summary: Plan of Correction - MHLCS Complaint

raw_content:
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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: __
Cc
MHL060968 B. WING 04/30/2025

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

ALEXANDER YOUTH NETWORK-CHARLOTT —-220-D THERMAL RD
CHARLOTTE, NC 28211

xa) | SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY ORLSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
| DEFICIENCY)
u ee
—__|_
V 000 INITIAL COMMENTS Vv 000

A complaint survey was completed on April 30, R ECEIVED
2025. The complaints were substantiated (intake —

| #NC00228706 and #NC00228713). Deficiencies )
| were cited.

Pe DHSR-MH Licensure Sect
This facility is licensed for the following service
category: 10A NCAC 27G .1400 Day Treatment
for Children and adolescents with Emotional or
Behavioral Disturbances.

| This facility has a current census of 30 . The
| survey sample consisted of audits of 1 current

client.
V 132, G.S. 131£-256(G) HCPR-Notification v132 HR Director and Vice President for 5/23/2025
Allegations, & Protection , _ Performance Improvement reviewed and |
, updated procedure for internal reviews of

G.S. §131E-256 HEALTH CARE PERSONNEL allegations against staff. When there is an

| REGISTRY allegation of abuse, neglect or exploitation
(g) Health care facilities shall ensure that the against staff, HR and the Program Director
Department is notified of all allegations against will suspend the accused staff member from
health care personnel, including injuries of working with any clients in any program
unknown source, which appear to be related to pending the outcome of the agency’s
any act listed in subdivision (a)(1) of this section. investigation.
(which includes:

| a. Neglect or abuse of a resident in a healthcare Upon becoming aware of an allegation of

| facility or a person to whom home care services abuse against a staff member, the Program
as defined by G.S. 131E-136 or hospice services Director, HR Director and Vice President for

as defined by G.S. 131E-201 are being provided. |
b. Misappropriation of the property of a resident
in a health care facility, as defined in subsection
(b) of this section including places where home
care services as defined by G.S. 131E-136 or
hospice services as defined by G.S. 131E-201
are being provided.

Performance Improvement immediately will _
| meet to initiate the internal review. At this |
time, HR Director and Vice President for
Performance Improvement will ensure the
accused staff member is suspended and not

working in any program pending the

| c. Misappropriation of the property ofa outcome of the investigation.
healthcare facility.
d. Diversion of drugs belonging to a health care | The Vice President for Performance
facility or to a patient or client. Improvement will monitor this process

monthly for any allegations against staff to
| ensure it is followed as described.

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L I
Division of Health Service Regulation
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATUR! pr TTL Copeons —

STATE FORM E02 KUZI1 If continuati

5Y5/2085

sheet 1 of 11

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

(X3) DATE SURVEY
COMPLETED

Cc

MHL060968 B.WING. 04/30/2025

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

ALEXANDER YOUTH NETWORK - CHARLOTT £220-D THERMAL RD
CHARLOTTE, NC 28211

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES. ID | PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVEACTION SHOULD BE COMPLETE
TAG REGULATORY ORLSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE. DATE
DEFICIENCY)
K__ ———
V 132) Continued From page 1 V 132

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

| Facilities must have evidence that all alleged
acts are investigated and must make every effort
to protect residents from harm while the
investigation is in progress. The results of all
investigations must be reported to the
Department within five working days of the initial
notification to the Department.

This Rule is not met as evidenced by:

Based on record reviews and interviews, the
facility failed to protect clients during an
investigation of abuse, neglect or exploitation.
The findings are:

Review on 4/21/25 of the Qualified Professional's
(QP) personnel record revealed:
-Date of hire 2/28/22
-Job Title QP. |

Record Review on 4/21/25 at 12:00pm of the |
Facility's Video Footage dated 3/14/25 revealed:
-Client #1 was in the classroom standing in a
chair yelling, "Dummy! Dummy! Dummy!"

-The QP said, "Don't start with me today, I'm the
wrong one."

-Staff #2 walked over to Client #1 and asked him
to sit in the chair but he continued standing in the
chair.

-There was an unintelligible exchange of words |
between Client #1 and the QP. |
-The QP got up from her seat, walked over to
Client #1, grabbed both of his shoulders and
pushed him to the floor then walked back over to
her seat.

-Client #1 fell over to the right out of his chair on
to the floor.

-Client #1 got up off the floor, sat in his chair and |
Division of Health Service Regulation

STATE FORM 6899 KUZI11 If continuation sheet 2 of 11

NAME OF PROVIDER OR SUPPLIER
ALEXANDER YOUTH NETWORK - CHARLOTT

PRINTED: 05/14/2025
FORM APPROVED

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA

AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
MHL060968

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

B. WING

(X3) DATE SURVEY
COMPLETED

Cc
04/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

6220-D THERMAL RD
CHARLOTTE, NC 28211

(X4) 1D
PREFIX
TAG

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

V 132)

Continued From page 2

made an unintelligible comment to the QP then |
Client #1 said, "Do something about it." in which
| the QP replied, "I just did."

Review on 4/16/25 of the North Carolina Incident
Response Improvement System (IRIS) revealed:
| -On 3/19/25 while reviewing video footage in
reference to another incident, the Program
Supervisor saw the QP walk over to Client #1 and
pushed him out of his chair on 3/14/25.

-Client #1 fell to the floor.

-The QP walked back over to her seat and Client
#1 got up and sat in his chair.

Review on 4/21/25 of the facility's document titled

"Internal Review Findings of Fact Summary-

| 3.31.24: Incident 3.19.25" revealed:

-"Allegation: While reviewing video for another

Internal Investigation, program manager saw staff

(QP) pull client (Client #1) off a desk and ‘throw

the to the floor.'"

-"The video shows the staff member (QP)

| approaching the youth (Client #1) after an

exchange of words and then the youth is on the

floor. The video is dark.”

| -"The youth (Client #1) is repeatedly saying

‘dummy.' The staff member (QP) can be heard

| Saying 'Don't start with me today, I'm the wrong
one.' After the physical exchanged the youth
challenged the staff verbally to which she stated,
‘| just did something about it.'"
-"The cause of the incident is seen as staff
member (QP) exacting revenge on the youth
(Client #1) for challenging her. Staff was
reactionary."
-"Recommendations: It is recommended that the |
staff member (QP) be on a 60-day Performance
Improvement Plan during which time she
completed TCI (therapeutic crisis intervention)

| refresher training with a concentration on Handle

ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH CORRECTIVEACTION SHOULD BE | COMPLETE
TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

———
V 132

—_—

Division of Health Service Regulation

STATE FORM

ese KUZI11

If continuation sheet 3 of 11

PRINTED: 05/14/2025
FORM APPROVED

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES. (X1) PROVIDER/SUPPLIERI/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
Cc
MHL060968 B.WING 04/30/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

6220-D THERMAL RD

CHARLOTTE, NC 28211

ALEXANDER YOUTH NETWORK - CHARLOTT

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

DEFICIENCY) |

‘ rs
V 132) Continued From page 3 V1320—O| |

with Care concepts that assist with being
proactive and utilizing verbal de-escalation
techniques as well as positive engagement
strategies."

Interview on 4/21/25 with the Program Supervisor
revealed:

-On 3/19/25 he was reviewing video footage in |
reference to another incident when he came upon
footage of the QP pushing Client #1 out of his |
chair on 3/14/25.

-Completed the NC IRIS report and reported the
incident to Human Resources (HR) on 3/20/25.
-HR did the internal investigation (3/27/25-

| 3/31/25).

-Did not question the QP.

| -Did not know the outcome of the internal
investigation.

-Client #1 did not sustain any injuries.

| Attempted interview on 4/25/25 with Client #1
revealed:

-His legal guardian would not consent to an
interview because Client #1 "does not speak
good english and he has trouble following

| conversations."

Interview on 4/28/25 with Staff #2 revealed:
-Did not remember a lot of the details of the
incident between the QP and Client #1 on |
3/14/25. |
-Remembered Client #1 was disrupting the other |
clients and "talking back, calling staff names like
black B**ch."
-"Whatever you saw on the video is what

| happened. | think she (QP) just lost her cool for a |
minute. That kid (Client #1) would push and push
and push.”

| -Did not hear the QP and Client #1 arguing with

| each other.

Division of Health Service Regulation

STATE FORM 6899 KUZI11 If continuation sheet 4 of 11

PRINTED: 05/14/2025

FORM APPROVED.
Division of Health Service Regulation

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

Cc
MHL060968 B. WING ____________ 04/30/2025

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

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

(X4) ID | SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)

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

DEFICIENCY)

[ | —___|
V 132| Continued From page 4 V 132

Interview on 4/28/25 the QP revealed:
-On 3/14/25 Client #1 kept using the saying "clock
that tea" and in a jokingly way she said "I will."
-"| walked over to his desk and tickled him and he
wiggled out of his chair. | was playing with him, |
wasn't trying to harm him."
-"I'm not that kind of person to harm children."
-"It was a playful interaction.”
-Denied telling Client #1 "Don't start with me
| today, I'm the wrong one."
-Denied Client #1 was standing in his chair yelling
"Dummy."
-Did not pull Client #1 out of his chair on to the
| floor.
-Could not recall which days she worked between |
3/27/25 and 3/31/25.

Interview on 4/22/25 with the HR Director
revealed: |
-The QP was suspended from the day program
pending investigation on 3/27/25.

-The QP worked with another program while
under investigation.

-The internal investigation took place from | |
3/27/25 to 3/31/25. |
-Did not know the QP was not supposed to work
with any clients while under investigation.

-"| thought the suspension was just for the day

| program."

| Interview on 4/29/25 with the Vice President of

| Performance Improvement revealed:
-Did not have a lot of details about the incident
between the QP and Client #1.

| -Verified the QP was allowed to work in another
Program while under investigation for abusing | |
Client #1. |
-The internal investigation was 3/27/25 through

| 3/31/25.

Division of Health Service Regulation

STATE FORM 6899 KUZI11 If continuation sheet 5 of 11

Division of Health Service Regulation

PRINTED: 05/14/2025
FORM APPROVED

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

B. WING
MHL060968

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

Cc
04/30/2025

——
NAME OF PROVIDER OR SUPPLIER

ALEXANDER YOUTH NETWORK - CHARLOTT

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

CHARLOTTE, NC 28211

PROVIDER'S PLAN OF CORRECTION (x6)
(EACH CORRECTIVE ACTION SHOULD BE COMPLETE
CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

-The QP was terminated on 4/29/25.
|

V 512 27D .0304 Client Rights - Harm, Abuse, Neglect V 512

10A NCAC 27D .0304 =PROTECTION FROM
HARM, ABUSE, NEGLECT OREXPLOITATION
(a) Employees shall protect clients from harm,
abuse, neglect and exploitation in accordance
with G.S. 122C-66.

(b) Employees shall not subject a client to any |
sort of abuse or neglect, as defined in 10ANCAC |
27C .0102 of this Chapter.

| (c) Goods or services shall not be sold toor

| purchased from a client except through
established governing body policy.

(d) Employees shall use only that degree of force
necessary to repel or secure a violent and
aggressive client and which is permitted by

| governing body policy. The degree of force that
is necessary depends upon the individual
characteristics of the client (such as age, size
and physical and mental health) and the degree
of aggressiveness displayed by the client. Use of
intervention procedures shall be compliance with
| Subchapter 10A NCAC 27E of this Chapter.

(e) Any violation byan employee of Paragraphs

| (a) through (d) of this Rule shall be grounds for
dismissal of the employee.

This Rule is not met as evidenced by:
| Based on record reviews and interviews, 1 of 1
| Qualified Professional (QP) abused 1 of 14 client
(#1). The findings are:

Review on 4/16/25 of Client #1's record revealed:
| - 9 years old

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID
PREFIX | (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX
TAG REGULATORY ORLSC IDENTIFYING INFORMATION) TAG
V 132) Continued From page 5 V 132

The Day Treatment Program Manager will 5/23/2025
continue to have staffing meetings with each
staff member. In this meeting the program
manager will reiterate the importance of
appropriate therapeutic interventions. The
program staff will conduct frequent check-ins|
with each client, especially with children that
have a tendency or history of constantly
antagonizing others for long periods of time.
When staff become frustrated staff will tag
out, reach out to the supervisor, and step
away to take a break outside away from the
escalated client.

The program manager will use the model of
care (MOC) observation forms monthly to
monitor each staff member regardless of the |
staff's credentials of QP, AP or |
paraprofessional, to prevent the problem
from occurring again. The Program Manager
will use the MOC Observation Forms to
ensure the staff are engaging in therapeutic |
interventions, effectively regulating their
own emotions and following effective
classroom guidelines and expectations. The
Program Manager will give feedback to each
staff member after the observation.

The Program Manager will routinely monitor
each classroom throughout the days to
provide oversight and support as needed.

The Regional Director will review compliance
and quality of the MOC forms monthly to
ensure monitoring is completed.

Division of Health Service Regulation
STATE FORM 6899

KUZI11

If continuation sheet 6 of 11

PRINTED: 05/14/2025
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 ee

(X3) DATE SURVEY
COMPLETED

Cc
04/30/2025

MHL060968 B. WING

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

ALEXANDER YOUTH NETWORK-CHARLOTT —-220-D THERMAL RD
CHARLOTTE, NC 28211

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ] ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY ORLSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
T
V 512) Continued From page 6 V 512

-Diagnoses of Oppositional Defiant Disorder and
Posttraumatic Stress Disorder

Review on 4/21/25 of the QP's personnel record
| revealed:

-Date of hire 2/28/22

-Job Title QP.

-Abuse training on 9/18/24.

Review on 4/21/25 at 12:00pm of the Facility's
Video Footage dated 3/14/25 revealed:

-Client #1 was in the classroom standing ina
chair yelling, "Dummy! Dummy! Dummy!"

-The QP said, "Don't start with me today, I'm the
wrong one." |
-Staff #2 walked over to Client #1 and asked him
to sit in the chair but he continued standing in the
| chair.

-There was an unintelligible exchange of words
between Client #1 and the QP.

-The QP got up from her seat, walked over to

| Client #1, grabbed both of his shoulders and
pulled him to the floor then walked back overto
her seat.

-Client #1 fell over to the right of the chair on to
the floor. |
-Client #1 got up off the floor, sat in his chair then
made an unintelligible comment to the QP and
challenged the QP to "Do something about it" in |
which the QP replied, "I just did."

Review on 4/16/25 of the North Carolina Incident |
Response Improvement System (IRIS) revealed: |
-On 3/19/25 while reviewing video footage in
reference to another incident, the Program
Supervisor saw the QP walk over to Client #1 and
| pushed him out of his chair on 3/14/25.

-Client #1 fell to the floor.

-The QP walked back over to her seat and Client |
#1 got up and sat in his chair.
Division of Health Service Regulation

STATE FORM se Kuzi11 If continuation sheet 7 of 11

PRINTED: 05/14/2025
FORM APPROVED

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHLO60968 B..WING 04/30/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

6220-D THERMAL RD
CHARLOTTE, NC 28211

ALEXANDER YOUTH NETWORK - CHARLOTT

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION | (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY ORLSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
i DEFICIENCY) |
i i
Vv 512| Continued From page 7 V 512

Review on 4/21/25 of the facility's document titled
“Internal Review Findings of Fact Summary-

| 3.31.24: Incident 3.19.25 revealed:

-"Allegation: While reviewing video for another
Internal Investigation, program manager
(Program Supervisor) saw staff (QP) pull client
(Client #1) off a desk and throw the to the floor.
-The video shows the staff member (QP)
approaching the youth (Client #1) after an
exchange of words and then the youth is on the
floor. The video is dark.

-The youth (Client #1) is repeatedly saying
dummy. The staff member (QP) can be heard
saying ‘Don't start with me today, I'm the wrong
one.’ After the physical exchanged the youth
challenged the staff verbally to which she stated,
‘| just did something about it.'

-The cause of the incident is seen as staff
member (QP) exacting revenge on the youth
(Client #1) for challenging her. Staff was
reactionary.

-Recommendations: It is recommended that the
staff member (QP) be on a 60-day Performance
Improvement Plan during which time she
completed TCI (therapeutic crisis intervention)

| refresher training with a concentration on Handle
with Care concepts that assist with being
proactive and utilizing verbal de-escalation
techniques as well as positive engagement
strategies."

Interview on 4/21/25 with the Program Supervisor
revealed: |
-On 3/19/25 he was reviewing video footage in |

reference to another incident when he came upon
footage of the QP pushing Client #1 out of his
chair on 3/14/25.

-Completed the NC IRIS report and reported the

| incident to Human Resources (HR) on 3/20/25.
Division of Health Service Regulation

STATE FORM 6899 KUZI11 if continuation sheet 8 of 11

$$ $$ __

PRINTED: 05/14/2025
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
04/30/2025

MHLO60968 BaWING

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

ALEXANDER YOUTH NETWORK-CHARLOTT —-©220-D THERMAL RD
CHARLOTTE, NC 28211

SUMMARY STATEMENT OF DEFICIENCIES. ID PROVIDER'S PLAN OF CORRECTION

(x4) ID (5)

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

V 512) Continued From page 8 V51I20 | |

-HR did the internal investigation (3/27/25-
3/31/25).

-Did not question the QP.

-Did not know the outcome of the internal |
investigation. |

-Client #1 did not sustain any injuries.

Attempted interview on 4/25/25 with Client #1 |
revealed:

-His legal guardian would not consent to an
interview because Client #1 "does not speak
good english and he has trouble following

| conversations."

Interview on 4/28/25 with Staff #2 revealed:
| -Did not remember a lot of the details of the |
incident between the QP and Client #1 on |
3/14/25. |

-Remembered Client #1 was disrupting the other
clients and "talking back, calling staff names like
black B***h."

-"Whatever you saw on the video is what |
happened. | think she (QP) just lost her cool for a
minute. That kid (Client #1) would push and push
and push."

| -Did not hear the QP and Client #1 arguing with
each other.

-Did not know if Client #1 sustained any injuries. |

Interview on 4/28/25 the QP revealed:

-On 3/14/25, Client #1 kept using the saying
"clock that tea" and in a jokingly way she said "!
will." | |
-"| walked over to his desk and tickled him and he
wiggled out of his chair. | was playing with him, |
wasn't trying to harm him."

-"I'm not that kind of person to harm children.”
-"It was a playful interaction." |
-Denied telling Client #1 "Don't start with me
| today, I'm the wrong one.

Division of Health Service Regulation

STATE FORM 6899 KUZI11 If continuation sheet 9 of 11

PRINTED: 05/14/2025
FORM APPROVED

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
Cc
MHL060968 B. WING 04/30/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

6220-D THERMAL RD
CHARLOTTE, NC 28211

ALEXANDER YOUTH NETWORK - CHARLOTT

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES | ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL | PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG | REGULATORY ORLSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 512) Continued From page 9 vVs12 | |
-Denied Client #1 was standing in his chair yelling
"Dummy."
-Did not pull Client #1 out of his chair on to the
| floor.

Interview on 4/22/25 with the HR Director
revealed:

-The QP was suspended from the day program
pending investigation on 3/27/25.

-The QP worked with another program while
under investigation.

-The internal investigation took place from
3/27/25 to 3/31/25.

-The QP was put on a 60 day performance plan.
| -The QP had to retake TCI training, "Handle with
Care" on 3/31/25. |

Interview on 4/29/25 with the Vice President of
Performance Improvement revealed:

-Did not have a lot of details about the incident
between the QP and Client #1.

-Verified the QP was allowed to work in another | |
Program while under investigation for abusing |

Client #1.

-The internal investigation was 3/27/25 through
| 3/31/25.

-The QP was terminated on 4/30/25.

Review on 4/30/25 of the Plan of Protection dated
4/30/25 signed by the Vice President of |
Performance Improvement revealed:
-"What immediate action will the facility take to |
ensure the safety of the consumers in your care?

[QP] was terminated from employment with
[Licensee] on 4/29/2025 and has not worked with |
any children since 4/4/2025.

Describe your plans to make sure the above
| happens.

Division of Health Service Regulation
STATE FORM 6899 KUZI11 If continuation sheet 10 of 11

PRINTED: 05/14/2025

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED
Cc
MHLO60968 BeWING) 04/30/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
ALEXANDER YOUTH NETWORK-CHARLOTT —-9#20-D THERMAL RD
CHARLOTTE, NC 28211
(x4) 1D | SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION | os)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY ORLSCIDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY) |
ee ee
v 512| Continued From page 10 V5120
| Human Resources has removed [QP] access to
| all systems and locations effective 4/29/2025."
| Client #1 was 9 years old with diagnoses of
Oppositional Defiant Disorder and PostTraumatic
Stress Disorder. On 3/19//25, Client #1 was seen
on a video from 3/14/25 standing in his chair and
yelling the word dummy. The QP told Client #1, |
don't start with me today, I'm the wrong one. The
_ QP walked over to Client #1, grabbed both of his
shoulders, pulled him to the floor. Client #1 |
ended up on the floor beside the chair. This
| Deficiency constitutes a Type A1 rule violation for
serious abuse and must be corrected with in 23
days.
|
|
ee —

Division of Health Service Regulation
STATE FORM 6699 KUZI11 If continuation sheet 11 of 11


state: NC

facility_name: Alexander Youth Network - Charlotte Day Treatment

summary: Statement of Deficiency - MHLCS Complaint

raw_content:
PRINTED: 05/14/2025
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA. (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
c
MHL060968 B. WING _____ 04/30/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE CHARLOTTE, NC 28211

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)
V 000} INITIAL COMMENTS V 000

Acomplaint survey was completed on April 30,
2025. The complaints were substantiated (intake
#NC00228706 and #NC002287 13). Deficiencies
were cited.

This facility is licensed for the following service

category: 10A NCAC 27G .1400 Day Treatment
for Children and adolescents with Emotional or

Behavioral Disturbances.

This facility has a current census of 30 . The
survey sample consisted of audits of 1 current
client.

V 132) G.S. 131E-256(G) HCPR-Notification, V 132
Allegations, & Protection

G.S. §131E-256 HEALTH CARE PERSONNEL
REGISTRY

(g) Health care facilities shall ensure that the
Department is notified of all allegations against
health care personnel, including injuries of
unknown source, which appear to be related to
any act listed in subdivision (a)(1) of this section.
(which includes:

a. Neglect or abuse of a resident in a healthcare
facility or a person to whom home care services
as defined by G.S. 131E-136 or hospice services
as defined by G.S. 131E-201 are being provided.
b. Misappropriation of the property of a resident
in a health care facility, as defined in subsection
(b) of this section including places where home
care services as defined by G.S. 131E-136 or
hospice services as defined by G.S. 131E-201
are being provided.

c. Misappropriation of the property of a
healthcare facility.

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

Division of Health Service Regulation
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

STATE FORM 6899 KUZI11 If continuation sheet 1 of 11

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL060968 B. WING

NAME OF PROVIDER OR SUPPLIER

6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE CHARLOTTE, NC 28211

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/14/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
04/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

(X4) ID
PREFIX
TAG

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

CROSS-REFERENCED TO THE APPROPRIATE

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

(x5)
COMPLETE
DATE

DEFICIENCY)

V 132] Continued From page 1 V 132

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

Facilities must have evidence that all alleged
acts are investigated and must make every effort
to protect residents from harm while the
investigation is in progress. The results of all
investigations must be reported to the
Department within five working days of the initial
notification to the Department.

This Rule is not met as evidenced by:

Based on record reviews and interviews, the
facility failed to protect clients during an
investigation of abuse, neglect or exploitation.
The findings are:

Review on 4/21/25 of the Qualified Professional's
(QP) personnel record revealed:

-Date of hire 2/28/22

-Job Title QP.

Record Review on 4/21/25 at 12:00pm of the
Facility's Video Footage dated 3/14/25 revealed:
-Client #1 was in the classroom standing in a
chair yelling, "Dummy! Dummy! Dummy!"

-The QP said, "Don't start with me today, I'm the
wrong one."
-Staff #2 walked over to Client #1 and asked him
to sit in the chair but he continued standing in the
chair.
-There was an unintelligible exchange of words
between Client #1 and the QP.

-The QP got up from her seat, walked over to
Client #1, grabbed both of his shoulders and
pushed him to the floor then walked back over to
her seat.

-Client #1 fell over to the right out of his chair on
to the floor.

-Client #1 got up off the floor, sat in his chair and
Division of Health Service Regulation

STATE FORM

6899 KUZI11

If continuation sheet 2 of 11

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL060968 B. WING

NAME OF PROVIDER OR SUPPLIER
6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE CHARLOTTE, NC 28211

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/14/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
04/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

made an unintelligible comment to the QP then
Client #1 said, "Do something about it." in which
the QP replied, "I just did.”

Review on 4/16/25 of the North Carolina Incident
Response Improvement System (IRIS) revealed:
-On 3/19/25 while reviewing video footage in
reference to another incident, the Program
Supervisor saw the QP walk over to Client #1 and
pushed him out of his chair on 3/14/25.

-Client #1 fell to the floor.

-The QP walked back over to her seat and Client
#1 got up and sat in his chair.

Review on 4/21/25 of the facility's document titled
"Internal Review Findings of Fact Summary-
3.31.24: Incident 3.19.25" revealed:
-"Allegation: While reviewing video for another
Internal Investigation, program manager saw staff
(QP) pull client (Client #1) off a desk and ‘throw
the to the floor.'"

-"The video shows the staff member (QP)
approaching the youth (Client #1) after an
exchange of words and then the youth is on the
floor. The video is dark."

-"The youth (Client #1) is repeatedly saying
‘dummy.’ The staff member (QP) can be heard
saying 'Don't start with me today, I'm the wrong
one.' After the physical exchanged the youth
challenged the staff verbally to which she stated,
‘| just did something about it.’ "

-"The cause of the incident is seen as staff
member (QP) exacting revenge on the youth
(Client #1) for challenging her. Staff was
reactionary.”

-"Recommendations: It is recommended that the
staff member (QP) be on a 60-day Performance
Improvement Plan during which time she
completed TCI (therapeutic crisis intervention)
refresher training with a concentration on Handle
Division of Health Service Regulation

STATE FORM

6899 KUZI11

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

DEFICIENCY)
V 132] Continued From page 2 V 132

If continuation sheet 3 of 11

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL060968 B. WING

NAME OF PROVIDER OR SUPPLIER
6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE CHARLOTTE, NC 28211

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/14/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
04/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

with Care concepts that assist with being
proactive and utilizing verbal de-escalation
techniques as well as positive engagement
strategies."

Interview on 4/21/25 with the Program Supervisor
revealed:

-On 3/19/25 he was reviewing video footage in
reference to another incident when he came upon
footage of the QP pushing Client #1 out of his
chair on 3/14/25.

-Completed the NC IRIS report and reported the
incident to Human Resources (HR) on 3/20/25.
-HR did the internal investigation (3/27/25-
3/31/25).

-Did not question the QP.

-Did not know the outcome of the internal
investigation.

-Client #1 did not sustain any injuries.

Attempted interview on 4/25/25 with Client #1
revealed:

-His legal guardian would not consent to an
interview because Client #1 "does not speak
good english and he has trouble following
conversations."

Interview on 4/28/25 with Staff #2 revealed:

-Did not remember a lot of the details of the
incident between the QP and Client #1 on
3/14/25.

-Remembered Client #1 was disrupting the other
clients and "talking back, calling staff names like
black B**ch."

-"Whatever you saw on the video is what
happened. | think she (QP) just lost her cool for a
minute. That kid (Client #1) would push and push
and push."

-Did not hear the QP and Client #1 arguing with
each other.

Division of Health Service Regulation

STATE FORM

6899 KUZI11

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

DEFICIENCY)
V 132] Continued From page 3 V 132

If continuation sheet 4 of 11

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

MHL060968

PRINTED: 05/14/2025

FORM APPROVED
(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
A. BUILDING: COMPLETED
c
B.WING 04/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

6220-D THERMAL RD
CHARLOTTE, NC 28211

ALEXANDER YOUTH NETWORK - CHARLOTTE

Interview on 4/28/25 the QP revealed:

-On 3/14/25 Client #1 kept using the saying "clock
that tea" and in a jokingly way she said "I will."

-"| walked over to his desk and tickled him and he
wiggled out of his chair. | was playing with him, |
wasn't trying to harm him."

-"I'm not that kind of person to harm children."

-"It was a playful interaction."

-Denied telling Client #1 "Don't start with me
today, I'm the wrong one."

-Denied Client #1 was standing in his chair yelling
"Dummy."

-Did not pull Client #1 out of his chair on to the
floor.

-Could not recall which days she worked between
3/27/25 and 3/31/25.

Interview on 4/22/25 with the HR Director
revealed:

-The QP was suspended from the day program
pending investigation on 3/27/25.

-The QP worked with another program while
under investigation.

-The internal investigation took place from
3/27/25 to 3/31/25.

-Did not know the QP was not supposed to work
with any clients while under investigation.

-"| thought the suspension was just for the day
program."

Interview on 4/29/25 with the Vice President of
Performance Improvement revealed:

-Did not have a lot of details about the incident
between the QP and Client #1.

-Verified the QP was allowed to work in another
Program while under investigation for abusing
Client #1.

-The internal investigation was 3/27/25 through
3/31/25.

Division of Health Service Regulation
STATE FORM

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

DEFICIENCY)
V 132] Continued From page 4 V 132

6899 KUZI11 If continuation sheet 5 of 11

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL060968 B. WING

NAME OF PROVIDER OR SUPPLIER
6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE CHARLOTTE, NC 28211

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/14/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
04/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

10A NCAC 27D .0304 PROTECTION FROM
HARM, ABUSE, NEGLECT OR EXPLOITATION
(a) Employees shall protect clients from harm,
abuse, neglect and exploitation in accordance
with G.S. 122C-66.

(b) Employees shall not subject a client to any
sort of abuse or neglect, as defined in 10A NCAC
27C .0102 of this Chapter.

(c) Goods or services shall not be sold to or
purchased from a client except through
established governing body policy.

(d) Employees shall use only that degree of force
necessary to repel or secure a violent and
aggressive client and which is permitted by
governing body policy. The degree of force that
is necessary depends upon the individual
characteristics of the client (such as age, size
and physical and mental health) and the degree
of aggressiveness displayed by the client. Use of
intervention procedures shall be compliance with
Subchapter 10A NCAC 27E of this Chapter.

(e) Any violation by an employee of Paragraphs
(a) through (d) of this Rule shall be grounds for
dismissal of the employee.

This Rule is not met as evidenced by:

Based on record reviews and interviews, 1 of 1
Qualified Professional (QP) abused 1 of 1 client
(#1). The findings are:

Review on 4/16/25 of Client #1's record revealed:
- 9 years old

Division of Health Service Regulation

STATE FORM 6899

KUZI11

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

DEFICIENCY)
V 132] Continued From page 5 V 132
-The QP was terminated on 4/29/25.
V 512) 27D .0304 Client Rights - Harm, Abuse, Neglect V 512

If continuation sheet 6 of 11

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL060968 B. WING

NAME OF PROVIDER OR SUPPLIER
6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE CHARLOTTE, NC 28211

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/14/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
04/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

-Diagnoses of Oppositional Defiant Disorder and
Posttraumatic Stress Disorder

Review on 4/21/25 of the QP's personnel record
revealed:

-Date of hire 2/28/22

-Job Title QP.

-Abuse training on 9/18/24.

Review on 4/21/25 at 12:00pm of the Facility's
Video Footage dated 3/14/25 revealed:

-Client #1 was in the classroom standing in a
chair yelling, "Dummy! Dummy! Dummy!"

-The QP said, "Don't start with me today, I'm the
wrong one."

-Staff #2 walked over to Client #1 and asked him
to sit in the chair but he continued standing in the
chair.

-There was an unintelligible exchange of words
between Client #1 and the QP.

-The QP got up from her seat, walked over to
Client #1, grabbed both of his shoulders and
pulled him to the floor then walked back over to
her seat.

-Client #1 fell over to the right of the chair on to
the floor.

-Client #1 got up off the floor, sat in his chair then
made an unintelligible comment to the QP and
challenged the QP to "Do something about it" in
which the QP replied, "I just did."

Review on 4/16/25 of the North Carolina Incident
Response Improvement System (IRIS) revealed:
-On 3/19/25 while reviewing video footage in
reference to another incident, the Program
Supervisor saw the QP walk over to Client #1 and
pushed him out of his chair on 3/14/25.

-Client #1 fell to the floor.

-The QP walked back over to her seat and Client
#1 got up and sat in his chair.

Division of Health Service Regulation

STATE FORM

6899 KUZI11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 512} Continued From page 6 V 512

If continuation sheet 7 of 11

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL060968 B. WING

NAME OF PROVIDER OR SUPPLIER
6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE CHARLOTTE, NC 28211

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/14/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
04/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Review on 4/21/25 of the facility's document titled
"Internal Review Findings of Fact Summary-
3.31.24: Incident 3.19.25 revealed:

-"Allegation: While reviewing video for another
Internal Investigation, program manager
(Program Supervisor) saw staff (QP) pull client
(Client #1) off a desk and throw the to the floor.
-The video shows the staff member (QP)
approaching the youth (Client #1) after an
exchange of words and then the youth is on the
floor. The video is dark.

-The youth (Client #1) is repeatedly saying
dummy. The staff member (QP) can be heard
saying 'Don't start with me today, I'm the wrong
one.' After the physical exchanged the youth
challenged the staff verbally to which she stated,
‘| just did something about it."

-The cause of the incident is seen as staff
member (QP) exacting revenge on the youth
(Client #1) for challenging her. Staff was
reactionary.
-Recommendations: It is recommended that the
staff member (QP) be on a 60-day Performance
Improvement Plan during which time she
completed TCI (therapeutic crisis intervention)
refresher training with a concentration on Handle
with Care concepts that assist with being
proactive and utilizing verbal de-escalation
techniques as well as positive engagement
strategies."

Interview on 4/21/25 with the Program Supervisor
revealed:

-On 3/19/25 he was reviewing video footage in
reference to another incident when he came upon
footage of the QP pushing Client #1 out of his
chair on 3/14/25.

-Completed the NC IRIS report and reported the
incident to Human Resources (HR) on 3/20/25.
Division of Health Service Regulation

STATE FORM

6899 KUZI11

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

DEFICIENCY)
V 512} Continued From page 7 V 512

If continuation sheet 8 of 11

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL060968 B. WING

NAME OF PROVIDER OR SUPPLIER
6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE CHARLOTTE, NC 28211

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/14/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
04/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

-HR did the internal investigation (3/27/25-
3/31/25).

-Did not question the QP.

-Did not know the outcome of the internal
investigation.

-Client #1 did not sustain any injuries.

Attempted interview on 4/25/25 with Client #1
revealed:

-His legal guardian would not consent to an
interview because Client #1 "does not speak
good english and he has trouble following
conversations."

Interview on 4/28/25 with Staff #2 revealed:

-Did not remember a lot of the details of the
incident between the QP and Client #1 on
3/14/25.

-Remembered Client #1 was disrupting the other
clients and "talking back, calling staff names like
black B***h."

-"Whatever you saw on the video is what
happened. | think she (QP) just lost her cool for a
minute. That kid (Client #1) would push and push
and push."

-Did not hear the QP and Client #1 arguing with
each other.

-Did not know if Client #1 sustained any injuries.

Interview on 4/28/25 the QP revealed:

-On 3/14/25, Client #1 kept using the saying
"clock that tea" and in a jokingly way she said "I
will."

-"| walked over to his desk and tickled him and he
wiggled out of his chair. | was playing with him, |
wasn't trying to harm him."

-"I'm not that kind of person to harm children."
-"It was a playful interaction."

-Denied telling Client #1 "Don't start with me
today, I'm the wrong one."

Division of Health Service Regulation

STATE FORM

6899 KUZI11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 512} Continued From page 8 V 512

If continuation sheet 9 of 11

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL060968 B. WING

NAME OF PROVIDER OR SUPPLIER
6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE CHARLOTTE, NC 28211

(X2) MULTIPLE CONSTRUCTION

PRINTED: 05/14/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
04/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Interview on 4/22/25 with the HR Director
revealed:
-The QP was suspended from the day program
pending investigation on 3/27/25.

-The QP worked with another program while
under investigation.
-The internal investigation took place from
3/27/25 to 3/31/25.
-The QP was put on a 60 day performance plan.
-The QP had to retake TCI training, "Handle with
Care" on 3/31/25.

Interview on 4/29/25 with the Vice President of
Performance Improvement revealed:

-Did not have a lot of details about the incident
between the QP and Client #1.

-Verified the QP was allowed to work in another
Program while under investigation for abusing
Client #1.

-The internal investigation was 3/27/25 through
3/31/25.

-The QP was terminated on 4/30/25.

Review on 4/30/25 of the Plan of Protection dated
4/30/25 signed by the Vice President of
Performance Improvement revealed:

-"What immediate action will the facility take to
ensure the safety of the consumers in your care?

[QP] was terminated from employment with
[Licensee] on 4/29/2025 and has not worked with
any children since 4/4/2025.

Describe your plans to make sure the above
happens.

Division of Health Service Regulation

STATE FORM

6899 KUZI11

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

DEFICIENCY)
V 512} Continued From page 9 Vv 512
-Denied Client #1 was standing in his chair yelling
"Dummy."
-Did not pull Client #1 out of his chair on to the
floor.

If continuation sheet 10 of 11

Division of Health Service Regulation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

ALEXANDER YOUTH NETWORK - CHARLOTTE

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

MHL060968

(X2) MULTIPLE CONSTRUCTION

A. BUILDING:

B. WING

6220-D THERMAL RD

CHARLOTTE, NC 28211

PRINTED: 05/14/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
04/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

PROVIDER'S PLAN OF CORRECTION

Human Resources has removed [QP] access to
all systems and locations effective 4/29/2025."

Client #1 was 9 years old with diagnoses of
Oppositional Defiant Disorder and Post Traumatic
Stress Disorder. On 3/19//25, Client #1 was seen
on a video from 3/14/25 standing in his chair and
yelling the word dummy. The QP told Client #1,
don't start with me today, I'm the wrong one. The
QP walked over to Client #1, grabbed both of his
shoulders, pulled him to the floor. Client #1
ended up on the floor beside the chair. This
Deficiency constitutes a Type A1 rule violation for
serious abuse and must be corrected with in 23
days.

Division of Health Service Regulation
STATE FORM

6899

KUZI11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 512] Continued From page 10 Vv 512

If continuation sheet 11 of 11

inspection_type: MHLCS Complaint

document_type: Statement of Deficiency


raw_content:
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING:

MHL060968 B. WING

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

ALEXANDER YOUTH NETWORK - CHARLOTTE CHARLOTTE, NC 28211

PRINTED: 09/10/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
04/30/2025

DEFICIENCY)

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

V 000} INITIAL COMMENTS Vv 000

Acomplaint survey was completed on April 30,
2025. The complaints were substantiated (intake
#NC00228706 and #NC002287 13). Deficiencies
were cited.

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

This facility has a current census of 30 . The
survey sample consisted of audits of 1 current
client.

This Statement of Deficiencies was amended on
9/9/25 as a result of the informal meeting on
7/22/25. Rule 10ANCAC 27D .0304 Protection
rom Harm, Abuse, Neglect or exploitation was
amended from a Type A1 to a Type B in Rule 10A
NCAC 27G .0203 Competencies of Qualified
Professionals and Associate Professionals.

V 109} 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.
(b) Qualified professionals and associate
professionals shall demonstrate knowledge, skills
and abilities required by the population served.
(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;

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

(X6) DATE

STATE FORM 6899 KUZI11

If continuation sheet 1 of 11

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL060968 B. WING

NAME OF PROVIDER OR SUPPLIER
6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE CHARLOTTE, NC 28211

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/10/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
04/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

cultural awareness;

analytical skills;

decision-making;

interpersonal skills;

communication skills; and

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
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
supervised by a qualified professional with the
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, 1 of 1
Qualified Professional (QP) failed to demonstrate
he knowledge, skills, and abilities to meet the
needs of clients. The findings are:

Review on 4/16/25 of Client #1's record revealed:
- 9 years old

-Diagnoses of Oppositional Defiant Disorder and
Posttraumatic Stress Disorder

Review on 4/21/25 of the QP's personnel record
revealed:

-Date of hire 2/28/22

Division of Health Service Regulation

STATE FORM

6899 KUZI11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 109} Continued From page 1 Vv 109

If continuation sheet 2 of 11

PRINTED: 09/10/2025
FORM APPROVED
Division of Health Service Regulation

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA. (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: . COMPLETED
A. BUILDING:
c
MHL060968 B. WING _____ 04/30/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE CHARLOTTE, NC 28211

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

DEFICIENCY)
V 109} Continued From page 2 Vv 109
-Job Title QP.

-Abuse training on 9/18/24.

Review on 4/21/25 at 12:00pm of the Facility's
Video Footage dated 3/14/25 revealed:

-Client #1 was seen sitting in his chair.

-The QP got up from her seat, walked over to
Client #1, pulled him to the floor and then walked
back to her seat.

-Client #1 got up off the floor and sat in his chair.

Review on 4/16/25 of the North Carolina Incident
Response Improvement System (IRIS) revealed:
-On 3/19/25 while reviewing video footage in
reference to another incident, the Program
Supervisor saw the QP walk over to Client #1 and
pushed him out of his chair on 3/14/25.

-Client #1 fell to the floor.

-The QP walked back over to her seat and Client
#1 got up and sat in his chair.

Review on 4/21/25 of the facility's document titled
"Internal Review Findings of Fact Summary-
3.31.24: Incident 3.19.25 revealed:
-"Allegation: While reviewing video for another
Internal Investigation, program manager
(Program Supervisor) saw staff (QP) pull client
(Client #1) off a desk and throw the to the floor.
-The video shows the staff member (QP)
approaching the youth (Client #1) after an
exchange of words and then the youth is on the
floor. The video is dark.

The youth (Client #1) is repeatedly saying
dummy. The staff member (QP) can be heard
saying 'Don't start with me today, I'm the wrong
one.' After the physical exchanged the youth
challenged the staff verbally to which she stated,
‘| just did something about it."

-The cause of the incident is seen as staff
member (QP) exacting revenge on the youth
Division of Health Service Regulation

STATE FORM 6899 KUZI11 If continuation sheet 3 of 11

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL060968 B. WING

NAME OF PROVIDER OR SUPPLIER
6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE CHARLOTTE, NC 28211

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/10/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
04/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

(Client #1) for challenging her. Staff was
reactionary.

-Recommendations: It is recommended that the
staff member (QP) be on a 60-day Performance
mprovement Plan during which time she
completed TCI (therapeutic crisis intervention)
refresher training with a concentration on Handle
with Care concepts that assist with being
proactive and utilizing verbal de-escalation
techniques as well as positive engagement
strategies."

nterview on 4/21/25 with the Program Supervisor
revealed:

-On 3/19/25 he was reviewing video footage in
reference to another incident when he came upon
ootage of the QP pushing Client #1 out of his
chair on 3/14/25.

-Completed the NC IRIS report and reported the
incident to Human Resources (HR) on 3/20/25.
-HR did the internal investigation (3/27/25-
3/31/25).

-Did not question the QP.

-Did not know the outcome of the internal
investigation.

-Client #1 did not sustain any injuries.

Attempted interview on 4/25/25 with Client #1
revealed:

-His legal guardian would not consent to an
interview because Client #1 "does not speak
good english and he has trouble following
conversations."

Interview on 4/28/25 with Staff #2 revealed:

-Did not remember a lot of the details of the
incident between the QP and Client #1 on
3/14/25.

-Remembered Client #1 was disrupting the other
clients and "talking back, calling staff names like
Division of Health Service Regulation

STATE FORM

6899 KUZI11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 109} Continued From page 3 Vv 109

If continuation sheet 4 of 11

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL060968 B. WING

NAME OF PROVIDER OR SUPPLIER
6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE CHARLOTTE, NC 28211

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/10/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
04/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

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

(X4) ID
PREFIX
TAG

ID
PREFIX
TAG

CROSS-REFERENCED TO THE APPROPRIATE

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

(x5)
COMPLETE
DATE

DEFICIENCY)

V 109} Continued From page 4 V 109

black B***h."

-"Whatever you saw on the video is what
happened. | think she (QP) just lost her cool for a
minute. That kid (Client #1) would push and push
and push."

-Did not hear the QP and Client #1 arguing with
each other.

-Did not know if Client #1 sustained any injuries.

Interview on 4/28/25 the QP revealed:

-On 3/14/25, Client #1 kept using the saying
"clock that tea" and in a jokingly way she said "I
will."

-"| walked over to his desk and tickled him and he
wiggled out of his chair. | was playing with him, |
wasn't trying to harm him."

-"I'm not that kind of person to harm children."
-"It was a playful interaction."

-Denied telling Client #1 "Don't start with me
today, I'm the wrong one."

-Denied Client #1 was standing in his chair yelling
"Dummy."

-Did not pull Client #1 out of his chair on to the
floor.

Interview on 4/22/25 with the HR Director
revealed:
-The QP was suspended from the day program
pending investigation on 3/27/25.

-The QP worked with another program while
under investigation.
-The internal investigation took place from
3/27/25 to 3/31/25.
-The QP was put on a 60 day performance plan.
-The QP had to retake TCI training, "Handle with
Care" on 3/31/25.

Interview on 4/29/25 with the Vice President of
Performance Improvement revealed:

-Did not have a lot of details about the incident
Division of Health Service Regulation

STATE FORM

6899 KUZI11

If continuation sheet 5 of 11

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL060968 B. WING

NAME OF PROVIDER OR SUPPLIER
6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE CHARLOTTE, NC 28211

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/10/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
04/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

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

(X4) ID
PREFIX
TAG

ID
PREFIX
TAG

CROSS-REFERENCED TO THE APPROPRIATE

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

(x5)
COMPLETE
DATE

DEFICIENCY)

Vv 109 V 109

Continued From page 5

between the QP and Client #1.

-Verified the QP was allowed to work in another
Program while under investigation for abusing
Client #1.

-The internal investigation was 3/27/25 through
3/31/25.

-The QP was terminated on 4/30/25.

Review on 4/30/25 of the Plan of Protection dated
4/30/25 signed by the Vice President of
Performance Improvement revealed:

-"What immediate action will the facility take to
ensure the safety of the consumers in your care?

[QP] was terminated from employment with
[Licensee] on 4/29/2025 and has not worked with
any children since 4/4/2025.

Describe your plans to make sure the above
happens.

Human Resources has removed [QP] access to
all systems and locations effective 4/29/2025."

ient #1 was 9 years old with diagnoses of
ppositional Defiant Disorder and Post Traumatic
ress Disorder. On 3/19//25, Client #1 was seen
na video from 3/14/25 sitting in his chair. The
ualifed Professional got up from her seat,

alked over to Client #1, grabbed him, pulled him
the floor, and then walked back to her seat.
ient #1 got up off the floor and sat in his chair.
his deficiency constitutes a Type B violation

hich is detrimental to the health, safety and
elfare of the clients and must be corrected

ithin 45 days.

=O2RO00

io

2=e2eH50

V 132} G.S. 131E-256(G) HCPR-Notification, V 132

legations, & Protection

Division of Health Service Regulation

STATE FORM 6899

KUZI11

If continuation sheet 6 of 11

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL060968 B. WING

NAME OF PROVIDER OR SUPPLIER
6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE CHARLOTTE, NC 28211

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/10/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
04/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

G.S. §131E-256 HEALTH CARE PERSONNEL
REGISTRY

(g) Health care facilities shall ensure that the
Department is notified of all allegations against
health care personnel, including injuries of
unknown source, which appear to be related to
any act listed in subdivision (a)(1) of this section.
(which includes:

a. Neglect or abuse of a resident in a healthcare
facility or a person to whom home care services
as defined by G.S. 131E-136 or hospice services
as defined by G.S. 131E-201 are being provided.
b. Misappropriation of the property of a resident
in a health care facility, as defined in subsection
(b) of this section including places where home
care services as defined by G.S. 131E-136 or
hospice services as defined by G.S. 131E-201
are being provided.

c. Misappropriation of the property of a
healthcare facility.

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

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

Facilities must have evidence that all alleged
acts are investigated and must make every effort
to protect residents from harm while the
investigation is in progress. The results of all
investigations must be reported to the
Department within five working days of the initial
notification to the Department.

This Rule is not met as evidenced by:

Based on record reviews and interviews, the
facility failed to protect clients during an
investigation of abuse, neglect or exploitation.
The findings are:

Division of Health Service Regulation

STATE FORM 6899

KUZI11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 132] Continued From page 6 V 132

If continuation sheet 7 of 11

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL060968 B. WING

NAME OF PROVIDER OR SUPPLIER
6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE CHARLOTTE, NC 28211

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/10/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
04/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Review on 4/21/25 of the Qualified Professional's
(QP) personnel record revealed:

-Date of hire 2/28/22

-Job Title QP.

Review on 4/21/25 at 12:00pm of the Facility's
Video Footage dated 3/14/25 revealed:

-Client #1 was seen sitting in his chair.

-The QP got up from her seat, walked over to
Client #1, pulled him to the floor and then walked
back to her seat.

-Client #1 got up off the floor and sat in his chair.

Review on 4/16/25 of the North Carolina Incident
Response Improvement System (IRIS) revealed:
-On 3/19/25 while reviewing video footage in
reference to another incident, the Program
Supervisor saw the QP walk over to Client #1 and
pushed him out of his chair on 3/14/25.

-Client #1 fell to the floor.

-The QP walked back over to her seat and Client
#1 got up and sat in his chair.

Review on 4/21/25 of the facility's document titled
"Internal Review Findings of Fact Summary-
3.31.24: Incident 3.19.25" revealed:

-"Allegation: While reviewing video for another
Internal Investigation, program manager saw staff
(QP) pull client (Client #1) off a desk and ‘throw
the to the floor.'"

-"The video shows the staff member (QP)
approaching the youth (Client #1) after an
exchange of words and then the youth is on the
floor. The video is dark."

-"The youth (Client #1) is repeatedly saying
‘dummy.’ The staff member (QP) can be heard
saying 'Don't start with me today, I'm the wrong
one.' After the physical exchanged the youth
challenged the staff verbally to which she stated,
‘| just did something about it.’ "

Division of Health Service Regulation

STATE FORM

6899 KUZI11

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

DEFICIENCY)
V 132] Continued From page 7 V 132

If continuation sheet 8 of 11

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL060968 B. WING

NAME OF PROVIDER OR SUPPLIER
6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE CHARLOTTE, NC 28211

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/10/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
04/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

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

(X4) ID
PREFIX
TAG

ID
PREFIX
TAG

CROSS-REFERENCED TO THE APPROPRIATE

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

(x5)
COMPLETE
DATE

DEFICIENCY)

V 132 V 132

Continued From page 8

-"The cause of the incident is seen as staff
member (QP) exacting revenge on the youth
(Client #1) for challenging her. Staff was
reactionary.”

-"Recommendations: It is recommended that the
staff member (QP) be on a 60-day Performance
Improvement Plan during which time she
completed TCI (therapeutic crisis intervention)
refresher training with a concentration on Handle
with Care concepts that assist with being
proactive and utilizing verbal de-escalation
techniques as well as positive engagement
strategies."

Interview on 4/21/25 with the Program Supervisor
revealed:

-On 3/19/25 he was reviewing video footage in
reference to another incident when he came upon
footage of the QP pushing Client #1 out of his
chair on 3/14/25.

-Completed the NC IRIS report and reported the
incident to Human Resources (HR) on 3/20/25.
-HR did the internal investigation (3/27/25-
3/31/25).

-Did not question the QP.

-Did not know the outcome of the internal
investigation.

-Client #1 did not sustain any injuries.

Attempted interview on 4/25/25 with Client #1
revealed:

-His legal guardian would not consent to an
interview because Client #1 "does not speak
good english and he has trouble following
conversations."

Interview on 4/28/25 with Staff #2 revealed:
-Did not remember a lot of the details of the
incident between the QP and Client #1 on
3/14/25.

Division of Health Service Regulation

STATE FORM

6899 KUZI11

If continuation sheet 9 of 11

Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING:

MHL060968 B. WING

NAME OF PROVIDER OR SUPPLIER
6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE CHARLOTTE, NC 28211

(X2) MULTIPLE CONSTRUCTION

PRINTED: 09/10/2025
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
04/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

-Remembered Client #1 was disrupting the other
clients and "talking back, calling staff names like
black B**ch."

-"Whatever you saw on the video is what
happened. | think she (QP) just lost her cool for a
minute. That kid (Client #1) would push and push
and push."

-Did not hear the QP and Client #1 arguing with
each other.

Interview on 4/28/25 the QP revealed:

-On 3/14/25 Client #1 kept using the saying "clock
that tea" and in a jokingly way she said "I will."

-"| walked over to his desk and tickled him and he
wiggled out of his chair. | was playing with him, |
wasn't trying to harm him."

-"I'm not that kind of person to harm children."

-"It was a playful interaction."

-Denied telling Client #1 "Don't start with me
today, I'm the wrong one."

-Denied Client #1 was standing in his chair yelling
"Dummy."

-Did not pull Client #1 out of his chair on to the
floor.

-Could not recall which days she worked between
3/27/25 and 3/31/25.

Interview on 4/22/25 with the HR Director
revealed:

-The QP was suspended from the day program
pending investigation on 3/27/25.

-The QP worked with another program while
under investigation.

-The internal investigation took place from
3/27/25 to 3/31/25.

-Did not know the QP was not supposed to work
with any clients while under investigation.

-"| thought the suspension was just for the day
program."

Division of Health Service Regulation

STATE FORM 6899

KUZI11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 132] Continued From page 9 V 132

If continuation sheet 10 of 11

PRINTED: 09/10/2025

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL060968 B. WING 04/30/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE
CHARLOTTE, NC 28211
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE

DEFICIENCY)

V 132] Continued From page 10 V 132

Interview on 4/29/25 with the Vice President of
Performance Improvement revealed:

-Did not have a lot of details about the incident
between the QP and Client #1.

-Verified the QP was allowed to work in another
Program while under investigation for abusing
Client #1.

-The internal investigation was 3/27/25 through
3/31/25.

-The QP was terminated on 4/29/25.

Division of Health Service Regulation
STATE FORM 6899 KUZI11 If continuation sheet 11 of 11


raw_content:
Division of Health Service Regulation

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

MHL060968

NAME OF PROVIDER OR SUPPLIER

A. BUILDING:

6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1

CHARLOTTE, NC 28211

(X2) MULTIPLE CONSTRUCTION

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 10/07/2024

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

10/01/2024

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

ID
PREFIX
TAG

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

DEFICIENCY)

(xs)
COMPLETE
DATE

V 000} INITIAL COMMENTS

Acomplaint survey was competed on 10-1-24
The complaints were unsubstantiated
(#NC00221991, #NC00222010). Deficiencies
were cited.

This facility is licensed for the following service

category: 10A NCAC 27G. 1400 Day Treatment
for Children and Adolescents with Emotional or
Behavior Disturbance.

This facility is licensed for 0 and currently has a
census of 26. The survey sample consisted of
audits of 2 current clients.

V 536] 27E .0107 Client Rights - Training on Alt to Rest.
Int.

10A NCAC 27E .0107 TRAINING ON
ALTERNATIVES TO RESTRICTIVE
INTERVENTIONS

(a) Facilities shall implement policies and
practices that emphasize the use of alternatives
to restrictive interventions.

(b) Prior to providing services to people with
disabilities, staff including service providers,
employees, students or volunteers, shall
demonstrate competence by successfully
completing training in communication skills and
other strategies for creating an environment in
which the likelihood of imminent danger of abuse
or injury to a person with disabilities or others or
property damage is prevented.

(c) Provider agencies shall establish training
based on state competencies, monitor for internal
compliance and demonstrate they acted on data
gathered.

(d) The training shall be competency-based,
include measurable learning objectives,
measurable testing (written and by observation of

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

STATE FORM

V 000

V 536

6899

2VUA11

TITLE

(X6) DATE

If continuation sheet 1 of 7

Division of Health Service Regulation

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

MHL060968

NAME OF PROVIDER OR SUPPLIER

A. BUILDING:

6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1

CHARLOTTE, NC 28211

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/07/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

10/01/2024

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 536 | Continued From page 1 V 536

behavior) on those objectives and measurable
methods to determine passing or failing the
course.

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

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

(g) Staff shall demonstrate competence in the
following core areas:

(1) knowledge and understanding of the
people being served;

(2) recognizing and interpreting human
behavior;

(3) recognizing the effect of internal and
external stressors that may affect people with
disabilities;

(4) strategies for building positive
relationships with persons with disabilities;

(5) recognizing cultural, environmental and
organizational factors that may affect people with
disabilities;

(6) recognizing the importance of and
assisting in the person's involvement in making
decisions about their life;

(7) skills in assessing individual risk for
escalating behavior;

(8) communication strategies for defusing
and de-escalating potentially dangerous behavior;
and

(9) positive behavioral supports (providing

means for people with disabilities to choose
activities which directly oppose or replace
behaviors which are unsafe).

(h) Service providers shall maintain
documentation of initial and refresher training for
at least three years.

Division of Health Service Regulation
STATE FORM

6809

2VUA11

If continuation sheet 2 of 7

Division of Health Service Regulation

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

MHL060968

NAME OF PROVIDER OR SUPPLIER

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1

A. BUILDING:

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/07/2024

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

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

10/01/2024

review/request this documentation at any time.
(i) Instructor Qualifications and Training
Requirements:

need for restrictive interventions.

by scoring a passing grade on testing in an
instructor training program.

(3) The training shall be

objectives, measurable testing (written and by

measurable methods to determine passing or
failing the course.

service provider plans to employ shall be

to Subparagraph (i)(5) of this Rule.

reducing and eliminating the need for restrictive
interventions at least one time, with positive
review by the coach.

Division of Health Service Regulation
STATE FORM

(1) Documentation shall include:

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

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

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

(1) Trainers shall demonstrate competence
by scoring 100% on testing in a training program
aimed at preventing, reducing and eliminating the

(2) Trainers shall demonstrate competence

competency-based, include measurable learning

observation of behavior) on those objectives and

(4) The content of the instructor training the

approved by the Division of MH/DD/SAS pursuant

(5) Acceptable instructor training programs
shall include but are not limited to presentation of:
(A) understanding the adult learner;

(B) methods for teaching content of the
course;

(C) methods for evaluating trainee
performance; and

(D) documentation procedures.

(6) Trainers shall have coached experience

teaching a training program aimed at preventing,

6809

2VUA11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 536 | Continued From page 2 V 536

If continuation sheet 3 of 7

Division of Health Service Regulation

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

MHL060968

NAME OF PROVIDER OR SUPPLIER

A. BUILDING:

6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1

CHARLOTTE, NC 28211

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/07/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

10/01/2024

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 536] Continued From page 3 V 536

(7) Trainers shall teach a training program
aimed at preventing, reducing and eliminating the
need for restrictive interventions at least once
annually.

(8) Trainers shall complete a refresher
instructor training at least every two years.

(j) Service providers shall maintain
documentation of initial and refresher instructor
training for at least three years.

(1) Documentation shall include:

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

(B) when and where attended; and

(C) instructor's name.

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

request and review this documentation any time.
(k) Qualifications of Coaches:

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

(2) Coaches shall teach at least three times
the course which is being coached.

(3) Coaches shall demonstrate
competence by completion of coaching or
train-the-trainer instruction.

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

This Rule is not met as evidenced by:

Based on interviews, one of one audited staff
(Staff #1) failed to demonstrate competency in
the use of alternatives to restrictive interventions.
The findings are:

Division of Health Service Regulation
STATE FORM

6809

2VUA11

If continuation sheet 4 of 7

Division of Health Service Regulation

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

MHL060968

NAME OF PROVIDER OR SUPPLIER

A. BUILDING:

6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1

CHARLOTTE, NC 28211

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/07/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

10/01/2024

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 536 | Continued From page 4 V 536

Review on 9-26-24 of Staff #1's record revealed:
-Hire date on 2-15-19.
-Handle With Care Refresher; 4-4-24,
Calming Children in Crisis, 3-7-19.

Review on 9-26-24 of Client #1's record revealed:
-Admitted 7-30-24.
-11 years old.
-Diagnoses of Oppositional Defiance
Disorder and Post Traumatic Stress Disorder.

Review on 9-26-24 of Internal Investigation dated
9-12-24 revealed:

-Summary of Incident: Client was
dysregulated and went to the quiet room where
he was upset. Staff observed something in his
hand and asked him to give it to the staff. He
stated that staff pushed him into the wall when he
refused to give up the item.

-Allegation: Client [Client #1] alleges that
staff [Staff #1] pushed him in his chest into the
wall.

-Findings of Fact: The internal panel review
team assessed and determined the following
items to be facts related to this incident based on
the review of the record, procedures, statements
from staff/clients and video:

-[Client #1] was in the calming room with 2
other clients.

-[Client #1] was in crisis, screaming, yelling.

-[Staff #1] responded to the noise and asked
him to stop.

-[Client #1] did not comply with requests.

-[Client #1] had something in his hand he
refused to give to staff.

-In an attempt to get the item the client made
contact with the wall.

-Cause of the Incident: Poor de-escalation
strategies utilized.

Division of Health Service Regulation
STATE FORM

6809

2VUA11

If continuation sheet 5 of 7

Division of Health Service Regulation

PRINTED: 10/07/2024

FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL060968 10/01/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
6220-D THERMAL RD
ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1
CHARLOTTE, NC 28211
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 536 | Continued From page 5 V 536

Interview on 9-23-24 with Client #1 revealed:

-"| was yelling hitting the wall, throwing
yourself against the wall."

-Staff #1 pushed him by the stomach against
the wall and his back hit the wall.

-He doesn't remember Staff #1 asking for
what was in his hand.

- He stated that the Director of the Transition
House was also in the room.

-He did not get hurt.

Interview on 9-18-24 and 9-23-24 with Client #2
revealed:
-He was in the calming room with Client #1.
-Client #1 was walking around, banging on
walls.
-Staff #1 pushed Client #1 by his shoulders.
-Staff #1 pushed Client #1 into a corner.
-Client #1 was hurt and was crying.

Interview on 9-18-24 with Staff #1 revealed:

-Client #1 and Client #2 were in the calming
room.

-Both Clients were banging on the wall.

-She went in to the calming room and asked
him to calm down.

-Client #1 said he would not and that he
wished he was dead and wanted to kill himself.

-Client #1 had something in his hand, and
since he was making suicidal threats, she felt that
she needed to know what it was.

-She approached him and he jumped back
and hit the wall.

-Client #1 dropped what was in his hand and
when Staff #1 saw that it was just a fidget
spinner, she left the calming room.

-"I never even touched him."

Interview on 9-23-24 with Staff #2 revealed:

Division of Health Service Regulation
STATE FORM

6809

2VUA11

If continuation sheet 6 of 7

Division of Health Service Regulation

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

MHL060968

NAME OF PROVIDER OR SUPPLIER

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1

A. BUILDING:

(X2) MULTIPLE CONSTRUCTION

PRINTED: 10/07/2024

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

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

10/01/2024

-She directed both Client #1 and Client #2
into the calming room.

-Client #1 was throwing things at the wall and
banging the wall. Client #2 had calmed down.

-Client #1 was throwing himself against the
wall.

-Staff #1 came in and asked him the stop.

-Staff #1 told Client #1 to "just chill" and that
he was aggravating her clients.

-Client #1 had something in his hand and
Staff #1 was trying to take it from him.

-Client #1 back into the wall trying to get
away.

-Staff #2 saw Client #1's arm jerk into the wall
several times, but did not see the final time when
Client #1's back hit the wall.

-Staff #1 did grab Client #1's hand, and Client
#1 jerked away.

Interview on 9-23-24 with the Director of the
Transition Home revealed:

-He was not in the calming room when Client
#1 was having a behavior.

Division of Health Service Regulation
STATE FORM

6809

2VUA11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 536] Continued From page 6 V 536

If continuation sheet 7 of 7


raw_content:
PRINTED: 03/06/2024

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
MHL060968 B. WING 03/05/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE CHARLOTTE, NC 28211

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000} INITIAL COMMENTS V 000

Acomplaint survey was completed on
03/05/2024. The complaint was unsubstantiated
(Intake #NC00213140). No deficiencies were
cited.

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

This facility has a current census of 35. The
survey sample consisted of audit of 1 current
client.

Division of Health Service Regulation
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

STATE FORM 6899 45BH11 If continuation sheet 1 of 1


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

raw_content:
Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

PRINTED: 09/08/2023

(X2) MULTIPLE CONSTRUCTION (x3)
A. BUILDING:

MHL060968

6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1
CHARLOTTE, NC 28211

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

) DATE SURVEY
COMPLETED

R-C
08/30/2023

A complaint and follow up survey was completed
on 8-30-23. The complaints were
unsubstantiated (Intake #'s NC00205944 and #
NC00205942). No deficiencies were cited.

This facility is licensed for the following service
category: 10A NCAC 27G .1400 Day Treatment
For Children And Adolescents With Emotional Or
Behavioral Disturbances.

This facility has a current census of 32. The
survey sample consisted of audits of 4 current
clients.

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

STATE FORM

6899

VHOZ11

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

DEFICIENCY)
V 000) INITIAL COMMENTS Vv 000

TITLE

(X6) DATE

If continuation sheet 1 of 1

inspection_type: MHLCS Annual and Follow-up


raw_content:
Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL060968

A. BUILDING:

6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1
CHARLOTTE, NC 28211

(X2) MULTIPLE CONSTRUCTION

PRINTED: 02/27/2023

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

02/20/2023

(x4) ID
PREFIX
TAG

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

ID
PREFIX
TAG

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

(xs)
COMPLETE
DATE

V 000!

V 184

INITIAL COMMENTS

Acomplaint survey was completed on 2-20-23.
The complaint was substaniated (#NC00195555).
Deficiencies were cited.

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

This facility has a current census of 19. The
survey sample consisted of audits of one former
client.

27G .1401 Day Tx Child/Adol - Scope

10A NCAC 27G .1401 SCOPE

(a) Day treatment is a day/night facility for
children and adolescents who are emotionally
disturbed which coordinates educational activities
and intensive treatment while allowing the
individual to live at home or in the community.

(b) This service is designed to increase the
ability of a child or adolescent to relate to others
and function appropriately within the community
while serving as an intervention to prevent
hospitalization or placement outside the home or
community.

(c) It shall provide a therapeutic environment as
well as other activities which may include
individual therapy, group therapy, recreational
therapy, language communication skills
development, social skills development,
pre-vocational service, vocational training, service
to parents, and individual advocacy.

(d) The client's educational activities may be
provided in this facility or in another educational
setting, such as regular classes or special
education programs within a typical school
setting.

Division of Health Service Regulation

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

STATE FORM

V 000

V 184

6899

HNSH11

TITLE

(X6) DATE

If continuation sheet 1 of 4

Division of Health Service Regulation

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

MHL060968

NAME OF PROVIDER OR SUPPLIER

A. BUILDING:

6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1

CHARLOTTE, NC 28211

(X2) MULTIPLE CONSTRUCTION

PRINTED: 02/27/2023

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

02/20/2023

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 184] Continued From page 1 V 184

(e) Treatment, services, and discharge plans
provided by day treatment programs shall be
coordinated with other individuals and agencies
within each client's local system of care.

(f) Day treatment facilities may include
before/after school and summer facilities, and
early intervention.

This Rule is not met as evidenced by:
Based on record reviews and interviews the
facility failed to provide a therapeutic
environment. The findings are:

Review on 2-19-23 of youtube video entitled "Evil
caretaker tries to kill grandma" revealed:

-Caretaker was taking care of elderly,
diabetic, blind woman.

-Caretaker gave woman who was not
supposed to have any sugar full sugar soda.

-Caretaker did not let the woman
communicate with her daughter.

-Caretaker persuaded woman to change her
will, leaving everything to the caretaker.

-Daughter finally shows up at the house and
the caretakers friend pulls a gun on them as the
caretaker reveals she was also giving the woman
sugar pills to try to kill her.

-The daughter gets the gun and calls the
police.

Interview on 2-15-23 with Client #2 revealed:
-They had watched a movie about a
caretaker.
-"It was bout a mean lady that was like her
nurse, she was trying to kill her so she could get
her money. The mean lady wouldn't let her speak

Division of Health Service Regulation
STATE FORM

6809

HNSH11

If continuation sheet 2 of 4

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL060968

A. BUILDING:

6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1
CHARLOTTE, NC 28211

(X2) MULTIPLE CONSTRUCTION

PRINTED: 02/27/2023

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

02/20/2023

to her daughter. The daughter found out and the
mean lady went to jail."

- "It was kinda about the right thing to do,
what not to do."

Interview on 2-15-23 with Client #3 revealed:
-She didn't remember a movie about a blind

woman being given sugar, but did remember a

movie about an elderly woman getting bullied.

Interview on 2-16-23 with Staff #1 revealed:
-They had watched a youtube video about an
elderly woman and her caretaker.
-She stated that they were inspirational
movies that were to teach the kids what they
should and should not be doing.

Interview on 1-23-23 with Former Client #1's
Mother/Guardian revealed:

-He daughter attended the day program
approximately 3 days, from the end of November
to the first week of December.

- Her daughter said there was a youtube
video about home nurse aide. "The nurse was
trying to kill the old blind lady with sugar and
soda, and there was a gun in it and they were
trying to kill the old lady."

-Her daughter has a recording device with her
to protect her.

-She had listened to the whole video and she
could hear her daughter asking what it was.

-She did not think the movie was appropriate
for children.

Interview on 2-15-23 with the Program Supervisor
revealed:

-He had only been the Program Supervisor
for approximately one month.

-He approved the movies and the facility had
a movie policy.

Division of Health Service Regulation

STATE FORM

6809

HNSH11

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 184] Continued From page 2 V 184

If continuation sheet 3 of 4

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL060968

6220-D THERMAL RD

ALEXANDER YOUTH NETWORK - CHARLOTTE DAY 1
CHARLOTTE, NC 28211

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 02/27/2023

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

02/20/2023

PROVIDER'S PLAN OF CORRECTION

-He was unaware of the movies and videos
that were shown before he became the Program
Supervisor.

Division of Health Service Regulation
STATE FORM

6809

HNSH11

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID (xs)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 184] Continued From page 3 V 184

If continuation sheet 4 of 4