summary: Plan of Correction - MHLCS Complaint

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PRINTED: 08/14/2024

FORM APPROVED

Division of Health Service Regulation

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

c
MHLO13-226 8. WING —______HHH_H4H§o§éhke 07/29/2024

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

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

UNION POINT

V 000) INITIAL COMMENTS

| Acomplaint survey was completed on 7-29-24
The complaint was unsubstantiated (intake
#NC00217596).A deficiency was cited

This facility is licensed for the following service
category: 10ANCAC 27G .1700 Residential
Treatment Staff Secure For Children Or
Adolescents

This facility is licensed for 6 and currently has a
census of 5. The survey sample consisted of
audits of 2 current clients.

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

Case vaneoe update all active
10A NCAC 27G .0205 ASSESSMENT AND client PCP's al (0 reflect applicable goals
TREATMENT/HABILITATION OR SERVICE such as AWOL behavior. Crisis plans will also be
PLAN updated to reflect behaviors and crisis response. |
(c) The plan shall be developed based on the Piavention® Prevention
assessment, and in partnership with the client or completed on
legally responsible person or both, within 30 days On 8/16/2024, Tuming Point Homes QM director —_8/162024
of admission for clients who are expected to reviewed AssessmentTreatment/Habilitation Plan
receive services beyond 30 days. expectations with the agencies program director, and
(d) The plan shall include: Case Manager who completes and updates PCPs,
(1) client outcome(s) that are anticipated to be
hieved by provision of the service and a ple Cae

achieved by pi Runaway Protocol Review
projected date of achievement; PGP development:
(2) strategies; - making sure goals match client behavior,
| (3) staff responsible - Goals should link back to the assessment.

(4) a schedule for review of the plan at least behavi Goals should be added based on new

annually in consultation with the client or legally behaviors displayed.

responsible person or both; Who will monitor/How often:

(5) basis for evaluation or assessment of Program Director: ctsepe-cy ay ite QM Director:

outcome achievement; and a: rent prans at least

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

Division of Health Service Regulation
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X68) DATE

Measures to Correct deficiencies: | 10/1/2024

STATE FORM Co SILP11 RECEIVED continuation sheet 1 of 7
AUG 30 2024

DHSR-MH Licensure Sect

PRINTED: 08/14/2024
FORM APPROVED

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

c
MHL013-226 8. WING —_______ 07/29/2024

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

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

UNION POINT

V 112] Continued From page 1

This Rule is not met as evidenced by

Based on record reviews and interviews, the
facility failed to develop and implement strategies
to meet the clients needs affecting 2 of 2 audited
clients (client #4 and client #5). The findings are:

Review on 7-25-24 of client #4's record revealed:
-Date of admission: 7-3-2024

-Age: 16

-Diagnoses: Post-traumatic Stress Disorder;
Adjustment Disorder; Conduct Disorder.
-Comprehensive Clinical Assessment (CCA)

| dated 7-11-24 documented the following:
-"[Client #4] has a history of elopement and was
| most recently AWOL (absent without leave) for
two weeks (unknown dates). Months prior
(unknown dates), he was AWOL for 2 months
Due to this, he is currently seeking placement.
Current Living Situation: [Client #4] is currently
residing at Turning Point emergency crisis
placement Union Point. He was picked up last
Tuesday (unknown date) after returning from a
2-week elopement. He states that it is not going
well because he feels that staff are judging him
"before they get to know me" (regarding his past
behaviors and elopement). He reports he has
heard staff talking negatively about him and when
this occurs it makes him want to elope..."
-Person Centered Plan (PCP) dated 7-8-24 had
no goals or strategies to address client #4's |

Division of Health Service Regulation

STATE FORM e209 3ILP11 If continuation sheet 2 of 7

PRINTED: 08/14/2024
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

c
MHL013-226 & WING —__________ 07/29/2024

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

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5)

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

DEFICIENCY)

UNION POINT

V 112} Continued From page 2

AWOL behavior.

Review on 7-19-24 of NC IRIS (North Carolina
Incident Response Improvement System) for the
period of April 1, 2024 to July 19, 2024
documented client #4's AWOL on 7-13-24

Unable to interview Client #4 because he was still
AWOL at survey exit.

Review on 7-22-24 of client #5's record revealed
-Date of admission: 5-8-24

-Age: 17.

-Diagnoses: Disruptive Mood Dysregulation
Disorder; Unspecified Trauma and Stressor
Related Disorder; Conduct Disorder unspecified.
Cannabis Dependency uncomplicated

-CCA dated 4-22-24 documenting client #5's

| history of elopement.

-PCP dated 11-20-23 and updated 6-24-24
documented the following:

~"5/23/24: On 5/14/24 [client #5] packed a bag
and when questioned she expressed that she
planned to leave the home (facility). On 5/21/24,
[client #5] left the home (facility) without
permission; however she returned when picked
up by staff (unidentified staff). She was taken to
get drug tested and the results came back
positive for marijuana."

-"6/24/24: On 6/19/24 [client #5] left the home
(facility) without permission and went AWOL:
however, she was returned the next day (6/20/24)
by [Local Police]. She reported to the staff
(Qualified Professional/QP) that she was in a car
accident. Staff (QP) transported [client #5] to the |
hospital. During her time of being AWOL, [client
#5] was with her child 's father, and they stole his |
mother's car which is now considered total from
the accident."

-"On 6/23/24, [client #5] went AWOL with
Division of Health Service Regulation
STATE FORM ome: 3ILP 11 H continuation sheet 3 of 7

(X4) ID
PREFIX
TAG

Division of Health Service Regulation

‘STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

UNION POINT

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER.

MHL013-226

519 UNION

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

Vv 112

STATE FORM

Continued From page 3

another peer. She returned home on 6/25/24. The
treatment team agreed to restrict all community
outings unti! authorized by the social worker
(Department of Social Services (DSS) Social
Worker) or clinical director. [client #5] phone list
has also been limited to her social worker (DSS),
GAL (Guardian Ad-Litem), and her sons foster
parent and his social worker. It is clinically
recommended that [client #5's] level of care is
PRTF (Psychiatric Residential Treatment Facility).
Moving forward any other infraction will result in
immediate removal from the facility."

-No goals or strategies documented in client #5's
plan to address client #5's AWOL behaviors

Review on 7-19-24 of the NC IRIS reports for the
period of April, 1, 2024 to July 19, 2024
documented the following AWOL incidents for
client #5:

6-19-24, 6-23-24, 7-13-24

Interview on 7-19-24 with client #5 revealed:
-"I've went AWOL about 3 times (since being
admitted to the facility). | don't know why. It's
something | always do in group homes. I've ran
away from every group home I've been in."
-"Staff was here every time. They follow you
(client), try to talk you into coming back, stuff like
that (staff attempted to prevent client from going
AWOL)."

-"No", not working on any goals to address AWOL
behaviors.

Interview on 7-19-24 with staff #1 revealed
-"Yes there have been some AWOL's. Ifa child
(client) goes AWOL and they are within distance
(line of sight of staff) and you (staff) have
eyesight (have the client in the line of sight), you
(staff) can follow them. Once you (staff)lose
eyesight we call the non emergency number for

—____|

B. WING

PREFIX
| TAG

(X2) MULTIPLE CONSTRUCTION
A. BUILDING

STREET ADDRESS, CITY, STATE, ZIP CODE
STREET SOUTH
CONCORD, NC 28025

PROVIDER'S PLAN OF CORRECTION

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

DEFICIENCY)

PRINTED: 08/14/2024
FORM APPROVED

(X3) DATE SURVEY
COMPLETED

Cc
07/29/2024

(xs)

Vv 112

oo

Division of Health Service Regulation

e008

3ILP11

If continuation sheet 4 of 7

PRINTED: 08/14/2024

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
(e}
MHL013-226 BEWING 07/29/2024

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

519 UNION STREET SOUTH

|ON POINT
UNION P CONCORD, NC 28025

(x4) ID SUMMARY STATEMENT OF DEFICIENCIES 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 bate

DEFICIENCY)
V 112} Continued From page 4 Vv 112

the police and make a report then call the
guardian/DSS (department of social services)
and file a report.”

Interview on 7-19-24 with staff #2 revealed:
-"Them (clients) running away, that's just
something that they will just do. If one of these
kids (clients) make up their mind they are going
to run, there is nothing you can do to stop them
The protocol is we (staff) follow them until they
get out of eyesight and try to talk them into
coming back (to the facility). Most of the time we |
can get them to come back. But once they get
out of eyesight we don't follow them any more."

Interview on 7-19-24, 7-22-24 and 7-29-24 with
the QP revealed

-2-6-24 the facility opened.: Since the home
opened there have been 9 AWOL's.

-"Once we (staff) realize its not them (clients) just
blowing off steam, (clients needing to calm down
and not leaving the property) we try to keep them
in eyesight as much as possible, or for as far as it
is safe for staff to do so (during a AWOL staff will
follow clients until the client is out of line of sight).
Once they are out of line of sight we call the
Police and let the guardian know."

-"Upon admission, if they (clients) have a AWOL
history, we (QP) will go over their (clients) history
and their behaviors with the staff. We make sure
all the staff are alerted to their (clients)
behaviors."

-"We (facility) have a minimum of 3 staff on shift.
We have window sensors on all the windows.
Movement sensors in the bedrooms (bells that
alert the staff when a client comes in or out of

| their rooms. Window sensors on the bedroom
windows connected to [security company], and
door chimes on the outside accessible doors."
-"The protocol starts before we get a kid (client).
Division of Health Service Regulation

STATE FORM ese SILP14 If continuation sheet 5 of 7

PRINTED: 08/14/2024
FORM APPROVED
Division of Health Service Requlation

STATEMENT OF DEFICIENCIES (<1) PROVIDER/SUPPLIER/CLIA
AND PLAN OF CORRECTION IDENTIFICATION NUMBER.

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

Cc
07/29/2024

MHLO013-226

STREET ADDRESS. CITY. STATE, ZIP CODE
519 UNION STREET SOUTH
CONCORD, NC 28025

NAME OF PROVIDER OR SUPPLIER

UNION POINT

(x4) 1D SUMMARY STATEMENT OF DEFICIENCIES 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)
— a —
V 112 | Continued From page 5 v2

It (AWOL protocol) starts with training, we make
sure staff know what we are getting (what
behaviors a client has before they are admitted)
When we look at the referral (application and
paperwork received from referral source)..., we
interview the client and look at the assessments.
We screen (clients) as best as we can. QP's are
involved, (in the process/admission/screening
process) and should be guiding the services.”
-"Before a client is admitted we look at their
history. We look at each one individually and
take it on a case by case basis. We look at how
long its been since the last AWOL, why they were
AWOL. All that (reasons) is taken into
consideration (for admission). If we have
concerns (regarding a clients AWOL behavior) we |
will increase supervion/monitoring (of the client)."
-"The behavior, AWOL or other behaviors they
(clients) have should be documented. We
document (AWOL's) in session notes, incident
reports, team meeting notes. Yes, the guardians
are involved. The client's guardian gives
feedback. If the guardian does not specify they
want a goal to address the AWOL we don't put
one in (the PCP)"

-"After a client has a AWOL, | will discuss the
AWOL with them (the client) and try to process
their reasoning for leaving. | discuss the safety
aspect with them and remind them of things they
can do to... coping skills they can use to avoid
going AWOL in the future."

-"We discuss all AWOL's in the clients CFT (Child
and Family Team) meetings. As far as updating
the PCP, no (does not update the PCP after an
AWOL) unless the team (the guardian) makes a
recommendation.”

Unable to interview Case Manager because she
was on vacation

Division of Health Service Regulation
STATE FORM (9099. 3ILP11 If continuation sheet 6 of 7

PRINTED: 08/14/2024
FORM APPROVED

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

c
MHL013-226 8 WING J _________ 07/29/2024

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

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

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

DEFICIENCY)

UNION POINT

Continued From page 6

Interview on 7-29-24 with the Clinical Director
revealed

-"A client's AWOL history should be documented
in the PCP and they should have a goal that
addresses that behavior somewhere in the plan.
[QP] can turn it into an intervention (within the
PCP) or put it (goal/strategy to address the AWOL
behavior) where it makes the most sense. There
needs to be a intervention or goal or crisis plan
noting the behaviors as part of the clients safety
plan. Sometimes it (behavior goal) will be put in
the day program part and not in the clients PCP
(the facility's PCP) but it needs to be in both
[Case Manager] needs to be doing this (making
sure client behaviors are documented in the
PCPs) The QP and the Case Manager (lead
Case Manager for the the facility) are suppose to
work closely with the staff and review client
behaviors with the staff. If a new behavior needs
to be addressed, it needs to be addressed at the
next CFT meeting, which we have regularly."

Division of Health Service Regulation
STATE FORM ose 3ILP 11 Ii continuation sheet 7 of 7

inspection_type: MHLCS Complaint


state: NC

facility_name: Union Point

summary: Statement of Deficiency - MHLCS Complaint

raw_content:
Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL013-226

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 08/14/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

Cc
07/29/2024

Assessment/Treatment/Habilitation Plan

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

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

(d) The plan shall include:

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

(2) strategies;

(3) staff responsible;

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

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

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

519 UNION STREET SOUTH
UNION POINT
CONCORD, NC 28025
(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 7-29-24.
The complaint was unsubstantiated (intake
#NC00217596).A deficiency was cited.
This facility is licensed for the following service
category: 10A NCAC 27G .1700 Residential
Treatment Staff Secure For Children Or
Adolescents.
This facility is licensed for 6 and currently has a
census of 5. The survey sample consisted of
audits of 2 current clients.
V 112| 27G .0205 (C-D) v112

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

STATE FORM

6899

TITLE

(X6) DATE

If continuation sheet 1 of 7

SILP11

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHL013-226

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 08/14/2024

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

Cc
07/29/2024

This Rule is not met as evidenced by:

Based on record reviews and interviews, the
facility failed to develop and implement strategies
to meet the clients needs affecting 2 of 2 audited
clients (client #4 and client #5). The findings are:

Review on 7-25-24 of client #4's record revealed:
-Date of admission: 7-3-2024.

-Age: 16.

-Diagnoses: Post-traumatic Stress Disorder;
Adjustment Disorder; Conduct Disorder.
-Comprehensive Clinical Assessment (CCA)
dated 7-11-24 documented the following:
-"[Client #4] has a history of elopement and was
most recently AWOL (absent without leave) for
two weeks (unknown dates). Months prior
(unknown dates), he was AWOL for 2 months.
Due to this, he is currently seeking placement.
Current Living Situation: [Client #4] is currently
residing at Turning Point emergency crisis
placement Union Point. He was picked up last
Tuesday (unknown date) after returning from a
2-week elopement. He states that it is not going
well because he feels that staff are judging him
"before they get to know me" (regarding his past
behaviors and elopement). He reports he has
heard staff talking negatively about him and when
this occurs it makes him want to elope..."
-Person Centered Plan (PCP) dated 7-8-24 had
no goals or strategies to address client #4's

Division of Health Service Regulation

STATE FORM

6808 SILP11

519 UNION STREET SOUTH
UNION POINT
CONCORD, NC 28025
(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 112] Continued From page 1 Vv 112

If continuation sheet 2 of 7

Division of Health Service Regulation

PRINTED: 08/14/2024

FORM APPROVED

AWOL behavior.

Review on 7-19-24 of NC IRIS (North Carolina
Incident Response Improvement System) for the
period of April 1, 2024 to July 19, 2024
documented client #4's AWOL on 7-13-24.

Unable to interview Client #4 because he was still
AWOL at survey exit.

Review on 7-22-24 of client #5's record revealed:
-Date of admission: 5-8-24.

-Age: 17.

-Diagnoses: Disruptive Mood Dysregulation
Disorder; Unspecified Trauma and Stressor
Related Disorder; Conduct Disorder unspecified;
Cannabis Dependency uncomplicated.

-CCA dated 4-22-24 documenting client #5's
history of elopement.

-PCP dated 11-20-23 and updated 6-24-24
documented the following:

-"5/23/24: On 5/14/24 [client #5] packed a bag
and when questioned she expressed that she
planned to leave the home (facility). On 5/21/24,
[client #5] left the home (facility) without
permission; however she returned when picked
up by staff (unidentified staff). She was taken to
get drug tested and the results came back
positive for marijuana."

-"6/24/24: On 6/19/24 [client #5] left the home
(facility) without permission and went AWOL;
however, she was returned the next day (6/20/24)
by [Local Police]. She reported to the staff
(Qualified Professional/QP) that she was in a car
accident. Staff (QP) transported [client #5] to the
hospital. During her time of being AWOL, [client
#5] was with her child's father, and they stole his
mother ' s car which is now considered total from
the accident."

-"On 6/23/24, [client #5] went AWOL with

Division of Health Service Regulation

STATE FORM

6808 SILP11

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL013-226 07/29/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
519 UNION STREET SOUTH
UNION POINT
CONCORD, NC 28025
(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 112] Continued From page 2 Vv 112

If continuation sheet 3 of 7

Division of Health Service Regulation

PRINTED: 08/14/2024

FORM APPROVED

another peer. She returned home on 6/25/24. The
treatment team agreed to restrict all community
outings until authorized by the social worker
(Department of Social Services (DSS) Social
Worker) or clinical director. [client #5] phone list
has also been limited to her social worker (DSS),
GAL (Guardian Ad-Litem), and her sons foster
parent and his social worker. It is clinically
recommended that [client #5's] level of care is
PRTF (Psychiatric Residential Treatment Facility).
Moving forward any other infraction will result in
immediate removal from the facility."

-No goals or strategies documented in client #5's
plan to address client #5's AWOL behaviors.

Review on 7-19-24 of the NC IRIS reports for the
period of April, 1, 2024 to July 19, 2024
documented the following AWOL incidents for
client #5:

6-19-24, 6-23-24, 7-13-24

Interview on 7-19-24 with client #5 revealed:
-"I've went AWOL about 3 times (since being
admitted to the facility). | don't know why. It's
something | always do in group homes. I've ran
away from every group home I've been in."
-"Staff was here every time. They follow you
(client), try to talk you into coming back, stuff like
that (staff attempted to prevent client from going
AWOL)."

-"No", not working on any goals to address AWOL
behaviors.

Interview on 7-19-24 with staff #1 revealed:
-"Yes there have been some AWOL's. If a child
(client) goes AWOL and they are within distance
(line of sight of staff) and you (staff) have
eyesight (have the client in the line of sight), you
(staff) can follow them. Once you (staff)lose
eyesight we call the non emergency number for

Division of Health Service Regulation

STATE FORM

6808 SILP11

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL013-226 07/29/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
519 UNION STREET SOUTH
UNION POINT
CONCORD, NC 28025
(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 112] Continued From page 3 Vv 112

If continuation sheet 4 of 7

Division of Health Service Regulation

PRINTED: 08/14/2024

FORM APPROVED

the police and make a report then call the
guardian/DSS (department of social services)
and file a report."

Interview on 7-19-24 with staff #2 revealed:
-"Them (clients) running away, that's just
something that they will just do. If one of these
kids (clients) make up their mind they are going
to run, there is nothing you can do to stop them.
The protocol is we (staff) follow them until they
get out of eyesight and try to talk them into
coming back (to the facility). Most of the time we
can get them to come back. But once they get
out of eyesight we don't follow them any more."

Interview on 7-19-24, 7-22-24 and 7-29-24 with
the QP revealed

-2-6-24 the facility opened.: Since the home
opened there have been 9 AWOL's.

-"Once we (staff) realize its not them (clients) just
blowing off steam, (clients needing to calm down
and _ not leaving the property) we try to keep them
in eyesight as much as possible, or for as far as it
is safe for staff to do so (during a AWOL staff will
follow clients until the client is out of line of sight).
Once they are out of line of sight we call the
police and let the guardian know."

-"Upon admission, if they (clients) have a AWOL
history, we (QP) will go over their (clients) history
and their behaviors with the staff. We make sure
all the staff are alerted to their (clients)
behaviors."

-"We (facility) have a minimum of 3 staff on shift.
We have window sensors on all the windows.
Movement sensors in the bedrooms (bells that
alert the staff when a client comes in or out of
their rooms. Window sensors on the bedroom
windows connected to [security company], and
door chimes on the outside accessible doors."
-"The protocol starts before we get a kid (client).

Division of Health Service Regulation

STATE FORM

6808 SILP11

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL013-226 07/29/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
519 UNION STREET SOUTH
UNION POINT
CONCORD, NC 28025
(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 112] Continued From page 4 Vv 112

If continuation sheet 5 of 7

Division of Health Service Regulation

PRINTED: 08/14/2024

FORM APPROVED

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
Cc
MHL013-226 07/29/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
519 UNION STREET SOUTH
UNION POINT
CONCORD, NC 28025
(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 112) Continued From page 5 Vv 112

It (AWOL protocol) starts with training, we make
sure staff know what we are getting (what
behaviors a client has before they are admitted).
When we look at the referral (application and
paperwork received from referral source)..., we
interview the client and look at the assessments.
We screen (clients) as best as we can. QP's are
involved, (in the process/admission/screening
process) and should be guiding the services."
-"Before a client is admitted we look at their
history. We look at each one individually and
take it on a case by case basis. We look at how
long its been since the last AWOL, why they were
AWOL. All that (reasons) is taken into
consideration (for admission). If we have
concerns (regarding a clients AWOL behavior) we
will increase supervion/monitoring (of the client)."
-"The behavior, AWOL or other behaviors they
(clients) have should be documented. We
document (AWOL's) in session notes, incident
reports, team meeting notes. Yes, the guardians
are involved. The client's guardian gives
feedback. If the guardian does not specify they
want a goal to address the AWOL we don't put
one in (the PCP)"

-"After a client has a AWOL, | will discuss the
AWOL with them (the client) and try to process
their reasoning for leaving. | discuss the safety
aspect with them and remind them of things they
can do to... coping skills they can use to avoid
going AWOL in the future."

-"We discuss all AWOL's in the clients CFT (Child
and Family Team) meetings. As far as updating
the PCP, no (does not update the PCP after an
AWOL) unless the team (the guardian) makes a
recommendation."

Unable to interview Case Manager because she
was on vacation.

Division of Health Service Regulation
STATE FORM

6808 SILP11

If continuation sheet 6 of 7

Division of Health Service Regulation

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

NAME OF PROVIDER OR SUPPLIER

MHL013-226

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 08/14/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

Cc
07/29/2024

Interview on 7-29-24 with the Clinical Director
revealed:

-"A client's AWOL history should be documented
in the PCP and they should have a goal that
addresses that behavior somewhere in the plan.
[QP] can turn it into an intervention (within the
PCP) or put it (goal/strategy to address the AWOL
behavior) where it makes the most sense. There
needs to be a intervention or goal or crisis plan
noting the behaviors as part of the clients safety
plan. Sometimes it (behavior goal) will be put in
the day program part and not in the clients PCP
(the facility's PCP) but it needs to be in both.
[Case Manager] needs to be doing this (making
sure client behaviors are documented in the
PCPs) The QP and the Case Manager (lead
Case Manager for the the facility) are suppose to
work closely with the staff and review client
behaviors with the staff. If a new behavior needs
to be addressed, it needs to be addressed at the
next CFT meeting, which we have regularly."

Division of Health Service Regulation
STATE FORM

6809

SILP11

519 UNION STREET SOUTH
UNION POINT
CONCORD, NC 28025
(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 112] Continued From page 6 Vv 112

If continuation sheet 7 of 7

document_type: Statement of Deficiency


facility_name: A Place of My Own  LLC

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

raw_content:
PRINTED: 03/28/2025

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL013-209 TT 03/27/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
315 LOWER POND ROAD
A PLACE OF MY OWN, LLC
KANNAPOLIS, NC 28083
(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

An annual and follow up survey was completed
on 3/27/25. Deficiencies were cited.

This facility is licensed for the following service
category: 10A NCAC 27G .5600B Supervised
Living for Minors with Developmental Disability.

This facility is licensed for 3 and has a current
census of 2. The survey sample consisted of
audits of 2 current clients.

V 112| 27G .0205 (C-D) v112
Assessment/Treatment/Habilitation Plan

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

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

(d) The plan shall include:

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

(2) strategies;

(3) staff responsible;

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

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

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

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

Administrative Director
QURo8\ 4/10/2025

STATE FORM 6609 KFW411 If continuation sheet 1 of 4

Division of Health Service Re

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

NAME OF PROVIDER OR SUPPLIER

(X1) PROVIDER/SUPPLIERICLIA
IDENTIFICATION NUMBER:

MHLO013-209

PRINTED: 03/28/2025

FORM APPROVED

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

STREET ADDRESS, CITY, STATE, ZIP CODE

315 LOWER POND ROAD
KANNAPOLIS, NC 28083

A PLACE OF MY OWN, LLC

(X3) DATE SURVEY
COMPLETED

03/27/2025

This Rule is not met as evidenced by:

Based on record review and interview the facility
failed to review the treatment plan annually with
written consent or agreement by the client's legal
guardian or responsible party affecting 2 of 2
audited clients (#1 and #2). The findings are:

Review on 3/26/25 of client #1's record revealed:
-Admission date of 8/7/23.

-Diagnoses of Intellectual Developmental
Disability, Attention-Deficit Hyperactivity Disorder,
and Autism.

-Short term goals were last updated 8/7/23.
-There was not a signature or written consent
from the guardian or responsible party on client
#1's short term goals.

Review on 3/26/25 of client #2's record revealed:
-Admission date of 11/7/23.

-Diagnoses of Autism Spectrum Disorder,
intellectual Impairment and Language
Impairment, Moderate Intellectual Disability.
-Short term goals were last updated 11/7/23.
-There was not a signature or written consent
from the guardian or responsible party on client
#2's short term goals.

Interview on 3/26/25 with the Owner/Qualified
Professional revealed:

-At the annual "ISP (Individual Support Plan)

meeting the care manager develops the long

term goals, then we develop the short term

Division of Health Service Regulation

STATE FORM

As discussed with the surveyor, goals are
developed annually and reviewed monthly with
the team to assess progress. While we
discuss and agree upon the goals in meeting,
we have not obtained in the past. Going
forward, at a minimum of annual, we will
obtain a physical or electronic signature from
the guardian at the implementation of a new
goal period.

Water temperatures are set and checked on a
quarterly basis in the home. In addition, they
are reviewed when Sanitation comes to
conduct an annual review. In 2023 we
received higher temperature readings that was
resolved by purchasing a new water heater.
We have currently adjusted the thermostat to
reduce the water temperature level. We will
continue to monitor and adjust weekly until we
can maintain temperature levels that are
between 100-116 degrees.

ene KFW411

(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 112] Continued From page 1 Vv 112

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:

MHLO013-209

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

315 LOWER POND ROAD
KANNAPOLIS, NC 28083

A PLACE OF MY OWN, LLC

PRINTED: 03/28/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R
03/27/2025

(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

Vv 112

V 752|

Continued From page 2

goals."

-Did not update short term goals until the goals
were achieved at 90%.

-Clients #1 and #2 had not achieved their goals at
90% and therefore they had not been updated.
-"We do not get a physical signature (from the
guardian) because we are all part of the
planning."

Interview on 3/26/25 with the Owner #2 revealed:
-"Guardians don't sign the short term goals."
-"They (guardians) sign the ISP."

-"There has never been a signature required for
the short term goals."

27G .0304(b)(4) Hot Water Temperatures

10A NCAC 27G .0304 FACILITY DESIGN AND
EQUIPMENT

(b) Safety: Each facility shall be designed,
constructed and equipped in a manner that
ensures the physical safety of clients, staff and
visitors.

(4) In areas of the facility where clients are
exposed to hot water, the temperature of the
water shall be maintained between 100-116
degrees Fahrenheit.

This Rule is not met as evidenced by:

Based on observation and interview, the facility
failed to maintain water temperature between
100-116 degrees Fahrenheit where clients are
exposed to hot water. The findings are:

Observation on 3/26/25 of the facility at
approximately 3:30pm revealed:

-Water temperature in the kitchen sink and
upstairs bathroom sink and shower was 118

Division of Health Service Regulation
STATE FORM

Vv 112

V 752

6809

KFW411

If continuation sheet 3 of 4

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

A PLACE OF MY OWN, LLC

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

MHLO013-209

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

315 LOWER POND ROAD

KANNAPOLIS, NC 28083

PRINTED: 03/28/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

R
03/27/2025

degrees Fahrenheit.
-Water temperature in the downstairs bathroom
sink was 120 degrees Fahrenheit.

Attempted interview with client #1 on 3/26/25 was
unsuccessful since he was nonverbal.

Attempted interview with client #2 on 3/26/25 was
unsuccessful because he answered yes to all
questions.

Interview on 3/26/25 with staff #1 revealed:
-Adjusted the water for clients #1 and #2.

-There had not been any injuries due to hot water.
-"When the fire department came out they told us
(facility staff) it was high and we lowered it.

-"We (facility staff) will lower it again."

Interview on 3/26/25 with the Program
Manager/Qualified Professional (QP) revealed:
-Was not aware the water was too hot.

-The water heater had recently been replaced.
-Staff adjusted the water for the clients.

-There had not been any injuries due to hot water.
-Would lower the water temperature.

Division of Health Service Regulation
STATE FORM

6809

KFW411

(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 752] Continued From page 3 V 752

If continuation sheet 4 of 4

inspection_type: MHLCS Annual and Follow-up

document_type: Plan of Correction


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

raw_content:
PRINTED: 03/28/2025

FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING: COMPLETED
R
MHL013-209 03/27/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
315 LOWER POND ROAD
A PLACE OF MY OWN, LLC
KANNAPOLIS, NC 28083
(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

An annual and follow up survey was completed

on 3/27/25. Deficiencies were cited.

This facility is licensed for the following service

category: 10A NCAC 27G .5600B Supervised

Living for Minors with Developmental Disability.

This facility is licensed for 3 and has a current

census of 2. The survey sample consisted of

audits of 2 current clients.

V 112| 27G .0205 (C-D) v112

Assessment/Treatment/Habilitation Plan

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

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

(d) The plan shall include:

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

(2) strategies;

(3) staff responsible;

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

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

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

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

STATE FORM

6899

TITLE

(X6) DATE

If continuation sheet 1 of 4

KFW411

Division of Health Service Regulation

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

MHLO013-209

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
315 LOWER POND ROAD
KANNAPOLIS, NC 28083

A PLACE OF MY OWN, LLC

PRINTED: 03/28/2025

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R
03/27/2025

(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 112] Continued From page 1 Vv 112

This Rule is not met as evidenced by:

Based on record review and interview the facility
failed to review the treatment plan annually with
written consent or agreement by the client's legal
guardian or responsible party affecting 2 of 2
audited clients (#1 and #2). The findings are:

Review on 3/26/25 of client #1's record revealed:
-Admission date of 8/7/23.

-Diagnoses of Intellectual Developmental
Disability, Attention-Deficit Hyperactivity Disorder,
and Autism.

-Short term goals were last updated 8/7/23.
-There was not a signature or written consent
from the guardian or responsible party on client
#1's short term goals.

Review on 3/26/25 of client #2's record revealed:
-Admission date of 11/7/23.

-Diagnoses of Autism Spectrum Disorder,
intellectual Impairment and Language
Impairment, Moderate Intellectual Disability.
-Short term goals were last updated 11/7/23.
-There was not a signature or written consent
from the guardian or responsible party on client
#2's short term goals.

Interview on 3/26/25 with the Owner/Qualified
Professional revealed:

-At the annual "ISP (Individual Support Plan)

meeting the care manager develops the long

term goals, then we develop the short term

Division of Health Service Regulation
STATE FORM

ene KFW411

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:

MHLO013-209

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

315 LOWER POND ROAD
KANNAPOLIS, NC 28083

A PLACE OF MY OWN, LLC

PRINTED: 03/28/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

R
03/27/2025

(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

Vv 112

V 752|

Continued From page 2

goals."

-Did not update short term goals until the goals
were achieved at 90%.

-Clients #1 and #2 had not achieved their goals at
90% and therefore they had not been updated.
-"We do not get a physical signature (from the
guardian) because we are all part of the
planning."

Interview on 3/26/25 with the Owner #2 revealed:
-"Guardians don't sign the short term goals."
-"They (guardians) sign the ISP."

-"There has never been a signature required for
the short term goals."

27G .0304(b)(4) Hot Water Temperatures

10A NCAC 27G .0304 FACILITY DESIGN AND
EQUIPMENT

(b) Safety: Each facility shall be designed,
constructed and equipped in a manner that
ensures the physical safety of clients, staff and
visitors.

(4) In areas of the facility where clients are
exposed to hot water, the temperature of the
water shall be maintained between 100-116
degrees Fahrenheit.

This Rule is not met as evidenced by:

Based on observation and interview, the facility
failed to maintain water temperature between
100-116 degrees Fahrenheit where clients are
exposed to hot water. The findings are:

Observation on 3/26/25 of the facility at
approximately 3:30pm revealed:

-Water temperature in the kitchen sink and
upstairs bathroom sink and shower was 118

Division of Health Service Regulation
STATE FORM

Vv 112

V 752

6809

KFW411

If continuation sheet 3 of 4

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

A PLACE OF MY OWN, LLC

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

MHLO013-209

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

315 LOWER POND ROAD

KANNAPOLIS, NC 28083

PRINTED: 03/28/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

R
03/27/2025

degrees Fahrenheit.
-Water temperature in the downstairs bathroom
sink was 120 degrees Fahrenheit.

Attempted interview with client #1 on 3/26/25 was
unsuccessful since he was nonverbal.

Attempted interview with client #2 on 3/26/25 was
unsuccessful because he answered yes to all
questions.

Interview on 3/26/25 with staff #1 revealed:
-Adjusted the water for clients #1 and #2.

-There had not been any injuries due to hot water.
-"When the fire department came out they told us
(facility staff) it was high and we lowered it.

-"We (facility staff) will lower it again."

Interview on 3/26/25 with the Program
Manager/Qualified Professional (QP) revealed:
-Was not aware the water was too hot.

-The water heater had recently been replaced.
-Staff adjusted the water for the clients.

-There had not been any injuries due to hot water.
-Would lower the water temperature.

Division of Health Service Regulation
STATE FORM

6809

KFW411

(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 752] Continued From page 3 V 752

If continuation sheet 4 of 4


summary: Plan of Correction - MHLCS Annual and Complaint

raw_content:
PRINTED: 03/20/2024
FORM APPROVED.
Division of Health Service Requlation

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

MHL013-209 ———___ 03/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
315 LOWER POND ROAD
KANNAPOLIS, NC 28083

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

DEFICIENCY)

A PLACE OF MY OWN, LLC

V 000 INITIAL COMMENTS.

An annual and complaint survey was completed
| on 3-14-24. The complaint was unsubstantiated
(4NC00213629). Deficiencies were cited.

This facility is licensed for the following service
category: 10A NCAC 27G 5600B Supervised
Living for Minors with a Developmental Disability

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

27G .0207 Emergency Plans and Supplies

VED
10A NCAC 27G .0207 EMERGENCY PLANS RECE

| AND SUPPLIES MAY 09 2024
(a) Awritten fire plan for each facility and
area-wide disaster plan shall be developed and ‘

shall be approved by the appropriate local DHSR-MH Licensure Sect
authority.

(b) The plan shall be made available to all staff
and evacuation procedures and routes shall be
posted in the facility.

(c) Fire and disaster drills in a 24-hour facility
shall be held at least quarterly and shall be
repeated for each shift. Drills shall be conducted
under conditions that simulate fire emergencies
(d) Each facility shall have basic first aid supplies
accessible for use.

The facility has adjusted the policy regarding
our fire drill and update the form to reflect
fire drill to be conducted quarterly on each
shift. This has been implemented and will

A F be monitored by Executive Staff and or the
This Rule is not met as evidenced by: OP by 4st of Re month of the quarter

Based on record review and interviews, the ending month to ensure drills are completed
facility failed to ensure that disaster drills were timely. This will also allow sufficient time
completed on each shift at least quarterly. The before quarter end to ensure compliance.
findings are:

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

STATE FORM “- 6QPU11 If continuation sheet 1 of 4

PRINTED: 03/20/2024
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

B. WING __

MHLO013-209 03/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
315 LOWER POND ROAD
KANNAPOLIS, NC 28083

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

DEFICIENCY)

A PLACE OF MY OWN, LLC

(x4) 1D
PREFIX
TAG

V 114! Continued From page 1

Review on 3-14-24 of facility's disaster drill
schedule for the second quarter of 2023 through
the 1st quarter of 2024 revealed

-The 2nd quarter of 2023 had no ‘st or 3rd
shift disaster drill documented.

-The 4th quarter of 2023 had no third shift
disaster drill documented.

Interview on 3-14-24 with the Executive Director
revealed:

-They would ensure that going forward,
disaster drills would be completed on each shift,
at least quarterly.

27G .0209 (C) Medication Requirements

410A NCAC 27G .0209 MEDICATION

REQUIREMENTS

(c) Medication administration:

(1) Prescription or non-prescription drugs shall

only be administered to a client on the written |

order of a person authorized by law to prescribe

drugs.

| (2) Medications shall be self-administered by
clients only when authorized in writing by the
client's physician.
(3) Medications, including injections, shall be
administered only by licensed persons, or by
unlicensed persons trained by a registered nurse,

| pharmacist or other legally qualified person and

| privileged to prepare and administer medications.

| (4) A Medication Administration Record (MAR) of
all drugs administered to each client must be kept

current. Medications administered shall be

| recorded immediately after administration. The

| MAR is to include the following
(A) client's name;

| (B) name, strength, and quantity of the drug;

Division of Health Service Regulation
STATE FORM oe 6QPU11 If continuation sheet 2 of 4

NAME OF PROVIDER OR SUPPLIER

A PLACE OF MY OWN, LLC

(x4) 1D
PREFIX
TAG

Division of Health Service Requlation

STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER;

MHL013-209

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

PRINTED: 03/20/2024
FORM APPROVED

(X3) DATE SURVEY

COMPLETED

03/14/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

315 LOWER POND ROAD

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

Continued From page 2

| (C) instructions for administering the drug;

(D) date and time the drug is administered; and
(E) name or initials of person administering the

| drug.

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

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

| interviews, the facility failed to ensure that all

medications were dispensed only by a registered
pharmacists, physicians, or other health care
practitioners authorized by law and registered
with the North Carolina Board of Pharmacy and
that medication was only administered with a
written order signed by a physician, effecting
three of three clients (Clients #1, #2, and #3). The

| findings are:

Observation on 3-14-24 at approximately 2:00 pm
revealed

-Pill dispenser with Client #1's name on it had
been filled for one week. AM had two pills, pm a
had three pills.

-Pill dispenser with Client #2's name on it had
been filled for the week. AM had 9 pills, pm had 4
pills.

-Pill dispenser with Client #3's name on it had
been filled for the week. AM had 3 pills, pm had 3
pills.

Review on 3-14-24 of Client #2's March 2024

Division of Health Service Regulation

STATE FORM

5800

ID
PREFIX
TAG

KANNAPOLIS, NC 28083

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

| (x)
| comPLeTe
| DATE

Pill dispensers have been removed from
use as of 3.15.24. Outreach was made to
all PCP, Medication Management
Providers and the pharmacy to obtain all
doctors orders for prescriptions. Doctors
Order have been obtained for all current
prescriptions and are maintained in a
binder separated by resident in the
medication closet. Client #2 does not
have a current order for Polyethylene.
This items has been updated and
removed from the MAR to reflect current
prescriptions. Client # 3 does not have a
current order for Polyethylene. This items
has been updated and removed from the
MAR to reflect current prescriptions.
Client #3 does not have current order for
Multivitamin gummies. Those items were
provided by his social worker at intake.
Since a doctors order is not current, they
have been removed from the MAR and
discontinued for use. If an updated order
is provided by his PCP, it will be
maintained and updated in the MAR.

The QP will review the MAR and doctors
orders at a minimum monthly or at
prescription refill to ensure the information
is correct.

6QPU11

If continuation sheet 3 of 4

Division of Health Service Regulation

PRINTED: 03/20/2024
FORM APPROVED

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

MHLO013-209

NAME OF PROVIDER OR SUPPLIER

(X2) MULTIPLE CONSTRUCTION

A BUILDING

B. WING

315 LOWER POND ROAD
KANNAPOLIS, NC 28083

A PLACE OF MY OWN, LLC

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

ID
PREFIX
TAG

(X3) DATE SURVEY
COMPLETED

03/14/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

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

Vv 118) Continued From page 3

MAR revealed:
- Polyethylene glycol 17 grams with juice or
water prn (as needed) (for constipation)

Review on 3-14-24 of Client #2's physician's
orders revealed

-No signed order for 17 grams of
polyethylene glycol 17 grams with juice or water
prn (as needed).

| Review on 3-14-24 of Client #3's March 2024
MAR revealed:
-2 multivitamin gummy each morning.
-Polyethylene glycol 17 grams with juice or
water daily. (for constipation)

| Review on 3-14-24 of Client #3's physician's
orders revealed:

-No signed physician's order for 2
multivitamin gummy each morning.

-No signed physicians order for Polyethylene
| glycol 17 grams with juice or water daily.

| Interview on 3-14-24 with the Qualified
| Professional revealed:

-Putting the pills in a pill dispenser made
giving the clients their medications easier.

-She understood why that should not happen
and would correct it immediately.

-She would make sure that all medications
had the correct orders signed by the physician

Division of Health Service Regulation
STATE FORM

be faioro , vin Du

Toi Jackson, Admin Director (May 9, 2024 09:04 EDT)

Vv 118

S00, 6QPU11

May 9, 2024

If continuation sheet 4 of 4

Survey Response - 3.23.24 - Lower Pond

Final Audit Report 2024-05-09

Created: 2024-05-09
By: HE in. dream.manifest@gmail.com)
Status: Signed

Transaction ID: CBJCHBCAABAAESs_0_HrTo7bja5CuAbwktjvGsqRpwiP-

"Survey Response - 3.23.24 - Lower Pond" History

Document created by HD (tin. dream.manitest@gmail.com)
2024-05-09 - 1:01:19 PM GMT- IP address: 65.184.76.48

Document emailed to Fe thinkdreammanifest.org for signature
2024-05-09 - 1:02:31 PM GMT

© Email viewed by (iE @ thinkdreammanifest.org
2024-05-09 - 1:02:54 PM GMT- IP address: 65.184.76.48

Signer Othinkdreammanifest.org entered name at signing as | | Admin Director

2024-05-09 - 1:04:01 PM GMT- IP address: 65.184.76.48
% Document e-signed by cease Director
Signature Date: 2024-05-09 - 1: - Time Source: server- IP address: 65.184.76.48

Agreement completed.
2024-05-09 - 1:04:03 PM GMT

(3 Adobe Acrobat Sign

inspection_type: MHLCS Annual and Complaint


summary: MHLCS Annual and Complaint


summary: Statement of Deficiency - MHLCS Annual and Complaint

raw_content:
PRINTED: 03/20/2024

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:
MHL013-209 03/14/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
315 LOWER POND ROAD
A PLACE OF MY OWN, LLC
KANNAPOLIS, NC 28083
(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

An annual and complaint survey was completed

on 3-14-24. The complaint was unsubstantiated

(#NC00213629). Deficiencies were cited.

This facility is licensed for the following service

category: 10A NCAC 27G 5600B Supervised

Living for Minors with a Developmental Disability.

This facility is licensed for three and currently has

a census of three. The survey sample consisted

of audits of three current clients.

V 114| 27G .0207 Emergency Plans and Supplies Vv 114

10A NCAC 27G .0207 EMERGENCY PLANS
AND SUPPLIES

(a) Awritten fire plan for each facility and
area-wide disaster plan shall be developed and
shall be approved by the appropriate local
authority.

(b) The plan shall be made available to all staff
and evacuation procedures and routes shall be
posted in the facility.

(c) Fire and disaster drills in a 24-hour facility
shall be held at least quarterly and shall be
repeated for each shift. Drills shall be conducted
under conditions that simulate fire emergencies.
(d) Each facility shall have basic first aid supplies
accessible for use.

This Rule is not met as evidenced by:

Based on record review and interviews, the
facility failed to ensure that disaster drills were
completed on each shift at least quarterly. The
findings are:

Division of Health Service Regulation

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

STATE FORM

TITLE

809 6QPU11

(X6) DATE

If continuation sheet 1 of 4

Division of Health Service Regulation

NAME OF PROVIDER OR SUPPLIER

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

MHLO013-209

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

315 LOWER POND ROAD
KANNAPOLIS, NC 28083

A PLACE OF MY OWN, LLC

PRINTED: 03/20/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

FORM APPROVED

(X3) DATE SURVEY

COMPLETED

03/14/2024

(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

V114

V 118)

Continued From page 1

Review on 3-14-24 of facility's disaster drill
schedule for the second quarter of 2023 through
the 1st quarter of 2024 revealed:

-The 2nd quarter of 2023 had no ‘st or 3rd
shift disaster drill documented.

-The 4th quarter of 2023 had no third shift
disaster drill documented.

Interview on 3-14-24 with the Executive Director
revealed:

-They would ensure that going forward,
disaster drills would be completed on each shift,
at least quarterly.

27G .0209 (C) Medication Requirements

10A NCAC 27G .0209 MEDICATION
REQUIREMENTS

(c) Medication administration:

(1) Prescription or non-prescription drugs shall
only be administered to a client on the written
order of a person authorized by law to prescribe
drugs.

(2) Medications shall be self-administered by
clients only when authorized in writing by the
client's physician.

(3) Medications, including injections, shall be
administered only by licensed persons, or by
unlicensed persons trained by a registered nurse,
pharmacist or other legally qualified person and
privileged to prepare and administer medications.
(4) A Medication Administration Record (MAR) of
all drugs administered to each client must be kept
current. Medications administered shall be
recorded immediately after administration. The
MAR is to include the following:

(A) client's name;

(B) name, strength, and quantity of the drug;

Division of Health Service Regulation
STATE FORM

Vv 114

V 118

6809

6QPU11

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:

MHLO013-209

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

315 LOWER POND ROAD
KANNAPOLIS, NC 28083

A PLACE OF MY OWN, LLC

PRINTED: 03/20/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

03/14/2024

(C) instructions for administering the drug;

(D) date and time the drug is administered; and
(E) name or initials of person administering the
drug.

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

This Rule is not met as evidenced by:

Based on record reviews, observation and
interviews, the facility failed to ensure that all
medications were dispensed only by a registered
pharmacists, physicians, or other health care
practitioners authorized by law and registered
with the North Carolina Board of Pharmacy and
that medication was only administered with a
written order signed by a physician, effecting
three of three clients (Clients #1, #2, and #3). The
findings are:

Observation on 3-14-24 at approximately 2:00 pm
revealed:

-Pill dispenser with Client #1's name on it had
been filled for one week. AM had two pills, pm a
had three pills.

-Pill dispenser with Client #2's name on it had
been filled for the week. AM had 9 pills, pm had 4
pills.

-Pill dispenser with Client #3's name on it had
been filled for the week. AM had 3 pills, pm had 3
pills.

Review on 3-14-24 of Client #2's March 2024

Division of Health Service Regulation
STATE FORM

6809

6QPU11

(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 118] Continued From page 2 Vv 118

If continuation sheet 3 of 4

Division of Health Service Regulation

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

MHLO013-209

NAME OF PROVIDER OR SUPPLIER

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

315 LOWER POND ROAD
KANNAPOLIS, NC 28083

A PLACE OF MY OWN, LLC

PRINTED: 03/20/2024

STREET ADDRESS, CITY, STATE, ZIP CODE

(X3) DATE SURVEY

FORM APPROVED

COMPLETED

03/14/2024

(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 118] Continued From page 3 Vv 118

MAR revealed:
- Polyethylene glycol 17 grams with juice or
water prn (as needed) (for constipation)

Review on 3-14-24 of Client #2's physician's
orders revealed:

-No signed order for 17 grams of
polyethylene glycol 17 grams with juice or water
prn (as needed).

Review on 3-14-24 of Client #3's March 2024
MAR revealed:
-2 multivitamin gummy each morning.
-Polyethylene glycol 17 grams with juice or
water daily. (for constipation)

Review on 3-14-24 of Client #3's physician's
orders revealed:

-No signed physician's order for 2
multivitamin gummy each morning.

-No signed physicians order for Polyethylene
glycol 17 grams with juice or water daily.

Interview on 3-14-24 with the Qualified
Professional revealed:

-Putting the pills in a pill dispenser made
giving the clients their medications easier.

-She understood why that should not happen
and would correct it immediately.

-She would make sure that all medications
had the correct orders signed by the physician.

Division of Health Service Regulation
STATE FORM

6809

6QPU11

If continuation sheet 4 of 4


facility_name: Adrienne's House II

raw_content:
Division of Health Service Re
STATEMENT OF DEFICIENCIES

(X1) PROVIDER/SUPPLIERICLIA

(X2) MULTIPLE CONSTRUCTION

PRINTED: 07/29/2024
FORM APPROVED

(X3) DATE SURVEY

Acomplaint survey was completed on 7/24/24.
The complaint was unsubstantiated (Intake
#NC00219313). No deficiencies were cited.

This facility is licensed for the following service
category: 10A NCAC 27G .1700 Residential
Treatment Staff Secure for Children or
Adolescents.

This facility is licensed for 4 and has a current
census of 3. The survey sample consisted of
audits of 1 current client and 1 former client.

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

STATE FORM

6899

AND PLAN OF CORRECTION IDENTIFICATION NUMBER: ‘A. BUILDING COMPLETED
Cc
MHL013-233 07/24/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
\ 1070 GAITHER PLACE NW
ADRIENNE'S HOUSE II
CONCORD, NC 28027
(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

YF1N11

TITLE (X6) DATE

If continuation sheet 1 of 1