 pm other/physical hold x 1 minute
| on NAG #22.

Division of Health Service Regulation

STATE FORM

STREET ADDRESS, CITY, STATE, ZIP CODE

882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

> ooo

PRINTED: 03/09/2021
FORM APPROVED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(3) DATE SURVEY
COMPLETED

c

B. WING ___________. 02/18/2021

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

DEFICIENCY)

Vv 500

gave LHPP11 continuation sheet 101 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation

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

(K2) MULTIPLE CONSTRUCTION
A.BUILDING:

(x3) DATE SURVEY
COMPLETED

Cc
02/18/2024

MHL011-204 Bim)

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

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

CUMMINGS COTTAGE

| Continued From page 101

7/4/20 at 8:46 pm other/physical hold x 1 minute
on NAC #22. | t
7/14/20 at 8:52 pm other/physical hold x 1 minute I!
on NAC #22. |
7114/20 at 8:54 pm other/physical hold x 1 minute
on NAC #22. j
7/14/20 at 8:56 pm other/physical hold x 8 |
minutes on NAC #22. i ) WE Sus Dott >= i
7/14/20 at 10:01 pm other/physical hold x 1 | p \ eS

minute on NAC #24, \ 1OZ) LOA, Og
7/19/20 at 10:56 am other/physical hold x 4
minute on NAG #23. |
7/19/20 at 10:58 am other/physical hold x 3 |
minutes on NAC #23. '
7/19/20 at 11:21 am othet/physical hold x 1 \
minute on NAC #23. ! |
7/19/20 at 11:51 am other/physical hold x 4 i
minute on NAC #23. i
7/19/20 at 11:53 am other/physical hold x 1 j
minute on NAC #23. i |
7/28/20 at 9:34 pm other/physical hold x zero
minutes on NAC #20.

8/11/20 at 5:28 pm other/physical hold x 1 minute
on NAC #21. !
8/18/20 at 6:18 pm other/physical hold x 2 | i
minutes on NAC #20. | 1
8/18/20 at 8:53 pm other/physical hold x 1 minute }
on NAC #20, |
8/19/20 at 11:54 am other/physical hold x 1
minute on NAC #22

8/23/20 at 7:54 pm other/physical hold x 1 minute
on NAC #22.

} 8/23/20 at 7:56 pm other/physicai hold x 1 minute |
on NAC #22.

8/23/20 at 8:15 pm other/physical hold x 2

; minutes on NAC #22.

9/8/20 at 5:48 pm other/physical hold x 4 minutes
on NAC #20.

9/8/20 at 5:53 pm other/physical hold x 1 minute

| on NAG #20. |
Division of Health Service Regulation
STATE FORM ase LHPP 411 If continuation sheet 102 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation
STATEMENT OF CEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

Cc
02/18/2024

B. WING.

MHLO11-204

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

882 ELIADA HOME ROAD

MING: TTAGE
— e comms ASHEVILLE, NC 28806

4)ID ‘SUMMARY STATEMENT OF DEFICIENCIES ID ; PROVIDER'S PLAN OF CORRECTION (EACH i 6)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVE ACTION SHOULD BE CROSS- COMPLETE

REGULATORY OR LSC IDENTIFYING INFORMATION) TAG ' REFERENCED TO THE APPROPRIATE. DATE
{ DEFICIENCY)

v 500 Continued From page 102

| 9/12/20 at 8:55 pm other/physical hold x 1 minute i
| on NAC #25. |
| 9/13/20 at 6:13 pm other/physical hold x 1 minute |
| on NAC #25.
| 9/43/20 at 6:28 pm other/physical hold x 1 minute
| on NAC #25. i
; 9/21/20 at 10:48 am other/physical hold x 1 |
| minute on NAG #25. ;
: 9/21/20 at 3:28 pm other/physical hold x zero
‘ minutes on NAC #25.
| 9/24/26 at 4:16 pm other/physical hold x 1 minute
on NAC #25.
9/21/20 at 7:17 pm other/physical hold x 1 minute
on NAC #25. |
9/21/20 at 7:40 pm other/physicat hold x 1 minute
on NAC #25.

Interview on 2/4/21 with the FCI Program
Manager and Instructor revealed: i i
-Any time someone put hands on an individual !
which limits their abifity to move, it is considered i
tobe a RI. | |
-The only RI techniques approved by the TCI
program were standing restraint, seated restraint,
small child restraint, prone floor restraint and
supine floor restraint.
-If any RI techniques were banned by any state,
TCI would not teach that technique in the that
H state. i
-The yoke position was the first step of a restraint |
which involves securing the arm of the child. It !
was not designed to be a stand-alone hold. /
i
i

-There was no TCI approved technique for

transport, or escort.

-TCl trainers were very clear that clients are to be
; restrained in place. |
: -If a facility was using other/physical holds, this i '
would make me question if they were TCi
compliant. i
: -If using a non-compliant hald, it should be | i
Division of Health Service Regulation
STATE FORM sem LHPP44 H continuation sheet 103 of 124

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X14) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

MHLO11-204

NAME OF PROVIDER OR SUPPLIER

CUMMINGS COTTAGE

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

Continued From page 103

explained in detail and documented as to where
they placed their hands and why they did not
follow the approved technique, such as a life
threatening emergency intervention like someone
was going to jump off a bridge and they grabbed

. them.

Interview with the Interim Residential Director on
1/14/21 revealed:
-Alll staff were trained in TCI.

Interview with the Residential Clinician/Licensed
Professional on 1/19/21 revealed:

-There was a high staff turnover rate at Eliada.
-Some of the staff were not much older than the
Clients. 7

| -Staff were inexperienced.

i
| This deficiency is cross referenced into 10A

| NCAC 27G.1901 Scope (V314) for a Type A1 rule
| violation for serious harm and neglect and must

| be corrected with 23 days.

V 501] 27D .0101(f) Client Rights - Policy on Rights
| 10A NCAC 27D .0101 POLICY ON RIGHTS
| RESTRICTIONS AND INTERVENTIONS
| (f) If restrictive interventions are allowed for use
! within the facility, the governing body shall
develop and implement policies which require
that:
(1) positive altematives and less restrictive
interventions are considered and are used
whenever possible prior to the use of more
i restrictive interventions; and

(2) consideration is given to the client's
physical and psychological well-being before,
during and after utilization of a restrictive
intervention, including:

Division of Health Service Regulation
STATE FORM

B. WING.

STREET ADDRESS, CITY, STATE, ZIP CODE

882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

iD
PREFIX
TAG

Doc
Vs

Vv 501

(2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 03/09/2021
FORM APPROVED

(3) DATE SURVEY
COMPLETED

¢c
02/18/2021

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

1010A NCAC 27D .0101

(x8)
COMPLETE
DATE

The Facility Trainer retrained and recertified
residential staff in TC! including physical holds.
The Cottage Supervisors were retrained on the
reporting guidelines of any restrictive
intervention which is released due to being
deemed a risk to the child’s health or safety.
‘Any restrictive intervention released prior to
{the client’s ability to gain behavioral control will]
pe reported to the Cottage Supervisor on site
jand a Performance and Quality Improvement
ffeam member. Performance and Quality
|mprovement member or the Facitity Trainer |
will review the video footage within 48 hours of|
the report. Performance and Quality
Improvement will document their finding and
review with Performance and Quality
improvement team and senior leadership

[Therapeutic Crisis Intervention refresher
Trainings will continue to occur in each team
Irecting for one hour every month. These |
refresher courses will include various actives for
proactive, less restrictive interventions twice a
quarter and a practice of restrictive
interventions once a quarter. In total, refresher
‘courses will result in three hours of additional |
competency training on the use of less
restrictive interventions and restrictive
interventions. Each Cottage Supervisor will
document the occurrence of the TCi refresher
in their team meetings.

LHPP1 ¥ continuation sheet 104 of 124

PRINTED: 02/09/2021
FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(%2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

Cc
02/18/2021

MHL011-204 B. WING

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

(X4) 1D SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (EACH (xs)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVE ACTION SHOULD BE CROSS- COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED 70 THE APPROPRIATE DATE

DEFICIENCY)

CUMMINGS COTTAGE

hese courses will be monitored within the HR
department and training department to ensure all
Staff are up to date on all required training.

Continued From page 104

(A) review of the client's health history or
the comprehensive health assessment conducted
upon admission to a facility. The health history or
comprehensive health assessment shall include
the identification of pre-existing medical
conditions or any disabilities and limitations that
would place the client at greater risk during the
use of restrictive interventions;

(B) continuous assessment and monitoring
of the physical and psychological well-being of
the client and the safe use of physical restraint
throughout the duration of the restrictive
intervention by staff who are physically present
and trained in the use of emergency safety
interventions;

(C) continuous monitoring by an individual
trained in the use of cardiopulmonary
Fesuscitation of the client's physical and
psychological well-being during the use of manual
restraint; and

(D) continued monitoring by an
individual trained in the use of cardiopulmonary
resuscitation of the client's physical and
psychological well-being for a minimum of 30
minutes subsequent to the termination of a
restrictive intervention; and

(3) following the utilization of a restrictive
intervention, staff shall conduct debriefing and

| planning with the client and the legally
responsible person, if applicable, as specified in
10A NCAC 27E .0104, to eliminate or reduce the
probability of the future use of restrictive |
interventions. Debriefing and planning shall be
conducted, as appropriate, to the level of
cognitive functioning of the client.

Division of Health Service Regulation
STATE FORM 6308 LHPP414 [continuation shest 105 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation
‘STATEMENT OF DEFICIENCIES 0X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

c
02/48/2021

MHLO11-204 B. WING

NAME OF PROVIDER OR SUPPLIER:

STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

‘SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (EACH 5)

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

DEFICIENCY)

CUMMINGS COTTAGE

Continued From page 105 (Attached is the facility report outlining
1 ork with BBI and Six Core as part of a

This Rule is not met as evidenced by: Based on tate pilot program to work towards

record reviews and interviews the facility failed to Iternatives to restrictive interventions and
implement policies which require

a Registered Nurse (RN) to be physically present [the progress of the agency. |

to monitor restrictive interventions (Rl's), orders
to be signed by a licensed practitioner, and client
debriefings to be conducted. The findings are:

! Refer to Tag V112 for additional client .
information. por
Review on 1/5/21 of Eliada Homes, Inc. | “7

Restrictive Intervention Policy dated 10/31/94 and
revised 1/21/02 revealed: i
- "3. Authorization/Ordering of Restrictive
Intervention

c) ...All written orders must be signed by the
licensed practitioner ..."
- "4. Monitoring of Restrictive Intervention |
a) Restraint and Seclusion must be monitored

| by a licensed nurse in PRTF (Psychiatric eB

: Residential Treatment Facility). Adresse a
b) For PRTF students, a Registered Nurse ps Cu, ere vious.
trained in emergency safety interventions must be D+ the

| physically present, continually assessing and P c wees |
monitoring the physical and psychological Poy SY i

well-being of the client and the safe use of
restraint throughout the duration of the
emergency safety intervention.

c) ARN (for PRTF) ...must conduct a health | |
status check prior to, continuously throughout, | '
and for a minimum of 30 minutes after completion !
of the restrictive intervention.”

-"7. Documentation/Notification and Review

b) A life space interview (LSI) must be
attempted or conducted with the client after a
restrictive intervention.

e) Restrictive Intervention incident reports
must be reviewed by the Supervisor/QP
Division of Health Service Regulation
STATE FORM $809 LHPP11 ff continuation sheet 106 of 124

PREFIX
TAG

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

PMHLO11-204

B. WING

STREET ADDRESS, CITY, STATE, ZIP CODE

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 03/09/2021
FORM APPROVED

882 ELIADA HOME ROAD

CUMMINGS COTTAGE

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

,; Continued From page 106

| (Qualified Professional) within 72 hours after use
: of restrictive intervention. The QP/Supervisar is

| responsible for assuring appropriate follow

! through and debriefing with the client, staff and

| the client's legal guardian."

i
| Review on 2/15/21 of Eliada Homes, inc.
Restrictive Intervention Policy/Procedure
AttachmentA dated 5/2016 revealed:

- The RN monitoring the restrictive intervention
would direct staff fo stop the intervention if any
risk to client safety was identified.

-The RN on site would conduct the follow up
assessment of the client within one hour from the
initiation of the restrictive intervention.

-It was the responsibility of the program
supervisor on site to provide Post Crisis

; Response in Therapeutic Crisis intervention's

! (TCI) which include "LSI for the young person."
i

Review on 2/8/21-2/10/21 and 2/15/21 of the

' facility PRTF Restrictive Intervention Report for
| Glient#1 revealed:

i 10/15/20:

; -RI #1 at 8:42 pm standing restraint x 1

| Minute.

! -RI #2 at 8:43 pm seated restraint x 19

| minutes.

i -RN was not present for RI #1, or for the

|

|

initiation of Ri#2.
-Debriefing with client was incomplete.
-Orders were acknowledged by the provider
on 12/14/20, but not signed.
14/7/20:
-RI #1 at 7:49 pm standing restraint x 0

| -RN was not present for the RI.

| -Debriefing with client was incomplete.

| -Orders were acknowledged by the provider
] on 12/14/20, but not signed.

Division of Health Service Regulation
STATE FORM

ASHEVILLE, NC 28806

PREFIX
TAG

Doc
[AZ

tec
As

Doc
ARS

I
|

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

Suppers Paves
jo-71- 12%

par<* lor \o4

;paa<s WoO -\We

i
pases iN 2-WY

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! pases WAR ANS

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LHPP411

(X3) DATE SURVEY
COMPLETED

02/18/2021

c

COMPLETE

"continuation sheet 107 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (41) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

c
02/18/2021

MHLO11-204 B. WING

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (EACH 65)
(EACH DEFICIENCY MUST BE PRECEDED BY FULL. PREFIX CORRECTIVE ACTION SHOULD BE GROSS- COMPLETE
REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

CUMMINGS COTTAGE

PREFIX

Continued From page 107

11/8/20:

-RI#1 at 7:26 pm standing restraint x 5
minutes.

-R! #2 at 7:31 pm standing restraint x 44
minutes.

-Unable to determine if RN was present due !
to lack of documentation.

-Debriefing with client was incomplete. i

-Orders were not signed until 1/22/21,
-11/11/20:

-RI #1 at 5:47 pm standing restraint x 21
minutes.

-RN documentation of a standing restraint
does not match the RI description documented by
staff.

-Unabie to determine if RN was present for
the Ri due to documentation inconsistent with t
staff report and lack of assessment monitoring
) details.

-Orders were not signed untit 1/22/21.
11/19/20:

-RI #1 at 9:56 pm standing restraint x 10
minutes.

-Unable to determine if RN was present for
the RI due to lack of documentation, j

-Debriefing with client was incomplete. |

-Orders were not signed until 1/22/21.
11/21/20: |

-RI#1 at 5:04 pm other/physical hold x 30
minutes.

-RN was not present for initiation of RI.

-Debriefing with client was incomplete.

-Orders were not signed until 1/22/21.
-11/27/20:

-RI #1 at 4:52 pm standing restraint x 4
minutes.

-RI #2 at 4:57 pm seated restraint x B |
minutes.

-RN was not present for initiation of RI #1.

-There was no documentation of debriefing
Division of Health Service Regulation
STATE FORM S809 LHPP11 {f continuation sheet 108 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regutation
STATEMENT OF DEFICIENCIES (X41) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X3) DATE SURVEY
COMPLETED

Cc
02/18/2021

(X2) MULTIPLE CONSTRUCTION.
A, BUILDING:

MHLO11-204 5. WING

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (EACH 5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVE ACTION SHOULD BE CROSS- COMPLETE
REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE. DATE

DEFICIENCY)

CUMMINGS COTTAGE

Continued From page 108

with the client.
: -Orders were nat acknowledged or signed by |

the provider.

-12/25/20:

-Ri#1 at 3:24 pm seated restraint x 15
minutes.

-RN was not present for initiation of the RI.

-Debriefing with the client was incomplete.

-Orders were not signed until 1/22/21.
-2/6/21:

-RI #1 at 5:24 pm seated restraint x 10
minutes.

-Unable to determine if RN was present due
' to lack of documentation.

-Ofders were not acknowledged or signed by
the provider.

-2/11/21:

-RI #1 at (no start time documented)
unknown hold (no end time documented)

-RI #2 at 9:00 am seated restraint x 18
minutes.

-Unable to determine if RN was present for
initiation of either RI due to discrepancies
between RN documentation and staff
documentation in the report,

-Orders were not acknowledged or signed by
the provider.

| Review on 2/8/21-2/10/21 and 2/15/21 of the
facility PRTF Restrictive Intervention Report for i
Client #2 revealed:
; -11/7/20:

-RI #1 at 8:10 pm other/physical hold x 3
minutes.

. RI #2 at 8:13 pm supine restraint x 9

minutes.

-Debriefing with the client was incomplete. |

-Orders were not signed until 1/22/21.
11/11/20: |

-RI #1 at (no start time documented) standing |

Division of Health Service Regulation

STATE FORM based LHPP14 (feontinuation sheet 109 of 124

PRINTED: 03/09/2021
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:

(3) DATE SURVEY
COMPLETED

c
02/18/2021

MHLO11-204 B. WING

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

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

CUMMINGS COTTAGE

Continued From page 109

restraint (no end time documented).
| -Ri #2 at 5:48 pm seated restraint x 10
minutes.

-Unable to determine if RN was present for
initiation of RI due to staff documentation of 2
restraints and RN documentation of 1 restraint in
the report.

-There was no order for Ri #1.

-Orders for RI #2 were not signed until
1/22/21.

-12/7/20:

-Ri #1 at 11:30 am seated restraint x 9
minutes.

-RN was not present for initiation of RI.

-Debriefing with the client was incomplete.

-Orders were not acknowledged or signed by
the provider.

-12/20/20:

-RI #1 at 8:59 pm supine restraint x 1 minute.

-Debriefing with the client was incomplete.

-Orders were not acknowledged or signed by
the provider. | i
-12/25/20: |

-RI #1 at 7:47 pm supine restraint x 9
minutes.

-Orders were not acknowledged or signed by
the provider.
| 16/21: |

-RI #1 at 10:30 pm supine restraint x 4
minutes.

-Debriefing with the client was incomplete.
17/21:

-Ri #1 at 8:10 pm seated restraint x 1 minute.

-Ri #2 at 8:11 pm supine restraint x 12
minutes. i

-Unable to determine if RN was present for
; Ri#2 due documentation being blank. i |

-Orders were acknowledged by the provider
on 2/8/21, but not signed.

-1/13/21:
Division of Health Service Regulation
STATE FORM ves LHPP1 Ifeontinuation sheet 110 of 124

PRINTED: 03/09/2021
FORM APPROVED

Division of Health Service Regulation

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

Cc
02/18/2021

MHL011-204. 8. WING

NAME OF PROVIDER OR SUPPLIER: STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD

CUMMINGS COTTAGE ASHEVILLE, NC 28806

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

Vv 501

Continued From page 110

-RI #1 at 7:14 pm supine restraint x 12
minutes.

-Orders were not acknowledged or signed by
the provider.
1/14/21: |

-RI #1 at 5:24 pm supine restraint x 4
minutes.

-RN was not present for initiation of RI.

-Orders were not signed until 2/8/21.
-1/16/21:

-RI #1 at 6:20 pm seated restraint x 2
minutes.

-RI #2 at 6:24 pm supine restraint x 7
minutes.

-RN was not present for initiation or release
of RI #1.

-RN was not present for initiation of RI #2.

-Orders were not acknowledged or signed by
the provider.
-U47/21:

-RI #1 at 6:47 pm standing restraint x 1
minute.

-RI #2 at 6:49 pm supine restraint x 1 minute.

-RI #3 at 6:52 pm supine restraint x 1 minute.

-Debriefing with client was incomplete.

-Orders were not signed until 2/8/21.
; -1/18/21:
I -RI #1 at 4:54 pm seated restraint x 1 minute.
| -RI #2 at 9:21 pm standing restraint x 5
minutes.

-Unable to determine if RN was present for RI
i #2 due to lack of documentation.

-There was no documentation of debriefing

with the client.

-Orders were not signed until 2/8/21.
| 1/28/21: '

-RI #1 at 2:47 pm supine restraint x 20
minutes.

-Ri #2 at 7:37 pm supine restraint x 21
minutes.
Division of Health Service Regulation
STATE FORM Lad LHPP1+ If continuation sheet 111 of 124

(X4)1D
PREFIX
TAG

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

CUMMINGS COTTAGE

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHLO011-204

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

Continued From page 114

-RI¥8 at 7:34 pm other/physical hatd x 1
{ minute.

- R's were not documented in time sequential
| order.
! -Unable to determine if RN was present for RI
| # 2 or RI#3 due to lack of documentation.

-Debriefing with client was incomplete.

-Orders were not signed until 2/8/21.
-1/29/21:
i -RI #1 at 6:22 pm other/physical hold x 1
minute.

-RI #2 at 6:23 pm standing restraint x 2
minutes.

-RI #3 at 6:26 pm standing restraint x 2
minutes.

-Ri #4 at 6:28 pm supine restraint x 7
minutes.

-RI #5 at 6:37 pm other/physical hold x 3
minutes.

-Unable to determine if RN was present for RI
#2, RI#3, RI #4 or RI#5 due to blank
documentation.

-Orders were not signed until 2/8/21.
-1431/21:

-RI#1 at 6:51 pm supine restraint x 46
minutes.

-RI #2 at 9:06 pm supine restraint x 26
minutes.

-Debriefing with client was incomplete.

-Orders were not acknowledged or signed by
the provider.
-2/4/21:

-RI#1 at 2:54 pm supine restraint x 10
minutes.

-Orders were not acknowledged or signed by
the provider,
2/12/24:

-RI #1 at 11:27 pm standing restraint x 0
minutes.

-Ri #2 at 11:29 pm supine restraint x 0

Division of Health Service Regulation

STATE FORM

STREET ADDRESS, CITY, STATE, ZIP CODE

882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

PRINTED: 03/09/2021
FORM APPROVED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

Cc
02/48/2021

B. WING

ID PROVIDER'S PLAN OF CORRECTION (EACH 5)
PREFIX CORRECTIVE ACTION SHOULD BE CROSS- COMPLETE

TAG REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

200 LHPP44 Woontinuation sheet 112 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X3) DATE SURVEY
COMPLETED

c
02/18/2021

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

MHLO11-204 B. WING

NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES: 1D PROVIDER'S PLAN OF CORRECTION (EACH 5)
PREFIX (EACH DEFICIENCY MUST 8E PRECEDED BY FULL PREFIX CORRECTIVE ACTION SHOULD BE CROSS- COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

CUMMINGS COTTAGE

Continued From page 112

minutes.
-Staff did not notify the RN of RI’s until 12:04

am. |
-RN was not present for RI #1 or RI #2.
-Orders were not acknowledged or signed by

the provider.

| Review on 2/8/21-2/10/21 and 2/15/21 of the
facility PRTF Restrictive Intervention Report for
Client #3 revealed:

~1/10/21:

-RI #1 at 1:10 pm standing restraint x 3
minutes.

-RI #2 at 3:28 pm standing restraint x 1
minute.

-RN was not present for Ri #1 or RI #2.

-Debriefing with client was incomplete.

-Orders were not signed until 2/8/21.
1/11/21:

-RI #1 at 2:47 pm supine restraint x 10
minutes.

-There was no debriefing since client was
involuntarily committed (IVC'd).

-Orders were not acknowledged or signed by
the provider. !
j 1/15/21:

-RI #1 at 7:36 pm seated restraint x 12
minutes.

-Orders were not acknowledged or signed by
the provider.

-1/18/21:

-RI#1 at 9:26 pm standing restraint x 9
minutes. i

-RI #2 at 10:17 pm seated restraint x 6
minutes.

-Orders were not signed until 2/8/21.
1124/21:

-RI #1 at 9:05 pm seated restraint x 15
minutes.

-RI #2 at 10:59 pm seated restraint x 10
Division of Health Service Regulation
STATE FORM 5009 LHPP1t Wf continuation sheet 113 of 124

PRINTED: 03/09/2021
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:

(X%3) DATE SURVEY
COMPLETED

Cc
02/18/2021

MHLO011-204 8. WING

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ASHEVILLE, NC 28606

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

CUMMINGS COTTAGE

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

PREFIX

Continued From page 113

minutes.

-Orders were not signed until 2/8/21.
1/29/21:

-RI #1 at 11:53 pm standing restraint x 1
minute.

-R! #2 at 12:56 pm standing restraint x 1
minute.

-Unable to determine if RN was present for
Ri#2 or Ri#2 due to lack of assessment
documentation.

-Orders were not acknowledged or signed by

i the provider.

| Review on 2/8/21-2/10/21 and 2/15/21 of the

facility PRTF Restrictive intervention Report for

_ FC #5 revealed:

~3/19/20:

-RI #1 at 7:05 pm standing restraint x 4
minute.

-Client fell backwards during the RI and hit
her head on a brick wall.

-RN was not present for the RI.

-Debriefing with the client was incomplete.

-Orders were acknowledged by the provider
on 3/20/20, but not signed.
-3/22/20:

-RI #1 at 12:59 pm other/physical hold x 1
minute.

-Staff and the client fell to the ground during
the RI.

-Debriefing with the client was incomplete.
-3/24/20;

-Ri #1 at 4:17 pm standing restraint x 5
minutes.

-RI #2 at 9:00 pm supine restraint x 2
minutes.

-Client was released from RI #2 due to an
“active crisis" in the courtyard.

-RN was not present for RI #2.
-3/26/20:

Division of Health Service Regulation

STATE FORM

e990

LHPP11

DEFICIENCY)

!fcontinuation sheet 114 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (41) PROVIDER/SUPPLIERICLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(8) DATE SURVEY
COMPLETED

Cc
02/18/2021

MHL011-204 B. WING

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

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

CUMMINGS COTTAGE

PREFIX

Continued From page 114

-RI #1 at (no start time) unknown hold (no
end time).

-RI #2 at 10:13 am supine restraint x 3
minutes.

-RI #3 at (no start time) seclusion (no end
| time).

-RN was not present for the R's.

-Orders were not signed until 4/7/20.
~4/21/20:

-RI #1 at 8:20 pm standing restraint x 1
minute.

-RN was not present for the RI and staff did
not notify the RN of the RI until 10:01 pm.

-There was no documentation of debriefing
with the client.

-Orders were not signed until 7/14/20.
4/22/20:

-RI #1 at 8:37 pm supine restraint x 4
minutes.

-RN was only present for the release of the

[RE
| -Orders were not signed until 5/26/20.
i ~4/25120;
| -RI #1 at 7:57 pm supine restraint x 8
| minutes. |
| ~RI #2 at 8:30 pm other/physical hold x 0
| minutes. ;
! -Client reported an injury to her right hand.
-Orders were not signed until 5/26/20. i
| 4/27/20:
1 -Ri #1 at 9:06 pm supine restraint x 9 |
| Minutes.
-RN was not present for the RI. ! '
| -Orders were not signed until 7/14/20.
| -4/28/20:
-RI #1 at 8:31 pm standing restraint x 4
minute.
-RI #2 at 8:32 pm seclusion x (no end time
| documented)

-RN was not present for RI #1 or RI #2.
Division of Health Service Regulation
STATE FORM eon LHPP1t ¥ continuation shest 115 of 124

PRINTED: 03/09/2021

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (43) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED:

Cc
MHL011-204 B.WING 02/18/2021

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

(04) ID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (EACH 8)

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

DEFICIENCY)

CUMMINGS COTTAGE

V 501 / Continued From page 115 v 501

-Orders were not signed until 7/14/20.
-4/30/20:

-RI #1 at 7:37 pm other/physical hold x 4
minute.

-RN was not present for the RI.

-Orders were not signed until 7/14/20. H
5/11/20:

-RI #1 at 8:40 pm standing restraint x 1
minute.

-RN was not present for the RI.

-Debriefing with the client was incomplete.

-Orders were not signed until 7/14/20.
-5/12/20:

~RI#1 at 9:34 pm other/physical hold x 4 |
minute. ©

-RI #2 at 9:35 pm standing restraint x 1
minute.

-RN was not present for Ri#1 or RI #2.

-Orders were not signed until 7/14/20.
--5/16/20:

-RI #1 at 8:00 pm other/physical hold x 1
minute.

-RN was not present for the RI.

-RN was monitoring an RN for another client
at this time.

~Debriefing with the client was incomplete. t

-Orders were not signed until 7/14/20.
: -7/6/20:

~R| #1 at 8:56 pm seated restraint x 2 t
minutes. |

-Unable to determine if RN was. present for
the initiation of the RI due to lack of
| documentation.

-There was no documentation of debriefing
with the client.

-Orders were not signed until 8/6/20. |
-7/12/20: i

-RI #1 at 5:52 pm standing restraint x 1
minute.

| -RN was not present for the RI due to it being

Division of Health Service Regulation
STATE FORM ead LHPP11 W continuation sheet 116 of 124

PRINTED: 03/09/2021
FORM APPROVED

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (Xt) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

(3) DATE SURVEY
COMPLETED

c
02/18/2021

MHL011-204 8. WING

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

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

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

CUMMINGS COTTAGE

Continued From page 116

near a comfield and only 1 minute in duration.

-Orders were not signed until 10/20/20.
-7/13/20;

-RI #1 at 5:23 pm other/physical hold x 1
minute. H

-R| #2 at 8:29 pm supine restraint x 14
minutes.

-RN was not present for RI #1 or for the
initiation of RI#2.

-Orders were not signed until 12/14/20.
-7/14/20:

-RI #1 at either 10:06 pm or 10:08 pm
{unable to determine time due to staff
documentation was not consistent with
documentation form the RN); supine resiraint x
11 or 13 minutes depending on the RI start time.

-Client reported her upper arm was pinched
by staff's fingernails during the RI.

-RN was not present for the RI due to
assessing 2 concurrent RI's on campus.

-Orders were acknowledged by the provider
on 10/20/20 but were not signed.

-7/26/20:

-RI#1 at 10:30 am other/physical hold x 1
minute.

-RI #2 at 10:36 am other/physical hold x 1
minute.

-RI #3 at 10:50 am other/physical hold x 1
minute.

-RN was not present for RI #1.

-Unable to determine if RI was present for
Ri#2 or RI #3 due to lack of documentation.

-Orders were not signed until 10/20/20.
-7/26/20:

-RI #1 at 8:27 pm supine restraint x 8
minutes.

-Debriefing with the client was incomplete.

-Orders were acknowledged by the provider
on 12/14/20 but were not signed.

Division of Health Service Regulation
STATE FORM 8e88 LHPP11 Mf continuation sheet 117 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

c
02/18/2021

MHLO11-204 B. WING ___

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

CUMMINGS COTTAGE

(x4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES 10 PROVIDER'S PLAN OF CORRECTION (EACH (5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL. PREFIX CORRECTIVE ACTION SHOULD BE CROSS- COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

Continued From page 117

Review on 2/8/21-2/10/21 and 2/15/21 of the
facility PRTF Restrictive Intervention Report for
FC #6 revealed:

~9/21/20:

-RI#1 at 10:44 am other/physical hold x 1
minute.

-RI #2 at 10:45 am other/physical hold x 1
minute.

-RN was not present for RI#1 or RI #2.

-Debriefing with the client was incomplete.

-Orders were not signed until 12/14/20.
-9/21/20:

-Ri #1 at 7:17 pm small child restraint x 1
minute.

-Debriefing with the client was incomplete.
-Orders were not signed unti! 12/14/20.
-9/23/20; |

-RI #1 at 8:03 pm standing restraint x 2
' minutes.

-RI #2 at 8:05 pm seated restraint x 4
minutes.

-Unable to determine if RN was present for RI |
#1 or RI#2 due to incomplete assessment {
documentation on the monitoring form.

-Orders were acknowledged by the provider
on 12/14/20 but were not signed.

9/27/21:

-RI #1 at 5:21 pm standing restraint x 2
minutes.

-RI #2 at 5:30 pm standing restraint x 4
minute. i

-RI #3 at 11:38 am standing restraint x 1
minute.

-RI's were not documented in time sequential | |
order.

-RN was not present for RI #1 and follow up
assessment was not completed due to the time
relation to the next RI. | i

-RN was not present for RI #2. |

-Unable to determine if RN was present for RI | i
Division of Health Service Regulation
STATE FORM co LHPP11 Hfcontinuation sheet 118 of 124

PRINTED; 03/09/2021
FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES 0X1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A, BUILDING:

(3) DATE SURVEY
COMPLETED

c
02/18/2021

MHLO11-204 B. WING

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (EACH 5)
(EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVEACTION SHOULD BE CROSS- (COMPLETE
REGULATORY OR LSC IDENTIFYING INFORMATION} TAG REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

CUMBINGS COTTAGE

TAG

1
v501 | Continued From page 118 v 501

| #3 due to assessment documentation being left
| completely blank.
} -There was a co-occurring RI at a sister
! facility on campus from 5:06 pm to 5:50 pm.
| 9/28/20:
i -RI #1 at 9:29 pm standing restraint x 1
; minute, |

-RI #2 11:58 pm small child restraint x 1 or 2
| minutes. (There was conflicting documentation of | |
i the end time of the restraint). |
' -RN was not present for RI #1.
| -RN was not present for the initiation of RI #2
| and It could not be determined if the RN was
| present for the ending of RI #2 due to restraint
| being documented as 11:58 pm - 11:59 pm in one
| portion of the report and as 11:58 pm - 12:00 am
| in another portion of the report.
| -Debriefing with the client was incomplete.

-Orders were not signed until 12/14/20.
-9/29/20:

-RI #1 at 8:18 pm seated restraint x 15
minutes.

-Orders were not signed untlt 12/14/20,
-10/2/20:

-RI #1 at 7:03 pm standing restraint x 0
minutes. |

-RI #2 at 7:03 pm seated restraint x 7
; minutes.

-RI #3 at 7:10 pm seated restraint x 2
minutes.

-RI #4 at 7:13 pm supine restraint x 8
minutes.

-RI #5 at 7:32 pm supine restraint x 4 |
minutes.

-Client complained of pain to her finger after
the Ri's.
{ -Debriefing with the client was incomplete.
i -Orders were not signed until 12/14/20.
-10/3/20:

-RI #1 at 4:39 pm standing restraint x 4
Division of Health Service Regulation
STATE FORM S888 LHPP41 tf continuation sheat 119 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (Xf) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

{X2) MULTIPLE CONSTRUCTION.
A, BUILDING:

(X3) DATE SURVEY
COMPLETED

c
02/48/2021

MHLO11-204 B. WING

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

CUMMINGS COTTAGE

(X4)(D SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (EACH (x6)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVEACTION SHOULD BE CROSS- COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

i Continued From page 119

minutes.

-RI #2 at 5:56 pm standing restraint x 4
minutes.

-RI #3 at 6:00 pm standing restraint x 5
minutes.

-Unable to determine if RN was present for
the initiation of RI #2 due to lack of assessment
documentation.

-Orders were not signed until 12/14/20.
-10/4/20:

-RI #1 at 4:15 pm other/physical hold x 1
minute.

-RI #2 at 4:18 pm other/physicat hold x 2
minutes.

-RN was not present for RI#1 or RI #2.
| -There were co-occurring Ri's at a sister
| facility on campus at 4:15 pm and 4:18 pm.
| -Debriefing with client was incomplete.
-Orders were not signed until 12/14/20,
| -10/6/20:

-RI #1 at 3:50 pm other/physical hold x 4
minute.

-RI #2 at 5:35 pm standing restraint x 2
minutes.

-RI #3 at 5:37 pm supine restraint x 13
| minutes.
| -RN was not present for the initiation of RI #1.
i -Unable to determine if RN was present for RI
#3 due to monitoring assessment being left blank.

-During RI follow up assessment, RN noted
| Client had a bruise to her right thigh and a photo
| was taken for record.

-There was no documentation of debriefing
with client.

~Orders were not signed until 12/14/20.
10/13/20:

-RI #1 at 7:45 pm seated restraint x 9
| minutes. i
-RI #2 at 7:57 pm other/physical hold x 3 |
| minutes. i
Bivision of Health Service Regulation

STATE FORM bead LHPP11 H continuation sheet 120 of 124

PRINTED: 03/09/2021
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

c
02/18/2021

MHL011-204 B. WING

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELt(ADA HOME ROAD
ASHEVILLE, NC 28806

(41D SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (EACH 4x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVEACTION SHOULD BE CROSS- COMPLETE
REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

CUMMINGS. COTTAGE

Continued From page 120

-Ri #3 at 8:07 pm supine restraint x10
minutes.

-Unable to determine if RN was present for
| initiation, duration, or ending of Ri's due to lack of \
documentation.

-All initial, ending and follow up assessment
checks were identical with no documented details
of abnormalities.

-RN placed a check mark in a box which
indicated “injury to client" but did not provide
details of the injury.

-Debriefing with client was incomplete.

-Orders were acknowledge by the provider on
12/14/20 but were not signed.

-10/18/20:

-RI#1 at 9:32 pm standing restraint x 2
minutes.

-RI #2 at 9:37 pm supine restraint x 6
minutes.

-RN was not present for RI #4 or for the
initiation of RI #2.

-Debriefing with client was incomplete.

-Orders were not signed until 12/14/20. i
-10/21/20:

-RI#1 at 8:35 pm small child restraint x 7
minutes.

-Debriefing with client was incomplete.

-Orders were acknowledged by the provider
on 12/14/20 but were not signed.

-10/29/20:

| -RI #1 at 5:30 pm standing restraint x 3

| minutes.

i -RI #2 at 5:33 pm supine restraint x 7

| minutes.

i -RN was not present for RI #1 or for the

| Initiation of RI#2.

i -Client complained of shortness of breath
| during the RI and requested an inhaler. |

-Orders were not signed until 12/14/20. i
-10/30/20:

Division of Health Service Regulation
STATE FORM 3009 LHPP11 continuation sheet 121 of 124

PRINTED: 03/09/2021

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (%1) PROVIDER/SUPPLIER/CLIA. {X2) MULTIPLE CONSTRUCTION (%3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING: COMPLETED

c
MHLO11-204 B.WING 02/18/2021

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

882 ELIADA HOME ROAD
ASHEVILLE, NC 268806

HID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (EACH

CUMMINGS COTTAGE

5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVE ACTION SHOULD BE CROSS- COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
¥ 501 | Continued From page 121 Vv 501
-RI #1 at 9:04 pm seated restraint x 3
; minutes,
-RI #2 at 9:07 pm supine restraint x 4 |
minutes.

-Unable to determine if RN was present for RI
#1 or RI #2 due to lack of detaifed documentation.

-There was a co-occurring RI from 9:03 pm to
9:21 pm with FC #7.

Debriefing with client was incomplete.

-Orders were acknowledged by the provider
on 12/14/20 but were not signed.
-11/1/20:

-RI #1 at 10:37 am standing restraint x 4
| minutes. i

-Ri #2 at 11:23 am seated restraint x 7
minutes.

-RN was not present for RI #1.

-Debriefing was not completed due to client
being IVC'd. ;

-Orders were not signed until 12/14/20.

Review on 2/8/21-2/10/21 and 2/15/21 of the
facility PRTF Restrictive Intervention Report for
FC #7 revealed:
-9/13/20: H i
~RI #1 at 6:17 pm supine restraint x 14
minutes. i
-RI # 2 at 7:30 pm supine restraint x (no end
time was documented).
-Staff informed the guardian that {FC #7] had
been placed in 3 restraints.
-Only 2 restraints were documented.
-RN was not present for the initiation of RI #1
and was not present for RI #2.
-Unable to determine if a 3rd R! occurred due |
to the lack of documentation.
-Debriefing with the client was incomplete.
-Orders were not signed until 10/20/20. i
-9/21/20: |
-R! #1 at 2:28 pm seated restraint x 5
Division of Health Service Regulation
STATE FORM som LHPP11 Mcontinuation sheet 122 of 124

PRINTED: 03/09/2021
FORM APPROVED
Division of Health Service Regulation

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

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

Cc
02/18/2021

MHLO011-204 B. WING

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
882 ELIADA HOME ROAD
ASHEVILLE, NC 28806

CUMMINGS COTTAGE

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION (EACH 5)
PREFIX {EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVE ACTION SHOULD BE CROSS- COMPLETE
TAS REGULATORY OR LSC IDENTIFYING INFORMATION) TAG REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
a ee |
¥ 501 | Continued From page 122 Vv 501
minutes.
-RI #2 at 7:40 pm other/physical hold x 4
minute.

-RN was not present for Ri #2.

-Debriefing was not completed due to client
being IVC'd.

-Orders were not signed until 10/20/20.
-10/30/20:

-RI#H at 5:27 pm supine restraint x 7
minutes.

-RI #2 at 5:37 pm supine restraint x 5
minutes.

-RI#3 at 7:44 pm supine restraint x 6
minutes.
| -RI #4 at 8:34 pm supine restraint x 28
Minutes.

~RI #5 at 9:03 pm supine restraint x 18
minutes.

-RN was not present for the initiation of RI #1. |

-Unable to determine if RN was present for RI
#2, RI, RI #4, or RI #5 due to lack of
documentation (limited details).

-All assessment checks were identical for the
57 minute duration of Ri's #2 through RI #5.

-There was a co-occurring RI at a sister
facility on campus from 5:30 pm to 5:32 pm.

-There was a co-occurting RI from 9:04 pm to
9:07 pm with FC #6.

-Debriefing with client was not competed due
to client being IVC'd.

-Orders were not signed until 12/14/20.

Interview on 1/14/21 with the Nurse Manager

} revealed:

-The RN's role during an RI was to obtain orders
and to monitor the client's medical status,

i positioning, circulation and breathing.

Interview on 1/11/21, 1/19/21 and 1/27/21 with the
Chief Operations Officer (COO) revealed:
Division of Health Service Regulation

STATE FORM 8800 LHPP11 fcontinustion sheat 123 of 124

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (4) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
MHLO011-204

NAME OF PROVIDER OR SUPPLIER

CUMMINGS COTTAGE

(X4) ID ‘SUMMARY STATEMENT OF DEFICIENCIES
PREFIX (EACH DEFICIENCY MUST 8E PRECEDED BY FULL
TAG REGULATORY OR LSC IDENTIFYING INFORMATION)

¥ 501) Continued From page 123

-The RN was supposed to be present for the RI
to monitor the client's blood pressure, breathing,
consciousness and vigilantly watch that the
client's airway was not obstructed.

-She was unaware of any circumstances in which
the RN would not be able to monitor an RI.

-"| have never known a nurse not to be present.”
-RN's were responsibie for debriefing with the
clients after an RI.

-She believed the time frame for a licensed
practitioner to sign orders was 72 hours.

-She stated, "Eliada has always done 72 hours.
It's not state rule. It's just what we do."

-There was a difference between an electronic
“acknowledgement” and an electronic “signature.”
-The system was set up to where the licensed
provider had to acknowledge the orders and then
“hit sign." It caused a problem.

-The facility changed the process last month.
“We are on top of those now."

This deficiency is cross referenced into 10A

NCAC 27G.1901 Scope (V314) for a Type A1 rule

| violation for serious harm and neglect and must
be corrected with 23 days.

1

1

Division of Health Service Regulation
STATE FORM

STREET ADDRESS, CITY, STATE, ZIP CODE

8862 ELIADA HOME ROAD
ASHEVILLE, NC 28806

PRINTED: 03/09/2021
FORM APPROVED

(2) MULTIPLE CONSTRUCTION
A. BUILDING:

3) DATE SURVEY
COMPLETED

Cc

edali 02/18/2024

1D PROVIDER'S PLAN OF CORRECTION (EACH
PREFIX CORRECTIVE ACTION SHOULD BE CROSS-
TAG REFERENCED TO THE APPROPRIATE
DEFICIENCY)
Vv 501

ff continuation sheet 124 of 124

boned LHPP11