Division of HeaIIh Service Reaulallon PRINTE D. 04/25/2013 FORM APPROVED STATEMENT oE nEErcrENcrES rm FLAN or CORRECTION roENTrErcATroN NUMBER MNLun-zl a A a WING < D. 04/25/2013 FORM APPROVED Division at Health ServiceReuulatlon STATEMENT eE txti txzi MULTWLE txai DATE SURVEY AND new or NUMBER COMFLETED a outcome 5 mm; 04I13IIU13 NAME oE NEW HORIZON GROUP HOME. STREET AD DRESS ciTv. STATE ZIP conE LUMBER BRIDGE. NC 28:51 my in STATEMENTOF iD FLAN or (xsi (EACH MUST eE FRECEDED ev FULL new (EACH CORRECUVEACYION SHOULDBE comm TAG m; CROSS-REFERENCEDYD sweepers" one 103 Continued me page 1 108 108 the Ameilcan Heart Association or their equivalence lor relieving airway obstruction, Maw-rm In place In camel the define-Icy: The governing body shall develop and implement policies and procedures identilying, 1 Re" ml the New 0'18"" reporting, investigating and controlling infectious Checklist include "wmmg "mm" and oammunlcable diseases ol personnel and ending that no new 5qu person can be 429718 alien's>> cheduled on slnit peninenl training has been completed he. medication ndminbu'nliun. Cl. documentation. etc See example attached 2 Revised the New Hunzon Dnenmliun This Rule is not met as evidenced by: Checklist to include stuff flaming 0n the 429718 Based on record review and interview, the tacility needs oflhe comumertei>> tailed to ensure stall were trained fol Example Attached Attachment (Mental Health/Develpmental Disabilities/Substance Abuse Services) needs ol 2 Clinical Dimmer/LPG Will mm the preset" the clients fat 5 of a audited stall mflwuh exumvles of venous #1 and the Operations Manager/Group Home diagnosis and how to address must 712718 Staff), The timings are: appropnntely/eiiectnelv u||l|l|ng the best methods in order to be equipped to Review on 04/10/13 ol Stalt #3'5 personnel lile meet the needs or the eonsnmers. revealed. Data at application on 02/20/13. Measure in plate to prevent meet-mote oi eNo documentation oi training in to he problem: meet the needs of the clients. 1 Clinical Director/LPC will be for interview on 04/05/13 staff #3 stated: miming the will ns new Ongomg She did not remember the trainers/instructors, Eonsumers nre admitted to the group home She didn't remember any training specific to dingnusb needs nre modified, 2 clinical Director/LPC will provide shadowing Ongomg Review on 04/10/13 ol Stalt #Z's personnel lile ithe dneot care stdi'lnnd doenment discussion revealed. ithe shadowing during iorntal supervision, rDaie ol application on 02/20/13, No documentation oi training in to Updnted copies oi the Onemdnon Checklist meet the needs of the clients. elevnnt to any staff penon the Prohattonnrv Ongomg ime period will be forwarded k) the CED/owner interview on 04/05/13 staff #2 stated: prior to hire. at the end oi the inst week. at the He did nm remembei the end of the first month and each subsequent ivlsinn dr Health Service Regulation STATE FORM azultt PRINTED: 04/25/2018 FORM APPROVED Division of Health Service Regulation V108 continued month during the first 90 days of new hire. Who is monitoring and how often to ensure the problem will not re-occur: Owner/CEO and Quality Management Director Ongoing will monitor the ongoing training, shadowing, and supervision documentation by review of personnel record documentation at least 10% of personnel records per month and the review of updated Orientation Checklist forms during a new hire’s first 90 days of hire. Division of Health Service Regulation STATE FORM 6899 8ZNI11 If continuation sheet 3 of Division of HeaIth Service Reaulatlon D. 04/25/2015 FORM APPROVED He did not have training in to meet the needs of the clients. Review on 04/10/15 or Start #65 personnel rile revealed. Date or application on 02/17/15, No documenlation or training in meet the needs of the clients. Interview on 04/12/15 Staff/16 slated, . She had received no training at the lacility, "[Slatr helped us and showed us videos, we were in a garage in [Licenseel's other level group home in [nearby county]." She had notralning 1n to meellhe needs oflhe clients. Review on 04/10/15 ol Sta/r #S's personnel rile revealed. Date or application on 02/02/15. 7No documenlation or training in meet the needs oflhe clients, Interview on 04/09/15 staff #9 slated, He had no training on to meet the needs ofthe cIients. He had received no training at the facility. 'All of my training was on the job Review on 04/10/15 at Staff #105 personneI file revealed. Date or application on 02/13/15. No documentation of training in to meet the needs ofthe clients. Interview on 04/10/15 Staff/110 slated, He worked his first day at the raoilhy oe/ore he turned in his application. . He had received "no training at all." He had no training In to meellhe swarm or rm reonosmorenzmro tle coNsrRuchoN txal one suevsv mo mm or NUMBER coverage A mum-:15 WING 0411312013 NAME OF may cirv. ewe Zip code NEW NORIZON GROUP HOME. LLC LUMBER BRIDGE. NC 28357 1x4) 1o summer/Tor DEFICIENCIES 10 mm or pa, rem (EACH MUST BE moron; av FULL mm EACH smuwfii comm no m; ms we V108 Continued From page 2 V108 o1 Healm Service Regmallon STATE FORM 52mm 1: sheerA Division of Heaith Service Reaulatlon D. 04/25/2013 FORM APPROVED STATEMENT 0E nEErclENclES AND FLAN or coRREchon loENTlErcATloN NUMBER MNL018-31E (le MULTWLE coNSTRuchoN A a WING txal DATE SURVEY COMFLETED 04l1 3201 3 NAME 0E pmvloERoAsuwtlEa STREET on NEW NORIZON GROUP HOME. LUMBER DRESS STATE ZIP conE BRIDGE. Nc 20357 1x4) in TAG SUMMARY oEElclENclES nEErclEch MUST BE FRECEDED av FULL nEElclENcV) 10 FLAN or coRREchon prey rEAcn CORRECUVEACTIONSHDULDEE cothTE TAG CROSS-REFERENCEDTD THE ApvxopRlATE V108 V112 Continued From page a needs of the clients. Review on 04/10/15 ol the Operations ManageT/Gmup Home Managers personnel rile revealed. Date or application on 02/20/15. No documentation or training in to meet the needs of the clients. interview on 04/05/15 the Opelation ManageT/Gmup home manager stated. he had only worked for one week at the lacility. He was not sure he had received training specific to to meet the needs or the clients. Interview on 04/10/15 the Licensee stated, she had paid to have the trainings completed tor Staff. She thought all siaff had trainings compieted. No contact lnfolmation or verification rrom the Licensee and/or the trainer was received by the completion or the survey process on 04/13/10. This dericiency is crossed reterenced into 10A NCAC 27s ,1301 SCOPE (V301) tor a Type A1 rule violation. 276 .0205 (GD) Plan 10A NCAC 27s .0205 ASSESSMENTAND OR SERVICE PLAN (0) The plan shall be developed based on the assessment, and in partnership with the client or legally responsible person or both, within 30 days V103 V112 at Health Service Regulation STATE FORM ltmnonumronsneero Division 0! Heakh ServiceReuulallon D. 04/25/2013 FORM APPROVED or DEFlclENclEs (xi) women/summons (le humus coNsTRuchuN (xal one suRva AND ms or sundae A BUWNG comma WING 0411312013 NAME OF i NEW HORIZON GROUP HOME. LUMBER namesorgy max (EACH DEFlclEch nusr er nnrcepsn sv FULL PREFIX (EACH SHOULDEE COMPLETE no m; rue snesopnms one DEFlclENch V112 Conhhued From page 4 V112 of admission fol cliems who are expected '12 "we've semces bgy'm" 30 days' Measum in place no toned the deficiency: The plan shall Include. . . . lemmg Dueeror Will |mm rhe sraricn rhe (1) clrenl ourcome(s) snal are Io be meme" [mm the new reamed an achieved by ol lhe service and a dmmem 0mm We 712,13 proyecied dale of achievement. '3 3' . enecred on the ueurnrenr plan. and the service (2) S'ra'eg'esone (3) staff responsible; goofinem'fun (4) a schedule lor review of ihe plan as leass annually in oonsullarion rhe cllem or legally responsible person or bmh: 22d (5) basis lor evaluation or assessmemol 2113"" 42,18 oumame achievemem: and (6) wrrdeh oonsemor agreemem byme cllenlol responsible pany, or a wrineh slaiemern by me gram "mg" provider slafing why such conseni could hm be 0" "m 42,18 . Schedule speerncullv . ressmg rhe edncduunal obtained. nne vs excessive TV See uuached copy or Daily Schedule This Rule is not mel as evidenced by: Mmsurfl in place in prevenr reoccurrence or Based on record reviews and interviews, <>. 17 year old male. (1318 Of 02/27/11 2 Clinical Drrecror/LPC and Qualuy Dlagnoses 0' Malor Depressmn Dlsorder, unugenrenr Direcrcr will renew medrcul Disorder. Schizophlen la and Adenlion semi documemm weekly p, mm me emee "mes are clearly semees lhul 0 Can'efed Plan (PCP) Updamd 0" address lhe needs oflhe consumer per lrealmenl 01/26/13 reyealed. Local DSS (Dapanmen' 0' plun and assessmenr. Resulrs of lhe Smal Sen/Ices of cum home evlew \Mll be ed In srulr meetings and ndludlml supem, ons ii needed. Clinical Dimmer/LPC Will "shadow" rhe group home soil |o ensure rhe services are gulallull STATE FORM BZNHI in PRINTED: 04/25/2018 FORM APPROVED Division of Health Service Regulation V112 continued being provided according to DMH Rules. Ongoing Results of the review will be addressed in staff meetings and individual supervisions if needed. 4. Clinical Director and Quality Management Director will complete “surprise” visits to the group home on various shifts to ensure the group home activity schedule are being followed. Results of the review will be addressed in staff meetings and individual supervisions if needed. Ongoing Who is monitoring and how often to ensure the problem will not re-occur: Daily and ongoing Clinical Director, Quality Management Director and CEO/Owner Division of Health Service Regulation STATE FORM 6899 8ZNI11 If continuation sheet 7 of Division of Heallh Service Reaulallon D. 04/25/2013 FORM APPROVED placemenls, "lrearmenl ol his aggressmn and psyohosis..hisrory ol responding to inlernal slimul' becomes easily by redirectio bserved ll" bolh slales of euphoria and home slafl lacililale srruciured aciivilres and urilrze behaVlol managemeni syslem and regular verbal and wrihen leedback to help lesidem beher manage behavrors.,.lherapisl will engage resrdem ll" indiVldual lherapy ll" order In explore lriggers lor anger and mhel slrong leelings and leach skills for more elreclrvely managing anger, aggressmn and olher impulsive behaviors. Therapisr lacililale group residem and peers in order lo increase posrlive oommunicalion and problem solving No implememalion ol slralegies lo address any ol lhe above relerenced behaviors and issues as nmed in rhe lrealmem plan. Review on 04/05/15 ol olieni was reoord revealed. . 9 year old male. . Admission dale of 03/17/15. . Diagnoses ol Bipolar Disorder, Posnraumalic Siress Disorder (PTSD), ADHD, DisruphveMood Disorder, Enoopresis and Rule om Condum Disorder. . Pelson Cemeled Plan (PCP) daled 04/26/17 revealed, "What's nol working section, "Norhing is walking, he cominues Io be aggressive and nonrcompllanl. He is slealing food, his aggressive behaviors, mood swings, defiamrwon'l lollow direolions and rules and sexual behaviors/geslures, need conslanl supervision, nolworking, and he is nm sleeping." 'He bulhes olher reponed lhal [chem has pushed and expressed majol concern abour swarm or DEFlclENclEs paovromsupeusmru <PRINTED: 04/25/2018 FORM APPROVED Division of Health Service Regulation VACANT PAGE DUE TO CONVERTING TO WORD DOCUMENT Division of Health Service Regulation STATE FORM 6899 8ZNI11 If continuation sheet 9 of PRINTED: 04/25/2018 FORM APPROVED Division of Health Service Regulation VACANT PAGE DUE TO CONVERTING TO WORD DOCUMENT Division of Health Service Regulation STATE FORM 6899 8ZNI11 If continuation sheet 10 of Dlvision of Heallh Service Reaulallon D. 04/25/2013 FORM APPROVED [olienl looching his sisler inapproprialely, Mom reponeo lhal [cliem 1:3] sluoh an object up his srsler's bud. Mom and [cliem reponeo lhal [oliem #31'5 ralher used 1o looch inapproprialely, [Chem 1:3] slaleo he did lhal lo his srsler so she can reel how he reels,.,mom feels for 1he girls sa/eiy. Mom repons lhal [cliem 1:3] has choked her and his younger srsler on more man one ocoasroh,.,he ohen has major lemper 1amrums,.,he screams, yells, slam doors and was involonlary oommided on 12/11/17 aher a physicalahercahoh 1he school 515". As a resuh ol his aggressive behaviors he has penoihg oharges Depl, (oepanmem) of Juvenile Juslioe for disorderly conduct and assaull on a govermem ofllciaLJI was reponed he ls aggresswe wi1h slal/ allhe was released from me hospilal aller 30 days,.,comihues lo be aggressive loward mhers.,.group home slalr will supporl use of car (oognhive behavioral [chem 1:3] and family on relapse prevemroh,.,1each leohhioues such as progresswe relaxalion, or behavioral allernalives.,.desrgh a loken a comingency oonlram lo [chem 1131's sooral skills.,.use a reeling char1,.,' Physician hole oaled 04/06/18, Assessmenl, needs higher level of care suchas PTRF (PRTF Resrdenhal Trealmenl Faoihiy), Review on 04/09/15 ol slal/ no1es revealed. 73/20/13 p01 in Ilme om room, 3/20/15 pm in rsolahoh envimnmem. 73/24/13 p01 in Ilme om room, 04/03/13 senl 1o hme om room, 04/04/137 lound blade and cm himself. swarm or DEFlclENclEs rm 1x2) coNsYRuchoN 1x31 oars soavsv Add mm or coRREchoN noueza cowlmo a sorrows mum-m WING 0411312013 have or srazsr crrv. srars zre CODE NEW "0mm" GROUP HOME, -- LUMBER BRIDGE. NC 28357 1x4) 1o summaxv DEFlclENclEs 1o PRoleERs mm or 1x5) cam (EACH DEFlclEch MUST es eazczoeo av FULL mm EACH CORREWVEWION SHOULDEE comm rac m; ms we V112 Conllnued From page 6 V112 o1 Healm Sen/me Regulahon STATE FORM azmu sheer 11 or Division of Heallh Service Reaulallon D. 04/25/2013 FORM APPROVED No oi siraiegies lo address any oi ine above reiereneed behaviors and issues as nmed in ihe ireairneni plan, Review on 04/09/15 oi olieni #4'5 reoord revealed. . 15 year old male. . Admission daie oi 03/07/15. . Diagnoses oi Deiiani Disorder (ODD), PTSD, ADHD, Anxreiy/Anger issues, Conduoi Disorder and Cannabis UseDisorder, Mild. . Pelson Cemeied Plan (PCP) daied 02/19/15 revealed, nisiory oi vandalism io mother's cal, "beai ear wiih a sledge hammel,' "siole guns from neighbors ioond wiih muliiple guns by law enioroemeni, broke inio elderly resrdeni's homes lo sieal and vandalized homes, hit his grandparenis, and moiner, and Mari/Liana oihers, 'lel me have wl1ai wani, when I wani ll.' Goal. elrmaie use oi all substances." 7N0 oi siraiegies io address any oiihe above reierenoed behaVlors and issues as nmed in ihe ireairneni plan, Review on 04/09/15 oi olieni #B's reoord revealed. . 17 year old male. . Admission daie oi 03/17/15. . Diagnoses oi Unspeoiired Schizophienla Spem/um 5 Oiher Psyenoiro Disordeis, eyeloihyrnie Disorder Anxious Drsiress, ADHD, Inle/mmem Exploswe Disorder, Oiher Drsrupirve Mood Disorder, impulse Conirol Disorder, Auirsrn Disorderand lniellecioal Developmeni Drsaorliiy, Moderaie. . PCP daied 05/03/17 revealed, 'He ihreaiens io hun mom's dog ihai she uses as a sen/ice dog swarm or DEFiclENclEs rm (x21 nurnm coNsIRuchoN 1x31 oars soavev ano mm or lDEmlFicAYloN nor/sea a sorrows WING 04/13/2013 NAME OF i NEW NORIZON GROUP HOME. LLC LUMBER BRIDGE. NC 28357 1x4) 1o sum/my 10 mm or my new (EACH nusr es eazozoeo av FULL mm EACH smuwfii comm no m; ms remover/ire we 112 Conirnued From page 7 V112 o1 Heaim Sen/ice Regulanon STATE FORM 52N11i or Division 0! Heal'h ServiceReuulallon D. 04/25/2013 FORM APPROVED and o1her family pels.,.hismly o1 mismg mom's needs conslam supemsion,.,lack o1 remorse, his behaviors scare her (mom). He smle his famel's 1ruck and wrecked nm see the danger. ruel1y 1o people or animals, onen bullies, lhreaiens inlimidales o1hers, flequenl lying .collabolale wim lherapisl. Therapisi Will fac1 iiale group nn [cheni :16] and peers in order 1o increase pos ve oommunicahon and problem solving 7N0 implemenlafion of slraiegies 1o address any loe above relerenoed behawors and issues as nmed in 1he Irealmem plan, Review on 04/09/13 o1 oliem #7'5 record revealed. . 14 year old male. . Admission da1e of 03/14/13. . Diagnoses o1 ADHD, Conduoi Disorder, Disruphve Mood Disorder and Cannabis Lise Disorder. . Pelsan Cemeled Plan (PCP) daled 12/14/17 and assessmeni daled 03/14/13 revealed, 'loved s1ree1lileu gang banging, smoking maniuana, hisiory o1 (involunlary commitment) due 1o 1nrea1s 1o kill la/mly and mhels, his la/mly is alrald of him.,.he canbeoome ememely angry, eaSlly irriialed and argumeniahve and ohen blames mhers. ne deliberalely annoys mhers and adempls 1o inlimidalelhem wi1h1nrea1s o1 Violence. of being spiielul and vindioiive as well as o1 properly. lying and leaving home without permission,.,1nrea1ened Ieachels 1o 'blow lneir brains oul' and has also 1nrea1ened his mo1ner on several occasions 1ha1 he was going 1o kill hel, on me acme unil pa1iem has displayed a ouick1emper, and has lhrealened 1o beat down' slalf 11 may do nm allow him 1o go home, Paliem swarm or (x1) peonomsupenemiu (x21 numne coNsYRuchDN (x31 one suevev one em or comerso A soimrnc WING 04/13/2013 NAME OF nooeess sure zrecode NEW HORIZON GROUP HOME. LLC LUMBER BRIDGE. NC 28:51 my in lo run or prey max (EACH nusr ea peeceoeo ev mu (EACH muwai comm rec m; ME "emperors one V112 Conhnued From page a "2 or Health Service Regulanon STATE FORM BZNHI Division of Heallh Service Reaulallon D. 04/25/2013 FORM APPROVED has signilicanl DSS (depanmenl of social services) and DJJ (depanmenl ol iuvenilejoslice) involvemeni," 'Group home siall Will a safe and slable enwronmenl lor [clieni am provide supervision and uiilize behavior managemeni lechnio oes, and creaie and implemenl corleclive inlervehlions Io lacihlale [cliem #71'5 improvemenl in demonslralioh ol respem, managemeni ol anger and elleciive coping skills. [Clienl will receive an indiwdualized educahoh based on needs, inslruchoh in core curriculum and independenl living skills, scolal skills, leisure skills, healln and wellness lraining, and vocalioh skills inrough recrealion amivkies five limes pel wee i" provide inleramlon to build compelence and slabiliiy inrough evidence based individual inerap lamily inerapy wiih guardian. rNo implemenlaiion of slraiegies Io address any ollhe above relerehced behavmrs and issues as hmed in he lrealrnehl plan, During inleview on 04/05/15 clieni #2 sialed. . No lherapisi ai ihe lacihly. . No assigned lherapisl lor lrealmenl needs. Duling mien/law on 04/05/15 Cliem #3 slated, . He had an incidenl ol smeallng leceswhile placed ll" lhe hme ool room. . No lherapisi ai ihe lacihly. . No assigned lherapisi lor lrealmenl needs. . The clienis are hm allowed lo go oulside lor recrealion, lust waich TV everyday, Duling mien/law on 04/05/15 Cliem #4 slated, . No lherapisl or Sobslance abuse counselor al lne lacilily fol lrealmehl needs. rThe clienis are hm allowed lo go oulside for recrealion, lust walch TV everyday. swarm or (x0 reoviore/sureuzmro <Division of Hean Service Reaulallon D. 04/25/2013 FORM APPROVED Dming lnleview on 04/05/18 client #6 slated. . No therapist at the facility. . No assigned therapist treatment needs. Duling inlewlew on 04/05/15 Client/17 slated, 7N0 therapist or Substance abuse counselor at the facility fol treatment needs. . The clients are nm allowed to go outside recreation, Just watch TV everyday, Duling inlewlew on 04/05/15 slafl #9 stated, . No LP (Licensed or QP (Qualilred to do therapy with the clients 'no one cenified at the facility." Clients watch TV most of the day and can't go outside fol lecreallona' amiVllies. Duling inlewlew on 04/05/15 slafl #10 stated, 7N0 therapist tor any client at the to work on treatment goals/needs, "clients watched Netthx all day or played Video games.- A posted schedule of activities are not lollowedtherapy with the clients. Duling rnteryrew on 04/05/10 the Operations Managel/Gmup Home Manager stated. He had worked at the facility fol one week. 7No therapist/LP or QP on stall at the facility 7N0 teacher on start at the facility. 7N0 recreatrcn ski": or actiyrties fol chents untrl a fence is built at the Duling rnteryrew on 04/05/10 the Licensee stated. she was in the process ol following up on the clients treatment plans/goals and strategies. rThele was no therapist, LP or OP cn stall, . They did not have a teacher on start, she would do it herseli, try to find a smenw or rm paovroemepenemra (X2) nutme coNsIRuchoN txal one sum/Ev me new or coRREchoN Muses cowtereo a mama--:13 a WING 0411312013 NAME OF srxeer clTv. srare zre CODE NEW "0mm" LLC -- LUMBER BRIDGE. NC 28357 1x4) 1D summaxv DEF1C1ENC1ES 1D mm or 0(5) (EACH nusr se eneceoeo av FULL mm EACH CORREPWUUPN SHOULPEE comm rac m; me teeapparm we V112 Continued me page 10 V112 01 Health Service Regulation STATE FORM BZNHI camlnuailcm sheet 11 D. 04/25/2013 FORM APPROVED Dlvision ol Heallh Service Reaulahbn STATEMENT OF (x1) (X2) MULTWLE (x3) DATE SURVEV mo mm or iozmincanon NUMBER cowrzreo a sorrows WING o4l13l201a NAME OF srxzer cirv. sure Zip code NEW NORIZON GROUP HOME. LUMBER BRIDGE uc "357 1x4) in summaxv 1o mm or 1x5) max (EACH nusr es eazczozo av rum CORRECWE ACTION SHOULDEE comm me m; ms we V112 Continued From page 11 V112 This deliciency is crossed referenced inlo 10A NCAC 275 .1301 SCOPE (vam) lor a Type A1 rule violalion. V114 27s ,0207 Emergency Plans and Supplies 114 10A NCAC 276 .0207 EMERGENCY PLANS AND SUPPLIES A wrihen fire plan lor each laciliiyand arearwide disasler plan shall be developed and shall be approved by lhe appropriale local aulhorily. The plan shall be made available in all slalf and evacuahbn procedures and routes shall be pbsled in the lacilily. Fire and disasler drills in a 241mm lacilily shall be held al leasl quanerly and shall be repealed fol each shih. Drills shall be conducled under condhions lhal simulale lireernergencies. Each facilily shall have basic lirsl aid supplies accessible for use. 114 This Rule is not met as evidenced by. Iensures in place no torml Ihe deficiency: Based on record review and inlerview, 1he lacilily failed 1o ensure fire and disas1er drills wele held LDeveloped a mndardued agency quanerly and repealed on each shih. The 'uh .norucuom mlemm Lhe required Dune findings lmelmes oi vzlnuus lypea or dinner drill>>. 4730718 ncludmg fire drills, renecied on Lhe New Review on 04/05/15 ol facility records revealed. Homo" amp Hume Emerge"Cy rFacilin admmed lhe firsl clienl on 0226/15. Hm 15' quafler 2013 (January Februaryr March), no See example copy oirhe Disaster umelme fire drills documenled and no disasler mm," documemed for any shih for review, LQudlny Management Direcmr Ml] mun mil Imerwews on 04/05/15 and 04/13/15 5 of 7 chants ii ihe abovermenuoned checklm, emphasizing 712718 slated>> he minimum and rhe umelmes, Qudlm Mm emem Direcmr Ml] mun mil 1 . nor "mgr .c gulall 1. STATE FORM BZNHI Ii cammuamrr sheet 12 PRINTED: 04/25/2018 FORM APPROVED Division of Health Service Regulation V114 continued on the Emergency Operations Plan for the Level 5-12-18 IV group home. Measures in place to prevent reoccurrence of the problem: 1.Quality Management Director will monitor the receipt of required Disaster and Fire Drill forms forwarded to the Corporate Office to ensure timely completion, completion on each shift, Ongoing and completed with realistic simulation. Who is monitoring and how often to ensure the problem will not re-occur: Ongoing Quality Management Director Division of Health Service Regulation STATE FORM 6899 8ZNI11 If continuation sheet 13 of Division of Heaith Service Reaulatlon PRINTE D. 04/25/2013 FORM APPROVED STATEMENT OF DEFICIENCIES [x0 AND FLAN or CORRECTION ioEuTiErcATioN NUMBER MNL018-315 tle MULTIFLE CONSYRUCTIDN A BUILDING a write my DATE SURVEY COMFLETED 04l1 3201 3 NAME 0E PROVIDERORSUFFLIER STREET AD NEW NORIZON GROUP HOME. LUMBER DRESS ciTy. STATE ZIP conE BRIDGE. Nc 28357 1x4) ID PREFIX TAG SUMMARY DEFICIENCIES nEErciEucv MUST BE FRECEDED av FULL DEFICIENCY) ii; PROVIDERS FLAN or CORRECTION ixs, PREFIX iEActt CORRECTIVEACYIONSHDULDEE COMPLEYE TAG CR055-REFERENCEDTD THE APPROPRIATE V114 Continued From page 12 Clients #3 and #6 stated they had not completed any tire or disaster drills at the faciIin. Interviews on 04/05/15 through 04/13/15 We Staff Stated, Staff #10, #3 and Start #2 Stated they had not completed any fire or disaster dlills at the With the clients, Interview on 04/05/10 the Licensee stated. she admitted the first client to the facility on 02/26/15. rThe shifts at the facility were 1st from Ba to 4p and second 4p to 12midnight and third shift from 12am to dam and weekends were 12 hour shifts Bam to aprn and aprn to Ham on Saturday and Sunday, She understood the tire and disaster drills were to be completed quarterly and repeated on each shilt, 276 .0209 (0) Medication Requirements 10A NCAC 276 .0209 MEDICATION REQUIREMENTS Medication administration. (1) Prescription or nonprescription dlugs shall only be administered to a client on the written order of a person authorized by law to prescribe drugs. (2) Medications shall be seltradministered 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 personstrained bya registered nurse, pharmacist or other legally qualified person and privileged to prepare and administer medications. V114 V118 Ivlslon at Health Semce Regulation STATE FORM azm1t 14 D. 04/25/2013 FORM APPROVED Dlvision a! Heakh ServiceReuulallon STATEMENT uE <> (EACH uusT eE FRECEDED av mu PREFIX (EACH CORRECWEACTION snourer coupler TAG m; CROSS-REFERENCEDYD THE one V118 Conllnued From page 13 "8 (4) A Medlcalion Record (MAR) ol all drugs adrninislered lo each clienl musl pe kepr curlem. Medlcafiuns aornlnisrered shall be recorded irnmedialely aher The "8 MAR is include the following. (A) clienrs name; . . . . easum in place In toned rue deficient "Tynan?" m: Medicauon flaming was 3 "'91 ompleled again wul. lhe preseru (D) dam and urne The drug rs . . . . eglslered Nurse. (E) name or ol person 5 drug ee nuaclred Training cemficmes wuh dale. "27,8 (5) c'liem lemmas med'cafim changes nendees name and [he signmure of lhe Lrnmer checks shall be recorded and kepr wilh the MAR "6 ""18 "dew" file followed up by appoimmenl or consultation mum in Mm In mum or a physician, he problem: The Direclor/LPC and ner This Rule l5 as evidenced by: renew the MAR's on daily bum re Based on record revrews and rnlervrews, 5 ol 5 "me me "New," ,s samplers audiled srall as, and the ammo," are gm. 3; pmmbed Darly and Opermions Manager/Grouphome Manager) egrsrererr Nurse wru renew when Free." rarled lo admnerer medrcamns only by he group home .0 emure medleallons are given unlicensed persons uained by a regislereo nurse, wording .0 Mm pharmacisl, or char legally quallfied person and prlvileged ro prepare and adminisler medicalions The pummel 0mm," Chem". and as ordered by me physiqan and mainAain an We reuerr lhe sperm mus assume MAR 'or 3 9f 5 audited them elnled lo resrdenunl services re . The afar CPR. 1" Am. erenew hire Rewew on 4/10/13 ol cllem #2'5 record revealed: OHM be placed on the flu" "Mule mm '17_ Year admme" ererus were eemplered. Dlagnoses 0' Malor Depressmn ee nuached Onenrauon Disorder. Schizophrenia and Anenuon ""th Dellcil Hypelaclivily Disorder (ADHD). Order dated 04/06/18. Plozac10 mg is monitoring and how men To ensure lablel daily. (antideplessanl). he Wm M. ream" llmcal and CEO/owner will review lly Nurse will review during scheduled mus ngolng or Healrh Service Reguleuon STATE FORM 15 Division GI Health ServiceRem/latlon D. {14/25/201 3 FORM APPROVED Review on 4/10/13 ol client #25 Aplil 2013 MAR revealed no documentation Plozac was administeled 04/06/18 04/10/18. Review on 04/10/13 ol client #25 medication label levealed medication was filled on 04/06/18. Review on 04/10/13 ol client as record revealed. . 9 year old male. . Admission date of 03/17/13. . Diagnoses ol Bipolar Disorder, Posttraumatic Stress Disorder (PTSD). ADHD, DisruptrveMood Disorder. Enoopresis and Rule Out Conduct Disorder. 70rdel dated 04/03/13. Arnantadine 100 mg, 1 tablet daily (treats dyskinesia. sudden uncontrolled movements). Review on 4/10/13 ol client #35 Aplil 2013 MAR revealed no documentation Amantadine was administeled 04/06/18 04/10/18. Review on 04/10/13 ol client #35 medication label levealed medication was filled on 04/06/18. Review on 04/09/13 ol client #6'5 record revealed. . 17 year old male. . Admission date of 03/17/13. . Diagnoses ol Unspecilled Schizophlenla Spectlum 3 Other Disordels. Disorder With Anxious ADHD, intermittent Exploswe Disorder. Other Specified Disruptive Mood Disorder, impulse Contlol Disorder, Disorder and intellectual Development Disability, Moderate. 70rdel dated 04/03/13. Arnantadine 100 mg, 1 tablet daily (treats dyskinesia. sudden uncontrolled movements). sure/w or DEFlclENclEs lxt) 1x21 numne coNisuchDN txal one suRva AND ms or NUMBER cor/stereo A sormruc a WING 0411312013 NAME OF srxeer tnoeess clTv. sure Zip code NEW HORIZON GROUP HOME. LLC LUMBER BRIDGE. NC 28351 (x4) in SUMMARY sum/Euro; 1D run or 1x5} (EACH DEFlclEch nusr ea onecenen av mu mm (EACH cokREchvEAcfloN SHMDEE comm res m; me Appxoperne one DEFlclENch Continued me page 14 Vt18 o/r Healrn Sen/Ice Regularron STATE FORM azulu ts Dlvision of Heallh Service Reaulatlon D. 04/25/2013 FORM APPROVED Review on 4/10/15 01 client #85 April 2015 MAR revealed no documenlation Amanladine was lrom 04/06/13 04/10/13, Review on 04/10/15 01 client #85 medlcation label revealed medication was filled on 04/06/18. Review on 04/10/15 01 me clients' MARS revealed. rSlal/ #12 and signed/initialed lhe clients' MARS to reflect they aanlnistered medications to the clients al lhe facility. Review on 04/10/15 oi Staff #25 personnel rile revealed. rDale or on 02/20/15. rDocumentallon oi Medication Administration oenihoaie contained a hand wrlnen and outline or a oopied and pasied date or February 22, 2015 inrough renewal date or February 25, 2019 and no signature by lhe lralneererview on 04/05/18 slalf #2 slated. +le adminisiered medications on his shin. +le did nm remember the . He did not have trainlng in to meet me needs or the chenrs. Review on 04/10/15 oi Staff #35 personnel rile revealed. rDale or on 02/20/15. rDocumentallon oi Medication Administration oenihoaie contained a hand wrlnen and outline or a oopied and pasied date or February 22, 2015 inrough renewal date or February 25, 2019 and no signature by me lralner. Review on 04/10/15 01 Staff #65 personnel file revealed. rDale or on 02/17/15, smenw or (x0 paovroemopenemn 1x2, coNsrRuchoN txal one sum/Ev nun new or lDEmlFIcArloN some oowrereo A mama--:13 a WING 0411312013 NAME OF srxeer errv. sure zre eons NEW NORIZON GROUP HOME. LLC LUMBER BRIDGE. NC 28357 1x4) lo summon 1D mm or prey <Division of Heaith Service Reaulatlon D. 04/25/2013 FORM APPROVED Documentation ot Medication Administration certiticate contained a hand written and outline or a oopied and pasted date of February 22, 2015 through renewal date of February 25, 2019 and no signature by the trainer. Review on 04/10/15 ot Start #S's personnel rile revealed. Date or application on 02/02/15. Documentation ot Medication Administration certiticate contained a hand written and outline or a oopied and pasted date of February 22, 2015 through renewal date of February 25, 2019 and no signature by the trainer. Review on 04/10/15 ot Start #105 personnel rile revealed. Date or application on 02/13/15. Documentation ot Medication Administration certiticate contained a hand written and outline or a oopied and pasted date of February 22, 2015 through renewal date of February 25, 2019 and no signature by the trainer. Review on 04/10/15 ot the Operations Managei/Gmup Horne Manager's personnel rile revealed. Date or application on 02/20/15. Documentation ot Medication Administration certiticate contained a hand written and outline of a oopied and pasted date of February 22, 2015 through renewal date of February 25, 2019 and no signature by the trainer Interview on 04/05/15 staff #2 stated, rHe administered medications to the clients, He couid nm recali who the trainer for medication admmistration, Interview on 04/05/15 staff #3 stated, swarm or rm paovromsoperiemro (X2) MULTWLE coNsYRuchoN txai one sum/Ev AND mm or ioeurinooriou houses oowtereo rt mum-:19 WING 0411312013 NAME OF eraser oirv. sure ZIP code NEW NORIZON GROUP HOME. LLC LUMBER BRIDGE. NC 28357 1x4) io summon i0 mm or 1x5) mm (EACH nusr es av FULL mm rem smuwfii comm no m; me repaopaim we 1/115 Continued From page 16 V115 rvisron at Health Semce Regulation STATE FORM 52N11t neonrnuanonsheer 15 D. 04/25/2013 FORM APPROVED Division or Health Service Reaulatlon STATEMENT OF DEFIC1ENC1ES [x0 0(2) MULTWLE CONSTRUCTMN txal DAVE SURVEV awo now or coRREchoN Nunsea covetereo a mums--:13 a WING -- 0411312013 NAME OF srazer crrv. snare zre CODE NEW NORIZON GROUP HOME. LLC LUMBER BRIDGE. NC 28357 DEF1C1ENC1ES 1D mm or rxs, cam MUST as paeczoeo av FULL mm EACH CORRECWUUION SHOULDEE comm rac m; me tppaoparm we Vt18 Continued me page 17 V118 She did nm Temembel the fol medication admmistration, rShe "sometimes" administered medications to the clients. Interview on 04/12/15 Staff #6 slated, . She had not received medication administration training. . She had received no medication administration training by a nurse. . "[Stall helped us and showed us Videos, we were in a garage in [Licenseel's other level group home in [nearby oounty].' Interview on 04/09/15 Staff #9 slated, rHe administered the clients' medications. . He had not received medication admmistratlon training. . "All ol mytraining was on the job training, no medication training." Interview on 04/10/15 Staff/110 slated, He worked his first day at the laorlhy oerore he turned in his application. rHe administered the clients' medications. . He had not received medication admmistratlon training. . He had received "no training atali,' . Staff showed me how to do meds (medications), she wanted to throw away meds and have me sign olr, I 531d I'm not doing that.- lnterview on 04/05/15 the Operation Managel/Gmup home manager stated. He had only worked for one week at the lacility. . He was not sule who the tlalners were ror any of the trainings. Interview on 04/10/15 the Licensee stated. rThe staff had not picked up the medications until at Health Service Regmallon STATE FORM as am". haornrnuananshesr to D1 Division of Heallh Service Reaulallon D. 04/25/2013 FORM APPROVED STATEMENT oE nEErclENclES rm AND FLAN or coAAEchou loEuTlErcATloN NUMBER MNL018-31E 1x21MulTlnE coNSTAuchou A eulmrus a wrus 1x3>> DATE SURVEY corrmETEo 04l1 3201 3 NAME oE STREET AD NEW NORIZON GROUP HOME. LUMBER DRESS clTy STATE ZIP conE BRIDGE. Nc 28357 1x4) in paEElx TAG SUMMARY oEElclENclES (EACH nEErclEucv MUST BE FRECEDED av FULL To pAoulnEAS mm or coAAEchou 0(5) paETlx rEAcu coxAEchvEAcTroNSuourneE COMPLEYE TAG THE AwaapalATE V118 V131 Conhnued From page is 4/1011 the cllems. . The pharmacy had nol called me racililylo inlorm lhem lne were ready. She had paid lo have me trainings compleled lor slalr. She had nohced lne dales on me training cenihcales looked as il lhe dale had been cul and pasled on me ceniricale and copied and maybe lne lrainer had copied mulliple cenrricares mar way. She would comacllhe trainer and have me lrainer conlaci DHSR (Division of Heallh SelVlce Regularion). She inoogm all slalr nad lrainings compleled. Due lo rhe larlure Io accoralely documenr medicalion admrnislralion ii could hm be delermined il cliems received ineir medicahons as ordered by me physician. This deliciency is crossed refelenced inlo 10A NCAC 27s .1301 SCOPE (V301) lor a Type A1 role yiolalion. as. 131E255 (D2) HCPR . Prior Employmenl Verihcalion as. ?131Eezss HEALTH CARE PERSONNEL REGISTRY (d2) Belore hiring nealrh care personnel inlo a heallh care racilily or service, every employer ar a heallh care racilily snail access lhe Healrh Care Personnel Regislry and shall hole each modem of access in < D. 04/25/2013 FORM APPROVED Division ol Heallh ServiceReuulallon STATEMENT 0E 1x1) coNsTRuchun 00/ DATE SURVEY AND pun or NUMBER COMFLETED a 5 mm; 04I13IIU13 NAME oE NEW HORIZON GROUP HOME. LUMBER no DRESS clTv. STATE ZIP CODE BRIDGE. Nc 23:51 (x4) in SUMMARY SYATEMENTOF 1D FLAN OF 1x5} max (EACH nosr EE FRECEDED av mu mm (EACH SHMDEE comm me m; CROSS-REFERENCEDYD YHE "were." one 131 Continued me page 19 131 131 This Rule is nol rnel as evidenced by: in place In correct the deficiency: Based on record review and interviews. the Qualny Management Director will renew the faciliiy lalled 1o aoeess rne Healin Cale Personnel Versonne' Onemdhon Checklm With the Gm"? .1248 and Regisiry (HCPR) pnor Io hlre alfecnng 4 pl 6 Hum Manager and Group Home "gmng audiieo slall (n2, :la and rne Operaiions 5w" emphasums lhe Managel/Gmup Home Managel). The findings eqmmenb "m must be compleled pnur are ire. including ihe Henlrh Cnre Regmrv Cheek, See copy onhe reused Personnel Oneninuon Review on 04/10/13 ol Slali #Z's personnel lile Checklm wuh warning "filament revealed. . Dam a, apphcafim on 0220,13>> Measnm In place In prevent reoccurrence oi EJob mle of residennal staff. he WNW: 7N0 documentation the HCPR had been 1 Updated copies uhhe Personnel Onenmuun accessed will be forwarded to Lhe CED/Owner nor in hire |u relieu all "prior |o lure" Review on 04/10/13 oi Sialf #3'5 personnel lile We been revealed_ olenlml swirl person can be onered Jub 0 0 Dale ol applicafion on 02/20/13, "hum awmml the "3 "3 Job of residential Sta". ee copy of [he Mmehed Personnel Onemauon documentation <PRINTED: 04/25/2018 FORM APPROVED Division of Health Service Regulation VACANT PAGE DUE TO CONVERTING TO WORD DOCUMENT Division of Health Service Regulation STATE FORM 6899 8ZNI11 If continuation sheet 21 of Division of Health Service Reaulallon D. 04/25/2013 FORM APPROVED Allegations, 8t Protection as. HEALTH CARE PERSONNEL REGISTRY (9) 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 (am) of this section. (which includes. a. Neglect orabiise of a resident in a healthcare facility or a person to whom home care services as delined by Gs. 131E135 or hospice services as defined by Gs. 131E101 are being provided. b. Misappropriation of the property of a resident in a health care lacility, as defined in subsection of this section including places where home care services as defined by Gs. 131E136 or hospice services as defined by as. 131E101 are being provided. c, Misappropriation of the propertyol a healthcare facility. d. Diversion ofdrogs belonging toa health care facility or to a patient or client. e. Fraud against a health care facility or against a patient or client lor whom the employee is providing semices). Facilities must have evidence that all alleged acts are investigated and miist make every effort smenw or (x1) (x2) MULTWLE coNsIRuchoN txai one soavev Add mm or iozmincarion noneza cowtzreo it mums--:15 WING 0411312013 NAME OF srazer nooaess cirv. sure Zip code NEW "0mm" GROUP HOME, LLC -- LUMBER BRIDGE. NC 28357 1x4) in summaxv SYATEMENTOF ii: mm or ixs, ram (EACH nosr ea eazczoeo av FULL omit CORREWVEWION SHOULDEE comm rac m; we 131 Continued me page 20 131 interview on 04/10/15 the Licensee stated. she believed the HCPR had been accessed on all staff. This deficiency is crossed referenced into 10A NCAC 27s ,1301 SCOPE (vaol) tor a Type A1 role violation. V132 V132 ivisicn at Health Service Regulation STATE FORM BZNHI it continuation sneer 22 in Division 0! Health ServiceReuulallon STATEMENT uE AND pun or (X1) NUMBER a D. 04/25/2013 FORM APPROVED tle MULTWLE coNsYRuchuN txal DAVE SURVEY A COMFLETED 5 MW 0411 3I201 a NAME oE pauleanasuqua NEW HORIZON GROUP HOME. STREET an DRESS clTv. STATE ZIP CODE onttnaed molluonng or the at he "Insider" Report Standard Dpemuun". onttnaed training at stair meetings. LUMBER BRIDGE. NC 28351 (x4) in SUMMARY SYATEMENTOF DEElclENclEs tp FLAN or mm (EACH nusT BE FRECEDED av FULL mm coserchEacTton snoutnsE conetETE TAG YAG YHE sensoretnr DATE taz Continued From page 21 V132 132 to protect lesidents from halm While the Mmsurm in place In toned the deficiency: investigation is in progress. The results ol all 1 Qualny Management Dlrecmr provide investigations must be reported to the Client Righ|s specifically related to Department Within five working days of the tninal abuse. neglect. and explanation. for all starr, notification to the Department, See Ille allathed copils oi Clienl Rights raining certificates "2 1' 1 8 This Rule ts not met as evidenced by: Based on record reviews and interviews, the 2 Qualny Management Direcmr Will prov/vie facility latled to report allegations ol abuse to the DMH inside!" Report Manual Health Cale Personnel Registry (HCPR) and to mentally |he that renew when cemtn investigate all alleged acts of abuse or neglect, Eddmonnl must be The findings are: ontpleted ror spectl'te types at for all tan. Quality Management Drrectcr also See Tag V367 lor specilics, emphasue constitutes an "madam" See the attached ccptes or Review on 04/05/13 ol facility records lrom ruining cemficmes 02/01/13 through 04/13/13 revealed: 03/30/13 client #7 made an allegation ol ahuse .Qaalny Management Dlrecmr provided a against stall #9 and agency reported to taming/renew at the New Honzon Standard of however. no internal investigation was conducted. pmuon related 10 the Rewmng of lnudems. 04/09/13 which involved client #7'5 allegation the tnneltnes tran incident is stalt #6 pushed him, cursed hitn. threw water on elated to abuse, neglect or explonduon, 89" Dam him and attempted to strike him with a metal pole See attached copy or Repumng or and no HCPR was completed on slafftfiB. Standard or Operation, incident (unknown specttic date) ol 03/2013 involved client #6 With allegations stall #9 4 Develop an entail reponmg system a start conducted a harmlul/ahusive action ol placmg person or consumer can unlue to report related client #B's arm up and back tnto the client's hack or abuse. neglect or explulmuun. and escorted Client #6 to the timeout mom and omplele Standard of Operation related the no HCPR was completed on stalt nrhouse repomng process. and, the stall 01"" haul the process The Standard of Operation 543'" also tnclatle the steps to complete when ompleung an internal investigation ensue-u in place to prevent reoccurrente oi he problem: 1 Quality Management Dueclur provide Ongomg it I gatanun STATE FORM BZNHI sneer z: in PRINTED: 04/25/2018 FORM APPROVED Division of Health Service Regulation V132 continued and individual personnel supervisions if warranted. 2.Clinical Director/LPC will provide daily shadowing and supervision. Ongoing Ongoing 3. Independent Compliance Consultant will monitor the reporting system and alert CEO/Owner and additional persons to begin any needed reporting processes and implement inhouse internal investigation, if warranted. Ongoing Who is monitoring and how often to ensure the problem will not re-occur: Quality Management Director Clinical Director/LPC Independent Compliance Consultant Division of Health Service Regulation STATE FORM 6899 8ZNI11 If continuation sheet 24 of Division 0! Heal'h ServiceReuulallon PRINTE D. 04/25/2013 FORM APPROVED as. CRIMINAL HISTORY RECORD CHECK REQUIRED FOR CERTAIN APPLICANTS FOR EMPLOYMENT. As used in <Division 0! Health ServiceReuulallon D. 04/25/2013 FORM APPROVED Justice under GS. 11471910 to conduct a criminal history record check required by this section or shall submit a request to a private enmy to conduct a State criminal histoly record check required by this section. GS. 114719.10. the Depanment ol Justice shall return the results of national criminal history record checks fol employment positions not covered by Public Law 1057277 to the Department ol Health and Human Services, Criminal Records Check Unit. Within hve business days of receipt ol the national cnminal history ol the person, the Department of Health and Human Sen/ices. Criminal Records Check Unit, shall notily the provider as to whether the inlormation received may altect the employability of the applicant. in no case shall the results ol the national criminal history record check be shared with the meders shall make available upon request venlication that a cnminal history check has been completed on any stall covered by this section, A county that has adopted an appropriate local ordinance and has access to the DiviSlon ol Criminal Infolmamn data bank may conduct on behall ol a a State criminal history record check required by this section without the pmwder having to submit a request to the Department of Justice, In such a case. the county shall commence with the State criminal history record check required by this section within five business days ol the conditional otter ol employment by the provider. All criminal history inlormation received by the provider is confidential and may not be disclosed, except to the applicant as provided in subsection ol this section, For purposes of this subsection, theterm 'private entity' means a business regularly engaged in conducting criminal history record checks public smevw or lxt) pacvromsuwuemru (le uutnne coNsIRuchuN (xal one suRva the pm or commerce a outcome a WING 0411312013 NAME OF srxeer tooeess crrv. sure zre cone NEW HORIZON GROUP HOME. LLC LUMBER BRIDGE. NC 28351 (x4) in Suwaxv in run or pray max (EACH DEFlclEch uusr er onscreen sv run mm (EACH SHMDEE comm rec m; me appaopame one was Continued From page 23 V133 or Healrh Service Regulanon STATE FORM BZNHI sneer 2s Division of Heahh Service Reaulallon D. 04/25/2013 FORM APPROVED records oo(ained from a 3(a(e agency. Ac(ion. . if an applicam's criminal his(ory record check reveals one or more convic(ions of a relevan( offense, (he provider shall consider all of (he following fac(ors in delermming whe(her (o hire (he The level and seriousness of (he crime, (2) The da(e of (he crime. (3) The age of (he person a( (he (rme of(he convrc(ion. (4) The circums(ances commission of (he crime, if known. (5) The nexus oe(ween (he criminal condoc( of (he person and (he )ob du(ies of (he posr(ion (o be filled. The prison, )ail, prooa(ion, parole, rehabili(a(ion, and employmen( records of (he person Since (he da(e (he crime wascommined. (7) The subseqoem commission by (he personof a relevan( offense. The lac( ol convichon of a relevan( offense alone shall nm be a baf (o employmenL however, (he hs(ed fac(ors shall be conSldered by (he provider. if (he pmwder disqualifies an applicam aher canSlderalion of (he relevan( lac(ors, (hen (he provider may disclose rnforma(ion con(ained in (he criminal his(ory record check (ha( is relevan( (o (he disqualificauon, om may nm provide a copy of (he crimmal his(ory record check (o (he applican(, eri(ed lmmuni(y, A provider and an officer or employee of a provider in good fanh, complies (his section shall be lmmuneffom civil liaoilr(y for. The failure of (he provider (o employ an indiVldual on (he basis of rnforma(ion pmwded in (he criminal his(ory record check of (he inleldual. (2) Failure (o check an employee's his(ory of criminal offenses if (he employee'scfiminal smevw or (x0 racvrormorerrexcro (x2) MULTWLE coNsTRuchoN (x3) one sum/Ev AND now or comcnoh NUMBER cowereo A sonorhc mums--m a WING 0411312013 NAME OF may access sme zrecooe NEW NORIZON GROUP HOME. LLC LUMBER BRIDGE. NC 28357 lx4) lo summon srarmsmor lo mm or 0(5) ram (EACH MUST ea parceoro av mo mm EACH CORRECWUUION SHOULDEE comm me m; me we 133 Continued me page 24 133 o( Healih Service Regulahcn STATE FORM azmu camlnuaflnn sheet 27 Division 0! Heakh ServiceReuulallon D. 04/25/2013 FORM APPROVED hisiery lecord check is requesieci and leoeived in compliance with ibis sermon. Relevam Diiense. As used in inis section; "relevant onense" means a ooumy. s1ate, or ledelal criminal hisiory pi cenvrcirpn or pending indictment oi a crime, vvneiher a mlsdemeanol or ielbny, inai bears upon an indiwdual's iimess ib nave responsibiliiy ipr ine saieiy and wellrbeing pi persons needing menial nealin, developmenial disabilities, or subsianoe abuse services. These crimes include ihe criminal oiienses sei ionn in any pi ine iollowing Ariicles pi cnapier i4 oi ine General much; 5. and issuing Moneiary Article 5A. Endangering Execuiive and Legislative Amcle a, Homicide: Ariicle 7A, Rape and Oiner Sex orienses; Ariicle a, Assaulis: Anicle io, Kidnapping and Abducirpn. Article 19. Malicious lnyury or Damage by Use oi Explosive or Incendiary Dewce or Maierial. Anicle 14, Burglary and Oiner Housebreakings: Ariicle 15, Arson and Oiher Burnings.Amcle16, Larceny: Ariicle i7, Robbery. Article 13. Embezzlemem: Anicle 19, False Freienses and oneai 'Anicle 19A, Qbiaining Frppeny or Services by False or Flaudulem Lise oi Green Dewce or Diner Means; Amcle19a, Financial Transaction Cald Clime Aci. much; 20. Flauds. Article 21. Folgery: Ariicle 2s, alienses Againsi Public Moraliiy and Decency; Anlcle 26A. Aduli Establishments; Amcle 27, Pmslilmion. Amcle za, Pellury. Amcle 29, Bribery. Amcle 31,Mlsoonduc1in Public Article 95. Oiienses Againsi ihe Public Peace: Ariicle 36A, Rims and civil Disorders; Amcle as, Prolecmn oi Minors. Anicle 40. Pimecllon oi ine Family; 59. Public Intoxication. and Anicle so. Compmeerela'ed Clime. Tnese crimes also include possessmn or sale bi dings in violaiion pi ihe Nonn Carolina smevw or DEFlclENclEs (xi) (le vumne coNsIRuchuN (xal one suRva me new or cavemen . surmruc a WING 0411312019 NAME OF srxeer "mess clTv. sure le cone NEW HORIZON GROUP HOME. LLC LUMBER BRIDGE. NC 28351 my in in mm or ixsy max (EACH DEFlclEch vusr ea vaccines ev mu mm (EACH SHMDEE comm rec m; me aeexoeeme one 133 Conimueri me page 25 V133 bi Heaim Service Regulanon STATE FORM BZNHI sheet 21: Division 0! Heallh ServiceReuulallon D. 04/25/2013 FORM APPROVED STATEMENT DE (xi) <> wuh wing lhe Personnel subsedion of mis swim a, me sample." nenmuun Checklisl and New Horizon Policy fingerprim cards as required in 931144910. l'rl relmed lo Pemgnnel (2) Tne snall submii ihe requesi lor a See Personnel Pol-<> criminal backgmund check fol a of a audiied siall :la, o. and me Opelafions Who Is mommy-u: and how men to ensure Managel/Gmup Home Manager). The lindings he problem W-ll nol rE-omm CEO/Owner Ongomg Division dr Balm ENIEE Regulation STATE FORM 52m" ll commuauun sham 29 Division of Heallh Service Reaulallon D. 04/25/2013 FORM APPROVED Review on 04/10/15 o1 s1a1r #Z's personnel 1ile revealed. rDale b1applrealion on 02/20/15. rJobmle of residennal srarl. 7N0 documenlalion rne criminal background check nad been regues1ed. Review on 04/10/15 o1 s1a1r #a's personnel 1ile revealed. rDale b1applrealion on 02/20/15. rJobmle of residennal srarl. 7N0 documenlalion rne criminal background check nad been regues1ed. Review on 04/10/15 OI Staff #65 personnel file revealed. rDale b/ on 02/17/15, rJobmle of residemral 51a". 7N0 documenlalion rne criminal background check nad been regues1ed. Review on 04/10/15 o1 s1a1r #S's personnel 1ile revealed. rDale b1applrealion on 02/02/15. rJobmle of residennal srarl. 7N0 documenlalion rne criminal background check nad been regues1ed,. Review on 04/10/15 o1 s1a1r #105 personnel 1ile revealed. rDale b1applrealion on 02/13/15. rJobmle of residennal srarl. 7N0 documenlalion rne criminal background check nad been regues1ed. Review on 04/10/15 o1 lne sperarions Managel/Gmup Home Manager's personnel 1ile revealed. swarm or (x11 reovroemurenemn 1x21MuLTleE coNsIRuchoN 1x3) one suRva AND Rum or coRREchoN resume/non nausea cowlereo A mama--:15 a WING 0411312015 NAME OF may crrv. ewe zre cone NEW NORIZON GROUP HOME. LLC LUMBER BRIDGE. NC 28357 1x4) lo sum/0w summer/Tor 10 pRovlnERs mm or coRREcrloN rxs, rem 1am nusr ea mceoeo av mm mm EACH CORRECWUUION SHOULDEE comm rec m; me mapper/re we 133 Continued me page 27 133 51 Health Service Regulanon STATE FORM 5mm 11 sneer 30 Division of Heallh Service Reaulallon D. 04/25/2013 FORM APPROVED STATEMENT oE nEErclENclES rm AND FLAN or loEuTlErcATloN NUMBER MNL018-31E 1x2>> MULTWLE coNSTauchou A eulmrus a Wine 1x3>> DATE SURVEY COMFLETED 04l1 3201 3 NEW NORIZON GROUP HOME. NAME 0E paovloanasuvaa STREET AD LUMBER DRESS clTv. STATE ZIP conE BRIDGE. Nc 28357 1x4) in paEElx TAG SUMMARY oEElclENclES (EACH nEErclEch MUST BE FRECEDED av FULL To paovlnEaS FLAN or pray paETlx rEAcn coxaEcTTVEAcTroNSnourneE COMPLEYE TAG THE waopalATE V133 V301 Comrnued l=rom page za rDale ol apphcalion on 02/20/15. Job lille ol speralions Manager/Group Home Manager. 7N0 documenlalion The criminal background check had been reouesled. lnrerview on 04/10/15 The Licensee slaled. aThe staff should have all had cnminal background checks requesled. She did nol know why The slalr ar her olrice had nm requesled crimmal backgmund checks lor all The slall, She saw in the personnel record book all The consenrs Io requesllhe crimmal backgmund checks lor The staff. This deficiency is crossed rererenoed imo 10A NCAC 27s ,1301 SCOPE (vaol) lor a Type A1 role violalion. 276 .1801 InlenSlve Res, TX. Child/Adol Scope 10A NCAC 27s .1501 SCOPE (3) An rnlensive residenhal Ilealmem raciliry is one Thai is a 24ehour residemlal lacihry Thai provides a svucmred environmenl wirhin a syslem ol care approach for children or adolescems whose needs require more inrensive lrealrnenr and supervision lhan would be available in a resrdenlial lrealrnenr slarl secure laciliry. shall nor be The pllmary residence olan indiwdual who is nor a clienl orlhe racihry. The populanon served shall be children or adolescems who have a primary diagnosis of menial illness, severe emohonal and behavioral disorders or subslanceorelaled disorders, and may also have caroccurring disorders including developmenlal disabiliries, These children or V133 301 o1 Healrh Service Regularron STATE FORM azmu :1 Dlvision a! Health ServiceReuulallon 04/25/2013 FORM APPROVED swarm or DEFlclENclEs eeovroce/sueensmru (le coNsTRuchuN txal our suRva AND em or caRREchuN NUMBER A BUWNG ceuetrrso WING 0411312013 NAME or srersr tooecss crrv. sure zre cons NEW nomzon GROUP HOME. LUMBER amass. m: ":51 (x4) rd summon lo FLAN or (EACH DEFlclEch nusr er eercrocd ev mu PREFIX (EACH SHOULDEE COMPLETE rec m; me one DEFlclENch 3m Conllnued From page 29 30' adolescents shall not meet criteria lor acute inpatient services. The or adolescents served shall reqmre the lollowing: removal lrom home to an intensive integrated treatment setting; and (2) treatment in a locked 301 Sen/Ices S_ha_|l be deSIgned '01 For each of the helow cross reference (1) aSSIsi In the development deficiencies involved with the failure In meet and Wham! management skulls: he scope of the license. see each of the (2) "'0'me Intenswev frequemand 'ndividnal cross referenced notes Ihal prerplanned slums management. re eraIe the plans refletled in the previous (3) prowde contalnmenfi and safsfiy'mm deficient sections related to the cross potentially harmful or destlucllve behawors; Mm" (4) promote involvement ln regular productive activity, such as school or work. and ms (5) support the child or adolescent ln mm" "mm: mm" of me gaining the skills needed for reintegration into mom. 0mm," Chard". mm more m, communfly epth directional requiremenb, clinical The rntensrve resrdentral treatment mum/LPG pmude Mduwmg and shall coordinate with other individuals and mm and mm by me Chm", agencres Wlthin the child or adolescents system mum/LPG on "mm mm! mm, 0' cam>> ruguosrs that would be evident In the group onre population, Rule ls not met as evrdenced by: Based on record reviews. observatlons and in pm. .9 mm interviews. the lacility lalled to meet the scope ol "mm: the license lor an inlenswe residential treatment owned mummng by me CEO/Owner facility identilred to provide intenswe treatment mug me new We Prose" use-us and supervisron in the residentlal setting aftecting mod mm". documents hams place 5 ol 5 audited clients tile. The M, and mum: "mug findings are: oniloring: Continued or ungorng 0'055 Rememe- 10" NCAC 279 0202 enonnel records by the Qudlny Management PERSONNEL REQUIREMENTS Based tremor. See the Agency Personnel Record udu Sheet 112 easum in place In correct the deficiency: Director will |mm staffcn medical BMW STATE FORM 52m" ll continuation sheet in PRINTED: 04/25/2018 FORM APPROVED Division of Health Service Regulation V301 (V112) continued record documentation and the correlation between consumer needs from the clinical 5-12-18 assessment, treatment plan goals/strategies, and service provided reflected on the service notes; Clinical Director will train staff recognizing new behaviors and how to address. QM Director will train the staff how to utilize the Group Home Daily Schedule. Measures in place to prevent reoccurrence of the problem: Clinical Director will review all clinical assessments and treatment plans, upon Ongoing completion to ensure the needs reflected on the assessment are addressed appropriately in the treatment plan; Clinical Director will review the assessment and treatment plan with the staff prior to the implementation; Clinical Director and QM Director will review medical record documentation weekly to ensure the service notes are clearly reflecting services that address the consumer’s needs; Clinical Director will shadow the group home staff to ensure services are being provided according to DMH Rules; unannounced visits will be completed at various shifts to ensure the group home Daily Schedule is being implemented. Who is monitoring and how often to ensure Ongoing the problem will not re-occur: Clinical Director, Quality Management Director and CEO/Owner Division of Health Service Regulation STATE FORM 6899 8ZNI11 If continuation sheet 31 of D. 04/25/2013 FORM APPROVED Division ol Heallh ServiceReuulallon STATEMENT uE nEElclENclES (XI) <PRINTED: 04/25/2018 FORM APPROVED Division of Health Service Regulation V301 (V131) continued will review personnel documentation prior to job offer; Quality Management Director will review all personnel records at least monthly. Ongoing V132 Measures in place to correct the deficiency: QM Director has provided Client Rights training again to the presently employed staff iterating4-21-18 the section related to abuse, neglect, and exploitation; QM Director will continue to train new hire staff and all staff at least annually; QM Director has provided DMH Incident Report4-21-18 Manual Training, especially the chart reflecting when certain additional notifications/documents are to be completed for specific types of incidents, also training what “constitutes” an incident. QM Director has provided training/review of the New Horizon Standard of4-21-18 Operation related to the Reporting of Incident, emphasizing the timelines if an incident is related to abuse, neglect, and exploitation. An in-house email reporting system will be developed for staff and/or consumer to utilize Prior to 5when suspect to or evidence of abuse, neglect, 12-18 or exploitation; a Standard of Operation related to the in-house reporting process will be developed and subsequent training for the staff/consumers. The Standard of Operation will also include the steps to complete when completing an internal investigation. Measures in place to prevent reoccurrence of the problem: QM Director will provide continued monitoring of the implementation of the “Standard of Operation for Reporting Incidents” through Ongoing review of service documentation and notification of incidents; Clinical Director/LPC will provide daily shadowing and supervision; Independent Ongoing Compliance Consultant will monitor the reporting system and alert CEO/Owner and additional persons to begin any warranted Ongoing reporting processes and implement an internal investigation, if warranted. Who is monitoring and how often to ensure the problem will not re-occur: Quality Management Director Clinical Director/LPC Ongoing Independent Compliance Consultant Division of Health Service Regulation STATE FORM 6899 8ZNI11 If continuation sheet 33 of FRINTE 0. 04/25/2013 FORM APPROVED DlviSion ol Health ServiCeRquIatlon STATEMENT OF DEFICIENCIES (XI) (XZI MULTIPLE CONSTRUCTION txal DATE SURVEV mu mm or coaeecnou rozunncanon noneze A BUWNG commerce manna" WING 04113I201a NAME or eeovrozeoesuwuza may uuoezss sure zre ceue NEW HORIZON GROUP HOME, --LUMBER BRIDGE. NC "351 my ID DEFICIENCIES ID pauvruzas FLAN or cuaescnuu 1x5} (EACH nusr es pazczozu av mu (EACH cexezcnve ACTION SHPULPEE COMPLETE rec m; cxossazrzazuczuro rue Apoxopawg one 301 Continued From page 31 301 133 Mmsurm in plane to correct the deficiency: the Health Care Personnel Registry (HCPR) and Revision of the agency Personnel Orientation"Hg to investigate all alleged acts at abuse of neglect. reflecting the criminal background must be completed poor to the offer of hue and Cross Reference. GS. ?1220780 CRIMINAL a note swung no offers of lure be HISTORY RECORD CHECK REQUIRED FOR given wtlhuul the approval or the CED. New CERTAIN APPLICANTS FOR EMPLOYMENT Hunzon Group Home Personnel Poltcy uas (V133) Based on record reviews and interviews. weed .0 mm: "Meme". thin five business days Of I"aking the background check musI be obtained at conditional offer ol employment, the facility failed em. me bunnest days pnor [u to request a criminal background check lor a of 6 0.1mm"; onerorempruymem, audited stall 1:3, 09. 1:10, and the 5mm, .he amp Home Opemfions Manager/Group Home ManageII- nnager and all 0 lm um for completion of the 7mg CIDSS Rafefeme- 10A NCAC 276 1302 background checks wl|h using the Personnel REQUIREMENTS OF LICENSED "mum" Chem". and PROFESSIONALS (VZWZI- Based 0" lewd Direcmr u-un nil 5|de on New Hon/.tm Imaxhan reVleW and interview the lacility laileo to have a my P71 filmed pummel and least one lull time licensed prolessional (LP) mum, pmvidlng the required clinical and administfative mum in Place '0 0 "Was '0 Chem sen/"595- be problem. Updated copies of the Personnel nenrnuon Checklm will be forwarded to the Cross Reference. 10A NCAC 27C .1003 Emma pm" hm one,>> no "mg 0 nee-us 0" otenual can be completed \MLhoul the Based 0" "mm pprotnl of the CEO/Owner ensuring all poor In reVleW and interview the lacility laileo to have a "e Mme"; place. least one lull time quallfied prolessional (OP) 0 is "worm and how on" H, mm pmvidlng the required clinical and administfative he problem will ml CED/Owner "gums duties related to client services. 302: Cross Reference. 10A NCAC 27C .1004 mum in Fla" mm" deficient" MINIMUM STAFFING REQUIREMENTS (V304). was employed and 1e" emplovenm 3359" 0" Imew'ewv "bserva'im- and rem" nor to die survev date. since the survey date. up 22 ,8 reVleW the lacility Ialled to ensure the minimum "Mme LPC gas been empluyed m1 my number of stall who were available in the facillty mm me "mug prom" m" to meet the clients' assessed needs. meme measure "merpmud ee nuaclted Jab deocnpuun Cross Reference. 10A NCAC 27C .1005 OPERATIONS (V305). Based on interview and mum in Fla" mm" record and observations, the Iacillty failed he problem>> to ensure the educational services were made E0 mum me manned Pemnnel lm ewlce Regulation STATE FORM an aleu continuation sheet 34 PRINTED: 04/25/2018 FORM APPROVED Division of Health Service Regulation V301 (V302) continued place to carry out the clinical and administrative Ongoing duties related to consumer services. Who is monitoring and how often to ensure the problem will not re-occur: CEO/Owner Ongoing V303 Measures in place to correct the deficiency: A QP was employed and left employment prior to the survey date. Since the survey date, a fulltime QP has been hired to carry out the clinical 4-25-18 and administrative related to consumer services. See the signed job description. Measures in place to prevent reoccurrence of the problem: CEO will ensure the required personnel are in place to carry out the clinical and administrative Ongoing duties related to consumer services. Who is monitoring and how often to ensure the problem will not re-occur: CEO Ongoing V304 Measures in place to correct the deficiency: 1.The New Horizon Group Home Organizational Chart reflects the correct number of staff for the number of consumers in the group home. Each shift will have (4) direct care5-03-18 staff one of which is a shift leader but is also responsible for direct care duties. 2.The agency Residential Level IV Policy and all job descriptions have been revised to include the correct staffing requirements. 5-03-18 3.QM Director will train all staff on the Residential Level IV Policy See the Residential Level IV Policy, On or before Organizational Chart, and job descriptions as 5-12-18 examples. Measures in place to prevent reoccurrence of the problem: CEO will ensure the required personnel are in place to carry out the clinical and administrative duties related to consumer services. Who is monitoring and how often to ensure the problem will not re-occur: CEO Division of Health Service Regulation STATE FORM V305: Measures in place to correct the deficiency: 1.A certified teacher has been contracted to 6899 8ZNI11 Ongoing Ongoing If continuation sheet 35 of PRINTED: 04/25/2018 FORM APPROVED Division of Health Service Regulation V301 (V305) continued provide the educational services to the 2-02-18 consumers residing at the group home. 2.New Horizon has collaborated with the local educational agency to obtain an approved 4-25-18 educational program to utilize in the educational component of the service. See contract with certified teacher. See signed approval letter from Robeson County School System Measures in place to prevent reoccurrence of the problem: CEO will ensure the required personnel are in Ongoing place to carry out the clinical and administrative duties related to consumer services. CEO will coordinate with the local educational Ongoing agency to ensure the educational services are provided to the consumers. Upon admission of a new consumer, the facility Upon teaching staff person will obtain an IEP, admission of schedule an IEP to make any needed revisions new to be meet the consumer’s educational needs, consumer and and review all goals and strategies with the Ongoing staff. Who is monitoring and how often to ensure the problem will not re-occur: CEO to make certain the educational services are provided Educational staff person will ensure the educational program is the most effective to meet the educational needs of the consumers. Division of Health Service Regulation STATE FORM 6899 8ZNI11 If continuation sheet 36 of FRINTE D. 04/25/2018 FORM APPROVED Division ol Healrn ServiCeReaulallon STATEMENT OF DEFICIENCIES (XZI MULTIFLE CONSTRUCTION (XII DAVE SURVEV sue me or cuaeecnuu sundae commerce eurcuruc a WING 0411312013 NEW HORIZON GROUP HOME. LLC LUMBER BRIDGE. NC 28351 my Iu SUMMARY STATEMENTOF DEFICIENCIES ID PROVIDERS FLAN or CORRECTION Ixsr <PRINTED: 04/25/2018 FORM APPROVED Division of Health Service Regulation V301 Continued From page 33 V301 V301 (V503) continued continued monitoring of service record documentation to ensure that incidents are Ongoing responded to appropriately and reported timely. Who is monitoring and how often to ensure the problem will not re-occur: Clinical Director/LPC QM Director Review on 04/10/18 of the Plan of Protection dated 04/10/18 completed by the Licensee revealed: What immediate action will the facility take to ensure the safety of the consumers in your care? -"Training will be done for medications MAR by a RN (Registered Nurse) trainer by 4/27/18 and 4/28/18. Will continue recruite QP, LPC to be hire on or before 4/30/18. Training will also be conducted for Incident, Internal Investigation, HCPR, 4/28/18 for all staff. The meet min (minimal) staffing requirements, I will recruite and training all new hire staff by 4/28/18. Will contact local education dept. (department) by 4/28/18." Immediate Action Taken: Measures in place to correct the deficiency: 1.Medication Administration training, including 2-22-18 the use of a MAR, was completed by RN. 3-07-18 See training certificates 4-15-18 2.Incident Reporting (including agency not utilizing time out as a behavior modification technique), Internal Investigation, HCPR 4-21-18 training for all staff was completed. See training certificates Describe your plans to make sure the above happens: -"The QA trainer will do all training for areas mentioned for compliance." 3.Recruited and hired LPC and QP. 4.Recruited through a web-based recruiting site Ongoing for more experienced staff. All of those persons are being trained as if employees and the selection for new hires will be selected from that Ongoing group once the agency’ s license has been reinstated. See various training dates The facility is licensed as an 1800 and serving 7 clients ages 9 to 17 during this survey. The facility currently has no professional staff, LP or QP, to provide supervision or coordinate other services for the clients. The direct care staff have reported not to have been trained to meet the needs of the clients including MH/DD/SAS needs, alternatives to restrictive interventions, Physical Restraint and Isolation Time-Out as well as medication administration. The clients' treatment plans do not include strategies to address behaviors of aggression, property destruction, substance use as well as smearing of feces. Clients have diagnoses including Impulse Control Disorder, Bipolar disorder, PTSD, ADHD, Oppositional Defiant Disorder, Encopresis, Intermittent Explosive D/O, Autism, IDD Moderate, Anxiety Anger Issues, Cannabis Use, History of substance use. The facility consistently fails to meet minimum staffing having only 2 staff present to attend to up to 7 clients per shift. Clients are 5.Contacted local education department regarding the educational component that will 4-25-18 be utilized at the group home. See copy of the approval letter Measures in place to prevent reoccurrence of the problem: Training events will continue. Will ensure all required staffing positions have Ongoing been filled and remain filled. Continued monitoring of medical record documentation to ensure incident reporting is being appropriately handled and reporting timelines are met. Who is monitoring and how often to ensure the problem will not re-occur: CEO/Owner Clinical Director/LPC Ongoing QM Director Continued From page 33 Division of Health Service Regulation STATE FORM 6899 8ZNI11 If continuation sheet 38 of PRINTED: 04/25/2018 FORM APPROVED Division of Health Service Regulation V301 Continued From page 34 V301 receiving no educational services as required and are inside the facility watching TV in a common area the majority of the day. Clients have diagnoses including Impulse Control Disorder, Bipolar disorder, PTSD, ADHD, Oppositional Defiant Disorder, Encopresis, Intermittent Explosive D/O, Autism, IDD Moderate, Anxiety Anger Issues, Cannabis Use, History of substance use. The facility consistently fails to meet minimum staffing having only 2 staff present to attend to up to 7 clients per shift. Clients are receiving no educational services as required and are inside the facility watching TV in a common area the majority of the day. There are no routine schedule outdoor/recreational times. The licensee reports she was unaware that she was required to coordinate with the Local Education Agency in order to meet the educational needs of the clients. Clients report they only do some worksheets occasionally. No staff are trained in the area of providing educational services and clients have no IEP that would identify their current educational needs as identified by the local education agency. Staff failed to complete documentation of services and incidents. No incident reports have been completed for any of the reported incidences including Isolation Time-Out. This deficiency constitutes a Type A1 rule violation for serious neglect. Division of Health Service Regulation STATE FORM 6899 8ZNI11 If continuation sheet 39 of Division of Heallh Service Reaulallon PRINTE D. 04/25/2013 FORM APPROVED DEFICIENCY) smenw or derrcrencres rm peevrcee/sueenemu (X2) numne coNisuchoN my one suevev Add new or ccwuerec A mama--:13 a WING 0411312013 NAME OF srxeer "mess ewe zreccde NEW NORIZON GROUP HOME. LLC LUMBER BRIDGE. NC 28357 Ix4) ID Summaxv SYATEMENTOF DEFICIENCIES In eaovlnzas mm or CORRECTION 9(5) (EACH derrcrencv nusr ee av rum mm EACH CORRECTIVEWION SHOULDEE comm rec m; me reenpeeure we 302 Cumrnued lrem page 35 276 ,1502 Imensive Res. TX, Child/Adol Req, of IDA NCAC 275 .1502 REQUIREMENTS OF LICENSED PROFESSIONALS Each Iacrliry shall have al leasl one fulHlme licensed prolessianal. For purposes el rhis Rule, licensed prolessional means an individual who holds a license or provisional license Issued by me governing board regulaling a human service prolessien in me Slale of Nonh Carolina. For subsrance relaled disordels lhis shall include a Licensed Clinical Addiction Specialrsl or a Cenilieu Clinical Supervisor. The govemlng body responsible fol each laciliry shall develop and Implemem wrmen poliCIeS lhal Specify rhe clinical and admmislrallve responsibililies or RS licensed prolessienalIs), Al a rnrnirnum lhese policies shall include, (1)5uperVISion or direcl care slall, (2) oversighl of emergencies (3) provision of dilect clinical ervrceslechildren, adolescems orlam es, (4) parlrcipalien in meehngs, and (5)coordinalion of each childor adolescenl's lrealrnem plan 302 cl Healm Service Regulanon STATE FORM 5mm camlnuallcm sheet 40 D. 04/25/2013 FORM APPROVED Dlvision of Healih Service Reaulallon STATEMENT oE rm (x2) MULTWLE lxai DATE SURVEY AND FLAN or NUMBER COMPLETED A 5 mm; 04I1SIZO13 NAME oE NEW NORIZON GROUP HOME. STREET no DRESS chv. STATE ZIP conE LUMBER BRIDGE. uc 23357 lx4) lD Summon STATEMENTOF To mm or 0(5) (EACH MUST eE FRECEDED av FULL TEACH CORRECUVEACYION snooier COMPLETE TAG m; CROSS-REFERENCEDTD THE reenoperm WE 302 Conhnued From page as 302 302 This Rule is not mel as evidenced by. Iensures in planero torml Ihe deficiency: 4 23 18 Based on record review and inlerview lne laciliry Rammed and hired {ullrlime LPC or The Level failed Io have a leasr one full lime hoensed See copy oiogned rob deocnpuon prolessional (LP) plovidlng the leqmred clinical and adminislrahve dulieS relaled Io cllenl Iensures in place In prevem "occurrence oi services. The findings are, he problem>> CED will ensure ch is filled. ll Review on 04/10/15 ol rne facility's personnel Mame). becomes npporenr, CEO Will binder revealed no personnel record lor a LP. Vigomuoly recnnr To fill The poonon. lnlerview on 04/09/151he Licensee stated, she did nm have a LP on slall. Who is moniloring and how onen Io ensure She believed she had oompleled a personnel he problem will nol re-occur: record lor a LP. CED . She nor have me dares when a LP worked al The facility. rThe LP "jusr came and left" the posrhon at me lacilily, This deliciency is crossed refelenced inlo 10A NCAC 275 .1301 SCOPE (vaoil lor a Type A1 rule violarion. ol Healrn Sewlce Regulallon STATE FORM BZNHI IT commuamn sheer Dlvision of Heallh Service Reaulallon PRINTE D. 04/25/2013 FORM APPROVED smenw or (in <PRINTED: 04/25/2018 FORM APPROVED Division of Health Service Regulation Continued From page 38 V 303 V 303 This Rule is not met as evidenced by: Based on record review and interview the facility failed to have a least one full time qualified professional (QP) providing the required clinical and administrative duties related to client services. The findings are: Measures in place to correct the deficiency: 1.Recruited and hired QP position. The QP that was previously employed as QP at the Level IV 4-25-18 returned to the position approximately three weeks after leaving. All new personnel documents were completed for the re-hire. Review on 04/10/18 of the facility's personnel binder revealed no personnel record for a QP. Measures in place to prevent reoccurrence of the problem: CEO will ensure LPC position is filled. If a Ongoing vacancy becomes apparent, CEO will immediately and vigorously recruit to fill the position. Interview on 04/09/18 the Licensee stated: -She did not have a QP on staff. -She believed she had completed a personnel record for a QP. - She did not have the dates when the QP worked at the facility. -The QP had "just quit" her position at the facility. Who is monitoring and how often to ensure the problem will not re-occur: CEO Ongoing This deficiency is crossed referenced into 10A NCAC 27G .1801 SCOPE ( V301) for a Type A1 rule violation. Division of Health Service Regulation STATE FORM 6899 8ZNI11 If continuation sheet 43 of Division ol Heakh ServiceReuulallon PRINTE D. 04/25/2013 FORM APPROVED swarm or awareness (XI) peovrnemumiemn (sz Irvmne coNsIRuchuN (xal one suevev AND em or common names>>: A BUWNG cavemen Manuals 5 WING 0411312013 NAME OF may rupees: clTv. sure ZIP eons NEW HORIZON GROUP HOME. LLC LUMBER BRIDGE. NC 28351 (X4) ID STATEMENT OF DEFICIENCIES ID VUN 0" Pm. (EACH Deneienev veer as ev FULL mm rem ACTION enemies comm me xeevmomxIseInemnvmewmwniom m; me reexepeme an: DEFICIENCY) Conlinued From page 39 3" 27s .1304 Inlensive Res. Tx. Child/Adel . Min 304 slalling 304 10A NCAC 276 .1304 MINIMUM STAFFING MEWS in mm mm" deficiency: anal snail be ava'lable by 1 Rem" "he de'mpm'm "1847(2ng and I I I I . 0 8'1 1310:. Ielepnone ol page. A direcl care slalf snail be 3 reach laeIlIIy wnnIn 30 mlnmes al all 2 Rectum qualified m" an a "3be ed "6'0 so a . . process of Ihese purenual Is If ol adolescenls are cared fol In . (Sgpalale units/buildings, me bemg Lump'md' The "I'm one"? numbers shall apply Ire W|ll be cumplered once Ihe agency meme . . . ,mI d. The number ol dIrecI care slall 'e are Remed New Honmn Level Iv 03 18 E1) Inree direcl care slalf enall be presenl "my "mm mm" "9 plesemfol 4 5' seven, eignI or nine enildren ol adolescents. and MEWS in In mm five dilecl care slalf snail be presenl fol he robIem 10. 11 ol12 children oradolescenls, . . I Dlrecmr/LPC. Q17. and Dunng cnIld oradolescemsleep owing direcl care sIaIl shall be presenl ol wnicn ma 5 shall be awake and Inemird may beasleep. we" "Em" . . . . 2 CEO wIll ermn'e LPC pusnmn Is filled. [Ya In addmon Ine mInImum numbel aldllecl care mm become_ CEO ungomg Ian sel fonh in Paraglaphs (aHd) ol this Rule, I d" [h are direcI care staff may be required Ine Iacilily "gm" ased on Ine child or adolescem's Individual needs 5 spemfied in Ine IreaImenI plan. Who is monitoring and how often to ensure problem will no: I-e-omIr: This Rule is not met as ewdenced by: Based CEO/Owner. Qunllfied Ongomg and remld reviews. we facillIy Pmlessmnal, and DIrecIor ale Io meen eminimum 513 mg quuiremems. The lindings are: Review on 04/09/13 al client #25 Iecord revealed: 717 year old male. or Healrn Service STATE FORM BZNHI sneer 44 PRINTED: 04/25/2018 FORM APPROVED Division of Health Service Regulation Continued from page 40 V 304 V 304 - Admission date of 02/27/18. - Diagnoses of Major Depression Disorder, Psychosis Disorder, Schizophrenia and Attention Deficit Hyperactivity Disorder (ADHD). - Person Centered Plan (PCP) updated on 01/26/18 revealed, "treatment of his aggression and psychosis..history of responding to internal stimuli...becomes easily irritated by redirection...observed in both states of euphoria and withdrawn/depression..... staff will facilitate structured activities and utilize behavior management system and regular verbal and written feedback to help resident better manage behaviors...group home staff will provide monitoring 24 hours per 7 days." Division of Health Service Regulation STATE FORM 6899 8ZNI11 If continuation sheet 45 of Division 0! Heal'h ServiceReuulallon D. 04/25/2013 FORM APPROVED STATEMENT DE nEElclENclEs AND PLAN or chAEchDN NUMBER a <PRINTED: 04/25/2018 FORM APPROVED Division of Health Service Regulation V 304 Continued From page 42 V 304 PTRF (PRTF) (Psychiatric Residential Treatment Facility). -Review on 04/05/18 of staff notes revealed: -"3/20/18 - put in time out room. -3/20/18 - put in isolation environment. -3/24/18 - put in time out room,. -04/03/18- sent to time out room. -04/04/18- found blade and cut himself." -PCP dated 02/10/18 revealed need for "constant supervision." Review on 04/09/18 of client #4's record revealed: - 16 year old male. - Admission date of 03/07/18. Diagnoses of Oppositional Defiant Disorder (ODD), PTSD, ADHD, Anxiety /Anger Issues, Conduct Disorder and Cannabis Use Disorder, Mild. - Person Centered Plan (PCP) dated 02/19/18 revealed, history of vandalism...stole guns from neighbors, found with multiple guns by law enforcement, broke into elderly resident's homes to steal and vandalized homes, hit his grandparents, and mother and marijuana use...bullies others, 'let me have what I want, when I want it.' Goal: elimate use of all substances. Staff will provide monitoring "24 hours per day, 7 days per week." Review on 04/09/18 of client #6's record revealed: - 17 year old male. - Admission date of 03/17/18. - Diagnoses of Unspecified Schizophrenia Spectrum & Other Psychotic Disorders, Cyclothymic Disorder With Anxious Distress, ADHD, Intermittent Explosive Disorder, Other Specified Disruptive Mood Disorder, Impulse Control Disorder, Autism Disorder and Intellectual Development Disability, Moderate. - PCP dated 08/03/17 revealed, "He threatens to hurt mom's dog that she uses as a service dog and other family pets...history of twisting mom's arm...He needs constant supervision...lack of remorse...impulsiveness...does not see the Division of Health Service Regulation STATE FORM 6899 8ZNI11 If continuation sheet 47 of PRINTED: 04/25/2018 FORM APPROVED Division of Health Service Regulation V 304 Continued From page 43 V 304 - danger...cruelty to people or animals, often bullies, threatens intimidates others, frequent lying...collaborate with therapist...his recent behaviors requires a locked setting...level IV residential treatment, 24 hours a day, 7 days a week..." Review on 04/09/18 of client #7's record revealed: - 14 year old male. - Admission date of 03/14/18. Diagnoses of ADHD, Conduct Disorder, Disruptive Mood Disorder and Cannabis Use Disorder. - Person Centered Plan (PCP) dated 12/14/17 and assessment dated 03/14/18 revealed, " 'loved street life'- gang banging, smoking marijuana, history of IVC due to threats to kill family and others, his family is afraid of him...he can become extremely angry, easily irritated and argumentative and often blames others, he deliberately annoys others and attempts to intimidate them with threats of violence. history of being spiteful and vindictive as well as destruction of property, lying and leaving home without permission...threatened teachers to 'blow their brains out' and has also threatened his mother on several occasions that he was going to kill her...has threatened to 'beat down' staff if they do not allow him to go home. Group home staff will provide a safe and stable environment for [client #7] provide supervision and structure, utilize behavior management techniques, and create and implement corrective interventions to facilitate [client #7]'s improvement in demonstration of respect, management of anger and effective coping skills...independent living skills, social skills, leisure skills, health and wellness training, and vocation skills through recreation activities five times per week...his behaviors require structure at all times...staff will provide monitoring 24 hours per day." Division of Health Service Regulation STATE FORM 6899 8ZNI11 If continuation sheet 48 of PRINTED: 04/25/2018 FORM APPROVED Division of Health Service Regulation V 304 V 304 Continued From page 44 Observation on 04/05/18 of the facility revealed: - 10:00am - 3 staff present with 7 clients at the facility. - Client #2 paced back and forth in the facility. Observation on 04/09/18 of the facility revealed: - 11:09am - 3 staff present with 6 clients at the facility. Client #2 paced back and forth in the facility. Observation on 04/10/18 of the facility revealed: - 6:00pm - 2 staff present with 6 clients at the facility. - Client #2 actively paced back and forth in the facility. During interview on 04/05/18 client #2 stated: -He was not sure how many staff were on each shift at the facility. During interview on 04/05/18 client #3 stated: -He was not sure how many staff were on each shift at the facility. During interview on 04/05/18 client #4 stated: - Sometimes 3 or 4 staff were at the facility. During interview on 04/05/18 client #6 stated: -He was not sure how many staff were on each shift at the facility. During interview on 04/05/18 client #7 stated: -"Mostly two staff" were on each shift at the facility. Division of Health Service Regulation STATE FORM 6899 8ZNI11 If continuation sheet 49 of Division of Heahh Service Reaulalion D. 04/25/2013 FORM APPROVED Conhhued me page 45 Interview on 04/12/15 staff #6 stated, There wefe two sfalf on each shifl. Interview on 04/09/15 staff #9 stated, "Mosfly two staff work on each shill." Interview on 04/09/15 Staff #1 sfaled, rTheie were "supposed each shin. rHe somehmes worked aione on his shin. There were rwo siaii someiimes on each shin. Interview on 04/05/15 the Licensee slated, She had Mo sfafl on each shi rThe Shifls were eignr nour shins on me weekday Monday through Friday and 12 hour shins on Saiurday and Sunday. She was nor aware oi ine minimal siaii reqmremems iar rhis level of care. This deficiency is crossed refeienced inia 10A NCAC 27s ,1301 scope (vam) iar a Type A1 ruie swarm or (x0 peewdemupeuzmd (x2) nurme coNsTRucTioN ixa>> one sum/Ev Add new or coRREcTioN Nuueze comings A mums--m a WING 0411312013 NAME OF may access: ciTv. ewe zre CODE NEW "0mm" LLC -- LUMBER BRIDGE. NC 28357 0(4) in summxv ezricizuciss in mm or my max (EACH nusr ea mecca; av mm mm EACH CORRECTWEWION SHOULDEE comm me m; ms Awedperm we 304 304 ivision or Health Service Reguiehon STATE FORM azmu eenhnuahdn sheet so 04/25/2015 FORM APPROVED Dwision of Heahh Service Reaulamn STATEMENT OF DEFICTENCTES (x0 (X2) MULTWLE (x3) DAVE SURVEV AND MN mammnm NUMBER comma A mums mum--m WING 0411312013 magmas: ms mcons NEW HORIZON GROUP HOME. LLC -- LUMBER BRIDGE. NC 28357 0(4) summxv u: paw/mans mm or coaascnoN 9(5) max (EACH MUST BE mama av mm mm (EACH comm me m; ms wowm w: VACANT PAGE DUE TO CONVERTING TO WORD DOCUMENT a mam. Semce Regmauon STATE FORM 5-9! 5mm 04/25/2015 FORM APPROVED Dwision of Heahh Service Reaulamn STATEMENT OF DEFICTENCTES (x0 (X2) MULTWLE (x3) DAVE SURVEV AND MN mammnm NUMBER comma A mums mum--m WING 0411312013 magmas: ms mcons NEW "0.1.20" GROUP HOME, LLC -- LUMBER BRIDGE. NC 28357 0(4) summxv u: paw/mans mm or coaascnoN 9(5) max (EACH MUST BE mama av mm mm (EACH comm me m; ms wowm w: TO WORD DOCUMENT VACANT PAGE DUE TO CONVERTING a mam. Semce Regmauon STATE FORM 5-9! 5mm cammuaucm 5m: 41 04/25/2015 FORM APPROVED Dwision of Heahh Service Reaulamn STATEMENT OF DEFICTENCTES (x0 (X2) MULTWLE (x3) DAVE SURVEV AND MN mammnm NUMBER comma A mums mum--m WING 0411312013 magmas: ms mcons NEW "0.1.20" GROUP HOME, LLC -- LUMBER BRIDGE. NC 28357 0(4) summxv u: paw/mans mm or coaascnoN 9(5) max (EACH MUST BE mama av mm mm (EACH comm me m; ms wowm w: T0 WORD DOCUMENT ACANT PAGE DUE TO CONVERTING a mam. Semce Regmauon STATE FORM 5-9! 5mm 04/25/2015 FORM APPROVED Dwision of Heahh Service Reaulamn STATEMENT OF DEFICTENCTES (x0 (X2) MULTWLE (x3) DAVE SURVEV AND MN mammnm NUMBER comma A mums mum--m WING-- 0411312013 magmas: ms mcons NEW HORIZON GROUP HOME. LLC LUMBER BRIDGE. NC 28357 0(4) summxv u: paw/mans mm or coaascnoN 9(5) max (EACH MUST BE mama av mm mm (EACH comm me m; ms wowm w: gamma) VACANT PAGE DUE TO CONVERTING TO WORD DOCUMENT a mam. Semce Regmauon STATE FORM 5-9! 5mm Division of Heallh Service Reaulallon D. 04/25/2013 FORM APPROVED swarm c; (x0 < D. 04/25/2013 FORM APPROVED Division 0! Healih ServiceReuulallon STATEMENT uE nEErclENclEs (xii < Measiim in place In correci ihe deficiency: Educdholml has been coniracred |u~'02'18 See rhe approval leuer from ilie LEA regarding4'2548 Ongomg Ongomg Ongomg Ongomg ivrsion or Healrh Service Regulanon STATE FORM BZNHI sneems in Division ol Heallh ServiceReuulallon D. 04/25/2013 FORM APPROVED STATEMENT DE nEElclENclEs 1x11 AND FLAN or NUMBER a 1le MULTWLE A a WING (xal DATE SURVEY COMFLETED 04I1 ("201 3 NEW HORIZON GROUP HOME. NAME oE STREET AD LUMBER DRESS clTv. ZIP CODE BRIDGE. Nc 23:51 (x4) lD TAG SUMMARY DEElclENclEs lEAcn nEElclEch MUST BE FRECEDED av FULL lD FLAN or prey PREFIX rEAcn CORRECUVE AchoN snDuLneE COMPLEYE CROSS-REFERENCEDYD THE APPROPRIATE DATE 305 Conhnued From page 43 educafional and intellectual needs, Review on 04/05/13 ol clienl was record revealed. . 9 year old male. . Admission dale of 03/17/13. . Diagnoses ol Bipolar Disorder, Poshraumalie Siress Disorder (PTSD). Allemion Delicil Hyperaeiiviiy Disorder (ADHD). Disruptive Mood Disorder. Enoopresis and Rule Om Condum Disorder. . Pelsan Cemeled Plan (PCP) daled 04/26/17 revealed "What's no1 working section; "Nothing is walking, he eoniinues 1o be aggressive and nonrcompllanl. He is slealing food. his aggressive behaviors, mood swings, defianrwon'l lollow dilecfions and rules and sexual behaviors/geslures. need constant supervision. medications nmworking. and he is nm sleeping." 'He bullies mhel reponed lhal [chem 1:3] has pushed and hi expressed major concern [cliem 1:3] muching his sislerinappropriaiely, Morn reponed mat [cliem 1:3] siuck an object up his sisler's bud. Mom and leheni :13] reponed mat [clienl #31'5 lalher used 1o loueh him inappropriaiely, [Clienl 1:3] slaled he did mat his sisler so she can feel how he leels,.,rnom feels fol 1he girls salely. Morn repons mat [cliem 1:3] has choked her and his younger sisler on more 1han one ohen has major lernper screams, yells. slarn doos and olhers. clienl was involuniary on 1 11/17 aher a physicalahercahon 1he school staff. As a resull ol his aggressive behaviors he has pending charges Dem, (depanmenl) of Juvenile Jusfice fol disorderly conduct and assaull on a govermem was reponed he is agglesswe wiih sail a 1he we] was released from 1he 305 or STATE FORM 1m ervrce I egulanon BZNHI sneer 4s Division of Heallh Service Reaulallon D. 04/25/2013 FORM APPROVED hospilal alrer 30 days.,cominues lo be aggressive loward others.,.gmup home srarl w1|| suppon use ol 051 (oognirive behavioral [chem and family on relapse prevenhon,.leach lechnigues such as progresswe relaxalion, sel/hypnoses, or bio/eedback, ,.,Ieach behavioral allemalives.,.d9519n a loken eoonomy.,.develop a comingency oonlracl lo [chem lays somal skills. use a /eeling chan,.,' Medical ysician nme dared 04/05/15, Assessmem. needs higher level ol care such as PTRF Residenhal Trealmenr FaCllin). Review of srarl holes on 3/20/15 pm in lime our room, 3/20/15 pur ll" isolarion enVlronmenI, 3/2411 pm in lime 0m room, 04/03/13 sent to me our room, 04/04/157 /ound blade and cm himself. 7N0 implemenlalion or developmem of slralegies lo address sexually inapproprrale behaviors, fol consram supervision needs, no slralegres implemenled lo address <Division 0! Heal'h ServiceRem/Iallon D. 04/25/2013 FORM APPROVED "beat car wilh a sledge hammel", smle guns lrom neighbors lound wiih mulhple guns by law enfolcemem, broke inlo elderly lesu'iem's homes seal and vandalized homes, hit his grandpalems, and molher, and maliluana use, bullies o1hers,'le1me have whal wanl, when wani n: Goal. ehmale use ol all substances. 7N0 developmem and moldinafion wiih the LEA address the educalional and inlelleclual needs. Review on 04/09/13 ol clienl #6'5 record revealed. 17 year old male. Admission dale of 03/17/13. Diagnoses ol Unspecihed Schizophrenia Spedlum Oiher Disordels. Cyclolhymic Disorder Anxious ADHD, lnlermmenl Exploswe Disorder. 01her Specified Disruptive Mood Disorder, lmpulse Conlrol Disorder, Auhsm Disorder and lnlellecmal Developmenl Disability, Moderale. PCP daled 03/03/17 revealed, "He 1hrea1ens hun mom's dog 1hal she uses as a service dog and olher lamily pels.,.hismly ol lwishng mom's needs conslam supemsion,.,lack ol remorse, his behaviors scare her (mom). He smle his famel's Ill/ck and wrecked hm see me danger.,.cruel1y people or animals, ohen bullies, lhreaiens inlimidales olhers, flequenl |ylng.,.Link [chem alleys school 1o discuss implemenlaiion ol his IEP and ensure he is on 1he besl educalional paih, ollaborale wilh 1herapisl. Therapisi will lamlilam group wilh [chem :la] and peers in order 1o increase and problem solving skills..,' 7N0 developmem and moldinafion wilh 1he Local Education Agency 1o address the eduoahonal and inlelleclual needs. sum/w or (x1) peowomsupeuemm (le numne coNisuchuN (xal one suRva one now or communion NUMBER cavemen . soicmnc a WING 04/13/2013 NAME OF nooeess sure accede NEW HORIZON GROUP HOME. LLC LUMBER BRIDGE. NC 28351 my in sum/Euro; in run or 1x5, <Division of Heallh Service Reaulallon D. 04/25/2013 FORM APPROVED Review on 04/05/15 o1 olien1 #7'5 record revealeo. 14 year old male. Admission da1e of 03/14/15. Diagnoses Disruplrve Mood Disorder and Cannabis Lise Disorder. Pelson Cemeled Plan (PCP) daled 12/14/17 and assessmenr oaled 03/14/15 revealeo, 'loved s1ree1lireu gang banging, smoking manjuana, hisrory o1 IVC due lo llrrears 1o kill family and o1ners, his 1amrly is a/raid can become ex1remely angry, easily irnla1eo and argomenralrve and o11en blames mhels, ne deliberalely annoys mhels and anempls lo inlimidale lhem wi1h1h/eals o1 vrolenoe. his1ory of being spirerul and vinoiorive as well as deslruorion o1 properly, lying and leaving home wirlroul permission,.,1nrealened leaoners 1o 'blow inerr brains 0111' and has also 1nrealened his mo1neron several occasions 1ha1 he was going 1o ner, on me aoore onir pa1ienl has displayed a guick1emper, and has lhrealened 1o beat down' slaif rrmey oo nm allow him 1o go home, Pallem has significam DSS (oepanmem of social services) and DJJ (depanmem o1 juvenile josnoe) involvemenr," 'Group home s1a1/ a sale and slable envrronmen1 1or [olienr am provide supervision and slrocrure, o1ilrze behavmr managemen11ecl1nigoes, and cleale and implemem oorreorive in1ervenlions lo 1aorlrla1e [cliem <<71's improvemen1 in demonslralion o1 respem, managemenr o1 anger and ei/eorive coping skills. [oliem will receive an indivrdualized eoucalron based on needs, ins1ruc1ron in core cornoolum and independenl living skills, socral skills, leisure skills, realm and wellness lraining, and vocalion skills inrougn recrealion ao1ivmes five limes perweek.,.will srarerrmr or DEFlclENclEs rm paovromsupenemo 1x2) coNsYRuchoN 1x3) one sum/Ev one now or NUMBER coverereo A mama--:13 a WING 04/13/2013 NAME OF srxeer crrv. srare Zip code NEW NORIZON GROUP HOME. LLC LUMBER BRIDGE. NC 28357 1x4) lo summon DEFlclENclEs lo mm or 1x5) ram 1am DEFlclEch nusr ea paeceoeo av mu mm EACH CORRECWUUION SHOULDEE comm rec m; rne one 305 From page 51 305 o1 Healrn Service Regularron STATE FORM azmu sneer 45 of HeaIIh Service Reaulatlon PRINTE D. 04/25/2013 FORM APPROVED provide interaction to build competence and stability through evidence based individual therapy. ramily therapy sessions with guardian. rNo implementation or development of strategies to address substance use/oounseling and treatment, no implementation of strategies to address a sale and stable environment, or recreation activities or implememtation of strategies to provide supervision and structure, no strategiesdeveloped or implemented to address a behavior management and no education plan developed or implemented. No health and wellness training strategies developed or implemented, no vocation skllIs strategies developed or implemented, and no evidence based individual therapy and family therapy strategies implemented for clientw. No development and coordination with the LEA to address the educational and intellectual needs. Interview on 04/05/15 client #2 stated. rThe clients do worksheets tor education/school at the facility. Interview on 04/05/15 client #3 stated. rThey do not have "schooI" at the IaciIity, "no schooI, no teachei," Interview on 04/05/15 client #4 stated. r" No school," Interview on 04/05/15 client #6 stated. "No teachers heie, no school yet." Interview on 04/05/15 client #7 stated. "No school, the staff gives us worksheets." Interview on 04/05/15 Staff #2 slated, "We are trying to establish a regimen for smeuw or DEFICIENCIES (xtl raovomsurerisacria (x2) MULTIFLE CONSYRUCTIDN txai one suavrv Add new or coaaecriow IDENYIFICAYION Nuneea cowtereo a BUILDING mums--:13 a we 0411312013 NAME OF may cirv awe zrecooe NEW NORIZON GROUP HOME. LLC LUMBER BRIDGE. NC 28357 IXA) io summon DEFICIENCIES ID paovinzas mm or CORRECTION ixs, ram (EACH DEFICIENCY MUST er parceoro av FULL omit IEACH CORRECTIVEWION SHOULDEE comm ms aroumoavoarsciowirvincwroamiom m; his teeaoraim we DEFICIENCY) 305 Continued From page 52 305 at Health Semce Regulation STATE FORM BZNIH II continuation sheet so Division of Health Service Reaulallon D. 04/25/2013 FORM APPROVED education. We don't have a curriculum, no educational program, We use worksheets. No teacher yet." Interview on 04/12/15 Staff #6 slated, We were tolo the boys were to have school work and therapy but no they just sat up there and watcheo TV all day. No teacher there, no school work, never seen it (school/eoucation program), no workbooks, no teacher, nobody teaching all they had to Interview on 04/09/15 Staff #9 slated, have never seen a teacher here or seen start doing eoucational services. . The clients watch Tv all day and talk among themselves." Interview on 04/09/15 staff #1 0 stated, brought in math books, No educational services at all." interview on 04/09/15 the Licensee stated. . She hao no teacher in place to provioe educational servioes to any of the clients. She had not ootaineo IEP's tlnoividualized Educational Plan) for any of the clients at the facility and is working to get the IEP's for the clients, do it myself. I try to lind a study guide." Site was not aware she needed to coordinate with the LEA fol each ol the clients residing at the facility. This oeiiciency is crossed reterenceo into 10A NCAC 27s ,1301 SCOPE (V301) tor a Type A1 rule violation. smenw or rm tle MULTWLE coNsTRuchoN txai one soevrv AND now or homers conetrreo it MNLun-zts a WING 0411312013 NAME OF srxrer aooerss cirv. sure Zip code NEW NORIZON GROUP HOME. LLC LUMBER BRIDGE. NC 28357 0(4) in summon SYATEMENTOF io mm or pray rem (EACH iiusr er eercroro av FULL emix EACH CORRECWEWION SHOULDEE comm me m; his one 305 Continued From page 53 305 ivision at Health Service Regulation STATE FORM BZNHI hceninuanonsneer st 01 Dlvision of Healm Service Reaulallon D. 04/25/2013 FORM APPROVED 276 .0503 lricidem Response Requiremen(s 10A NCAC 275 .0603 INCIDENT RESPONSE REQUIREMENTS FOR CATEGORY A AND PROVIDERS Caiegory A and providers shall develop and implemem wrinen policies governing (heir response (o level I, II or incidenis. The policies shall require (he provider (o respond by, anending (o (he heal(h and saleiy needs of individuals involved in (he inciden(, (2) de(ermining (he cause ol (he inciden(, (3) developing and implemen(ingcorrec(ive measures according (o provider specified (imelrames no( (o exceed 45 days, (4) developing and implemen(ing measures (o prevem similar inciden(s according (o provider spemfied (imelrames no( (o exceed 45 days (5) assigning person(s) (o oeresponsiole fol implemen(a(iori ol (he corrections and preven(ive measules, adhering (o requiremems se( fonh in 6,8. 75, Anicle 2A, 10A NCAC 255, 42 CFR Pans 2 and 3 and 45 CFR Paris (on and 164, and (7) maimaining documen(a(ion regarding Subparagraphs (hrough ol(his Rule. In addi(ion (o (he requiremenis se( lonh in Paragraph of (his Rule, providers shall address iricideriis as required by (he lederal regula(ions in 42 CFR Pan 453 Subpanl. In (o (he requiremems se( lor(h in Paragraph of (his Rule, Caiegory A and providers, excluding providers, shall develop and implemem wrinen policies governing (heir response (o a level inciden( (ha( occurs while (he provider is delivering a billable service or while (he clien( is on (he provider's premises, The policies shall require (he provider (o respond swarm or reovomsurerisxcrix (x2) coNsYRuchoN (xa) one sum/Ev xuo mm or coRREchoN coimereo mama--:13 a WING 0411312013 NAME OF i NEW NORIZON GROUP HOME. LLC LUMBER BRIDGE. NC 28357 lx4) io summon SYATEMENTOF io mm or coRREcriou 0(5) (EACH MUST er paeczoro av FULL pmix CORRECWEACHON SHOULDEE comm no m; his (eexoreim we 365 Con(iriued From page 54 365 (vision o( Healih Sen/me Regulaiicn STATE FORM azmu coininuarieii sheer 52 Dlvision of Health Service Reaulallon D. 04/25/2013 FORM APPROVED by, (1) immediately securing the clientrecord by. (A) obtaining the client record, maklng a photocopy, (C) certifying the oopy's completenessand (in) transferring the copy to aninternal reVlew team (2) convening a meeting of an internal review team within 24 hours of the incident. The internal review team shall consist of individuals who were not involved in the incident and who were not Tesponsible for the client's direct care or with direct professional oversight of the cllenl's services at the time of the incident. The internal review team shall complete all of the activities as follows. (A) review the copy of the client record to determine the facts and causes of the incident and make recommendations for occurrence of future incidents, gather other information needed, (C) issue written prelirnmaryfindings of fact within five working days of the incident. The preliminary findings of fact shall be sent to the LME in whose catchment area the provider is located and to the LME where the client resides, if different and issue a final written report signed by the owner within three months of the incident. The final repon shall be sent to the LME in whose catchment area the provider is located and to the LME where the client resides, if different. The final written report shall address the issues identified by the internal review team, shall include all public documents peninent to the incident, and shall make recommendations for minimizmg the occurrence of future incidents. If all documents needed for the report are not swarm or [x0 txzi MULTWLE coNsTRuchoN txai ours suevzv run mm or NUMBER covetzrzo A MltLun-zts WING 0411312013 NAME or uooezss cirv. snare Zip code NEW NORIZON GROUP HOME. LUMBER BRIDGE. NC 2am lxt) io summon it: pmvinzas mm or 0(5) nusr es eazczozo av FULL (EACH CORRECWE ACTION SHOULDEE COMPLETE rec m; our: 356 Continued From page 55 365 ivisicn at Health Sen/me Regulation STATE FORM azmtt it continuation sneer 5: D. 04/25/2013 FORM APPROVED Division 0! Heals/1 ServiceRem/Iallon STATEMENT uE nEElclENclEs 1x11 pauonR/suqux/cm 1x31 DAVE SURVEY and new or NUMBER COMFLETED a 301mm 5 mm; 04I13IIU13 NAME oE pauvloanasl/WLTER NEW HORIZON GROUP HOME. STREET no LUMBER anss STATE ZIP conE BRIDGE. Nc 23:51 area where 1ne sen/ices are provided pulsuam 1o Rule .0604. (B) 1he LME where 1he clien1 resides, if dilfereni; (C) 1he agency wiih fol maintaining and upda1ing 1he client's 1rea1rnen1 plan, if dilleren1 1mm 1he reponing pmvider: (in) me Depanmem; (E) 1he cllem's legal guardian,as applicable; and (F) any mher au1hori1res required bylaw. This Rule is not me1 as evidenced by: Based on record reviews and in1erviews1he laciliiy lalled 1o implement policy and lo documem melr response 1o level II and incidences. The findings are: See Tag V367 In! specifics, Review on 04/05/13 oi 1acili1y records from 02/01/13 mlough 04/13/13 oi inciden1s nm documemed as level revealed: . 04/09/13 which involved cheni :17 allega1ion s1a11 #6 pushed him, cursed hirn.1hrew wa1er on him and anempred1o sinke nim wi1h a rnelal pole. . lncidenl (unknown spa/:lfic dare) 0103/2013 involved clieni #0 when s1a11 1:9 conducted a Repomng Manual, munmg ror rne 1he lnenleni Reponmg Policy. rne ageney Slandarrl e1 Operanon relnled 1o incidenl response |o level ii and level 111 nenlenrs and repumng 1o venous ngenues. ncludmg 1he MCO. l-lealrn Cnre Reglery. em See lnudem Repunmg Policy See mulling cemficnres See oi Opemlmn Measnm in place In prevent oi he problem, 1 review ofmedlca] record documenmuun re ensure nny incidenls lhal are no|ed have been appropnnrely reperled and umelmes. 2 Complere any lolleweup as a resulr illie review oimedreal records. shadowing nrunironng of nail gne "hands on" and advice nrrnediarely Who is monitoring and how onen to ensure he problem will nol reoeenr: linrenl Director/LPG Emmi-led Mnnagemem Drreciur 1x41 in STATEMENTOF oEElclENclEs lo run or prey (EACH MUST BE FRECEDED av FULL PREFIX (EACH CORRECUVE ANION SHOULDEE COMPLEYE TAG m; rnE eerE 356 From page 56 365 available wnhin 1nree monlns of me incidem. 1he LME may give 1he provider an enension of up 1o 3" ""99 '"m'hs '0 "hm" Measnm in place In some: the deficiency: (3) immedla'ely "O'Ifi/Ing 1.Tm|ned will. die DMH (A) 1he LME fol 1he calchmem Repomng emphasumg 1he reporting umelmesmurlx Ongomg Ongomg Ongomg Ongomg d/ Healrn Sen/Ice Regulanen STATE FORM BZNH 1 Cami/walla" sneersa in Dlvision of Heallh Service Reaulallon PRINTE D. 04/25/2013 FORM APPROVED 10A NCAC 276 .0504 INCIDENT REPORTING REQUIREMENTS FOR CATEGORY AAND PROVIDERS Calegory A and providers shall repon all level II incidenls, exoepl dealhs, Ihaloccurdullng Ine provision of billable selwces or while Ine consumer Is on me providers premises or levelIlI incidenls and level II dealhs involving Ine cliems Io whom Ine pmVIder rendered any sen/Ice wilhin 90 days prior 1o Ine incidem Io Ine LME responsible lor 1he calcnmenl area whele services are provided wrinin 72 hours of becoming aware of 1he incrdem. The repon shall be svbmined on a form provided by 1he Secrelary. The repon may be svbmined via marl, in person, facsimile or eleclronic means, The repon shall include Ine lollowing inlormalion. (1) reponing provider oonlacland idenlihcalion information swarm or oerrcrencres (x0 peovromsoperremo (x2) mums CONSYRUCTIDN (x3) one sum/Ev AND mm or common NUMBER coverereo A sonornc mama--:13 a WING 0411312013 NAME OF may sure zrecooe NEW NORIZON GROUP HOME. LLC LUMBER BRIDGE. NC 28357 lx4) lo summon SYATEMENTOF DEFICIENCIES lo PROVIDERS mm or CORRECTION rxs, rem (EACH oerrcrencv MUST er peaceoeo av FULL mm EACH CORRECTIVE acnoN SHOULDEE comm ms m; me APPROPRIATE we 366 Conllnued me page 57 366 harmful/abusive amlon ol placing chem #G's arm up and back imo Ine cliem's back and esooned cliem #6 lo lhe limeroul room. 7No pollcy implememed or documenlahon lor response or level incidenis. Rel/lew flom 04/05/15 1hrovgl1 04/13/15 revealed cliem #3 and clienl #6 were placed in me lime am on a1 Ieas17 occasions win no documemed response 1o incidences, This deliciency is crossed refelenced inlo 10A NCAC 27s ,1301 SCOPE 1 V301) lor a Type A1 role violalion. 367 276 ,0604 Ineldem Repomng Requirements 367 o1 Healm Sen/Ice Regulallon STATE FORM azmu comrnvanon sheer 55 Division of Healm Service Reaulallon D. 04/25/2013 FORM APPROVED or responding. Calegory A and providers shall explain any missing or inoomplele informaliori. The provider shall submi( an upda(ed reponlo all required repon reciplems by (he end ol (he nex( business day whenever. (he provider has reason (o believe (ha( inlorma(ion provided in (he repon may be erroneous, misleading or mherwise unreliable, or (2) (he provider oblains inlorma(ion required on (he incidenl lorm (ha( was previously unavailable. oa(egory A and providers shall submi(, upon reoues( by (he LME, o(her lnformafion oblairied regarding (he ineidem, including. hospnal records including conliden(ial informaliom (2) repor(s by o(her authomiea and (3) (he prowder's response (o (he incidem. Ca(egoryAarid providers shall send a copy of all level ineidem repor(s (o (he Division or Men(al Heallh, Developmemal Disabili(ies arid Subslance Abuse Services wi(hin 72 hours of becoming aware or (he ineidem. Ca(egory A providers shall send a oopy or all level ineidems involving a elieri(dea(h (o (he Division or Heal(h Service Regula(ion wi(hiri 72 hours ol becoming aware or (he ineidem. in cases of clien( dea(h wimin seven days or use or seclusion or res(rain(, (he provider shall repomhe dea(h immedia(ely, as required by NCACZGC .0300 and 10A NCAC 27E ,0104(e)(1a), Ca(egory A and providers shall send a smeuw or (x0 raovomsurerieacria (x2) MULTWLE (x3) one suavev (no mm or coRREchoN Nuoeza ooimrreo a suivowe mums--:15 WING 0411312013 NAME OF may eirv. sure zre CODE NEW NORIZON GROUP HOME. LLC LUMBER BRIDGE. NC 28357 W) in summon srarmsmor io mm or 0(5) ram (EACH MUST er paragon; sv FULL emix (EACH CORRECWEACHON SHOULDEE comm me m; his (eeaoraim we 367 Con(iriued From page sa 367 (2) clien( iden(ilica(ion (3) (ype ol ineidem, (4) descrip(ion ol inciden(, (5) slams ol (he ellon (o de(ermine(he cause loe lncidenL and o(her individuals or aumorilies nmilied (vision o( Healih Service Regulaiion STATE FORM azmu sheer 56 Division 0! Health ServiceReuulallon D. 04/25/2013 FORM APPROVED smenrnr or nEFlclENclEs (X1) recvrore/surenemiu (le nutnne coNisuchuN txal one suRva nun em or caRREchuN worsen A BUWNG conetrreo WING 0411312013 NAME or srarer tooerss crrv. sure zre CODE -- NEW HORIZON GROUP HOME, LLC LUMBER BRIDGE. NC 28351 (x4) in SUMMARY u: run or as} (EACH DEFlclEch nusr er eercrord av run mm SHDULDEE comm rec m; one DEFlclENch 367 Continued me page 59 367 367 report quarlerly to the LME responsible lor the catchment area where services are provided, The report shall be submmad on a form pmwded Mmum in mum mm. deficiency: by the Secretary Via electronic means and shall "when 5m" DMH inane". include summary inlormation as follows: Reporting Manual, new for [he (1) medlcafion film's "181 d0 "'8th inn the incident Reponmg Valley, and rhe definition ol a level II or level incident; agency swam umpmm filmed .0 mm," (2) restrictive interventions that up not meet Reponmg mg mpomg "mum the of a level II or level lnCIdenl. mpum .0 Mel 1m. (3) searches of a client or his liVlng area;_ "Men" repunmg .0 "mm agencm'eezlelx (4) selzmes ofqllemplopefly Orpmper'yln ncludmg rhe Mco, Henllh Care Reglery. etc. the Possessmn 0' 8 Chem: Also covered in the flaming is the correcr Maps (5) thetotal number ol level ll and level Ill .1 n.e complain" ofan mourn morgue. as incidents that occurred; and mm um, made," a statement Indlcallng that there have ea nude," "pawns "my peen no reportable incidents whenever no es "mums cemficm InCIdenls have occurred durlng the quarter that ea "Open" meet any of the cnteria as set forlh in Paragraphs and (oi oi this Rule and Subpalaglaphs through (4) or this Paragraph. more or place In prevent or he problem. This Rule '5 no' me' as evidenced by: Commued review of medical record Based on record reviews and interviews the ""men'm'm' facility lalled to ensure critical incident repons "Wm?""ely "me" were submitted to the Local Management Enmy *hndumg 0' '0 ""48 Bugging (LME)/Managed Care Organization (MOO) within "mm" "f be" me'hu'i' 72 hours as reqmred. The lindings are. '1 P0 "e Follquup smfl' n3 needed an resuh of Review on 04/05/13 ol facility records lrom he "'8de WW 02mm 3 through 04/13/18 revealed: 04/09/13 which involved client #7'5 allegation 0 '5 "mum?" and h" '0 stalt tie pushed him, cursed hirn. threw water on he problem not ream-r: him and attempted to stnke him with a metal pole. Incident (unknown spemfic date) ol 03/2013 ""66""ch 0 0 involved client #6 when stall #9 conducted a "dilly Managemenl "3 "3 harmquabusive action ol placing client #6'5 arrn up and back into the cllem's back and esconeo dr Health Service Regulation STATE FORM BZNHI continuation sneer Division of Heallh Service Reaulallon D. 04/25/2013 FORM APPROVED clienl #6 lo 1he limeroul room. No level inciden1 repons were comple1ed on above re/erenced incidenls. Finding #1 Review on 04/13/15 01 lhe IRIS (lncidem Response lmprovemenl Syslem) revealed. rNo IRIS repor1 1or inciden1 on 04/09/15 was available fol review a1 lhe oomplelion ol lhe survey process on 04/13/13, No in1ernal inveshgalion was provided fol 1he inciden1 on 04/09/15 for review a1 lhe complehon onhe survey process on 04/13/13. lnlerview on 04/11/15 a11he local hospilal wilh clienl #7 who was under an IVC (involunlary commhmenl) order s1aled. lncidenl on 04/09/13 was in [clienl room she (s1a/l a) would come in and s1an s1ull wilh us, She would cuss like cullhe P'mg ligh1olr, [Clienl had a phone. I called my mom and lelling her whal was happening, Hhink [slah heard me calling my mom. was playing wilh a soccer ball, it was loud, [Staff said give me lhe ball. She pul her lingers in my lace and pushed me wall. 1 was mad, 1 kepl lhrowing 1he ball hard againsnhe wall. [Slali Said, wish you would hit me as hard as you lhrowlhal ball. 1 weni in [chem room and he was on lhe phone. re/used meds (medicines) lhal nighl, because 1 didn't know whai she was going lo do. 1alked lo [operalions manager/group home manager] bul he look up fol [slah [Slall came in [cliem <<11's room [operalions manager/group home manager] came in and lold me 1o go lo bed. She (sla/l came in and 1hrew wa1er on me, a big cup wilh ice and waler, go1 on [clienl <<11's bed and i1 was wel. blanked oul, she s1ar1ed swinging and or rm raoviormureusacua 1x2) norms coNsIRuchoN 1x3) one suavrv mo new or iosmincanon homers concierge a mama--:13 a WING 04/13/2013 NAME OF eaovioraoasuwura may cirv. ems zre CODE NEW NORIZON GROUP HOME. LLC LUMBER BRIDGE. NC 28357 1x4) lo summaxv lo mm or rxs, cam (EACH nusr er earczoro av FULL CORRECWUUION SHOULDEE comm rac m; his maoram we 367 Conhnued From page 60 367 o1 Heelih Service Regulahcn STATE FORM 02mm 11 conrnuanon sheer 52 Dlvision of Heallh Service Reaulallon D. 04/25/2013 FORM APPROVED hir me on rhe shoulder. lwem lo punch and hil her. [Slall #14] came in and rold me to go In bed. [Slafl came back in a big pole, They look my bed oul of my room and a rolling closer rhing. She lried lo hii me wilh iI (lhe pole). She swung al me, She called lhe police and lried lo press charges, [Slafl slaned crying when lhe police came." rThe polioe look him to <Dlvision of Health Service Reaulallon D. 04/25/2013 FORM APPROVED come to the group home,.,l lelt unsale with 7 boys. [Client relused his meds (medications) andl told [client home of water in my hand and waving my hands and he said don't pour water on me' some ol the water spilled on his leet and [stall called me (date unknown) and asked me why I poured water on him. They put me in a unsafe place, Hetclient w) punched me in the lace and injured my lelt eye, hit me with a closed list and broke my glasses and I got gashes on my face around my and optical bone is lractured,., [Stall came out to see my lace and todo IVC order on [clientm,., [Operations manager/group home managerltold [start I poured water on him (client and in his tace,., {Opelalions manager/group home manager] tackled [client alter [client attacked me. We look [client ms bed out and rolling closet 'cause [client was tearing itup. A bar, broke ofl the closet, a metal closet pieces Ididn'l do nothing to him with no metal pole (stall #6 laughed), I Just reacted on pure emotion, Ijust went to get him and they had to hold me back but I didn't hit him, couldn't get to him, never hit him, couldn't get to him, [operations manager/group home manager] held me back." was cursing at him (cllem well generally, because I was Finding #2 Review on 04/09/15 ol client #B's record revealed. 17 year old male. Admission date of 03/17/15. Diagnoses ol Unspecilied Schizophrenia smenw or rm raovioea'suwrieacria (x2) MULTWLE coNsYRuchoN txai one suavev ano mm or coRREchoN nuosea couptereo a mums--:13 a WING 0411312013 NAME OF sraeer cirv. awe Zip code NEW "0mm GROUP HOME, LLC -- LUMBER BRIDGE. NC 28357 lxt) in summaxv in mm or prey ram (EACH MUST so parceoeo av FULL omit CORRECWUUION SHOULDEE comm ms m; his tomorrow we 367 Continued From page 62 367 ivision at Health Sen/me Regulation STATE FORM BZNHI camlnuallnn sheet on Division oi Heakh ServiceReuulallon D. 04/25/2013 FORM APPROVED Spedlum Oiher Disordels. Disoroer th Anxious ADHD, lnlermmem Exploswe Disorder. Oiher Specified Drsruplive Disorder, impulse Conlrol Disorder, Amrsm Disorder and Imeliecmal Developmenl Disability, Moderale. PCP daled 03/03/17 revealed, "He ihrealens hurl mom's dog lhal she uses as a selvice dog and olher famiiy pels.,.hismly ol misnng mom's needs conslam superwsion,.,lack ol remorse.,rmpulsiveness,.,ooes noi see ihe danger.,.cruelly people or animals, oken bullies, lhreaiens imimidales olhers, frequent lmerview on 04/05/13 chem #6 slaleo. rYou go In lhe nme om roorn 'cause nol behavmg, slalf [slall ma] saio I had a bad animde," small wenl inlo my pockel and took my IPod." lmerview on 04/10/13 slall #9 stated: He had noi lecelved any NCI (Nonh Camlina lmervenhon) uaining aI ihe laciliiy. 'One slall allowed him (cliem :la) la have cell phone, anone or sornelhing like <Division of Health Service Reaulatlon D. 04/25/2013 FORM APPROVED survey process on 04/13/15. No internal invesligalion was provided for the incident on 03/2015 for review a1 the complelion orlhe survey process on 04/13/13. Finding 1:3 Review on 04/11/15 oi local police repons revealed. 03/23/15 . "Caller adVlsed that one o/ the children allne group home lnrew a rock through the windshield other 2014 black lord 150." 04/02/15 . DSS called my local Delectlve assigned, . No level II repons oompleled in IRIS to reflect lhese police involved incidenls. Finding 1:4 Interviews on 04/09/13 With Client #3 and Client #8 revealed lhey were placed in the time oul room on occasions. Interviews lrom 04/05/1Blhrough 04/13/13 with all slalf revealed time out room was used on multiple occaSlons lor client #3 and client Review lrom 04/05/1 through 04/13/13 revealed no documentation of incident reports for use of lhe lime out room, Molliple interview anempls were made lo interview the Operations Manager/Group Home Manager in regards lo lne allegallon on 04/09/15 and ineldenl on 03/2015, There was no response from the Operations Manager/Group Home Manager allne completion orlne survey process on 04/13/15. smenw or reowoemureoemoa (x2) MULTWLE coNsrRuchoN 0(3) oars sum/Ev mo mm or coverage a eunowe mum-:15 5 Wine 04/13/2015 NAME OF may ewe zre cooe NEW "0mm" LLC -- LUMBER BRIDGE. NC 28357 lx4) lo summer/Tor lD mm or 1x5, rem (EACH Musr es av mo mm EACH smuwfii comm me m; caossasreemoeoro ms we 357 Continued From page 64 367 5/ Healm Service Regularion STATE FORM 52mm 11 Cami/maxim! sheet oz 171 Division of Heallh Service Reaulallon D. 04/25/2013 FORM APPROVED Policy 10A NCAC 27D .0103 SEARCH AND SEIZURE POLICY Each chem shall be free lrom unwarranled invasion of privacy, The govemlng body shall develop and implemen( pohcy(ha( spemfies (he condnions under which searches of (he chem or his living area may occur, and if permr((ed, (he procedures for seizure oi (he client's belongings, or propeny in (he possessmn of (he chem. Every search or seizure shall be documemed. Documenla(ion shall include. scope of seafchv (2) reason (or search, (3) procedures followed in (he search (4) a descriphon of any propeny seized and (5) an accoun( oi (he disposr(ion olserzed propeny. swarm or DEFlclENclEs (x0 (x2) humm coNsTRuchoN (x3) oars soevsv (no mm or coRREchoN houses coherzreo a sorrows WING 0411312013 NAME OF may crrv. sure zre CODE NEW NORIZON GROUP HOME. LLC LUMBER BRIDGE. NC 28357 lx4) lo summon srarmsmor DEFlclENclEs lo PRoleERs mm or 0(5) max (EACH DEFlclEch MUST so mczoeo av rum mm EACH CORREWVEACTION smuwfii comm rec m; ms (eexoeerm we 357 Conhnued From page 65 367 ln(erview on 04/09/15 (he Licensee s(a(ed, She was aware of an NC for chen( #7 due (o an assaull on Slaff #6 on 04/09/15 and Chem #7'5 allegahon agains( s(aff #6 on 04/09/15, The IRIS repons were in process (o be comple(ed (or (he incrden(s on oa/zmaand 04/09/1 B. No IRIS repons were comple(ed by (he comple(ion oi (he survey process on 04/13/15. This deficiency is crossed refefenced in(o 10A NCAC 27s ,1301 SCOPE (vam) (or a Type A1 rule violalion. so 27D mus Clienl Righ(s Search And Seizure 503 (d Healrh Service Regularron STATE FORM azmu comrnuaner. sheet 91 Division 0! Health ServiceReuulallon D. 04/25/2013 FORM APPROVED smeuw or DEFlclENclEs rm (le coNsTRuchuN (xal one suRva the seen or sources A consume WING 0411312013 new or nooeess sure Zip code NEW HORIZON GROUP HOME. LUMBER names. NC 28351 my in lD run or as} (EACH DEFlclEch uusr es ev mu mm (EACH SHOULDEE COMPLETE rec m; rne one 503 Continued From page as 503 This Rule is not met as evidenced by: 503 Based on lMel'Vlew and record review the facility conducted unwarranted search and seizure altecting one of five audited clients The Mmum in mm", mm. "m deficiency: findings ale: 1 Reuhed New Horizon Search and Seuure Policy in include smell-rem regarding following 703718 Rewew on 04/09/13 ol client #6'5 record epomng umehm 'e'lea'EG- See artached copy of New Horizon Search and 17 yea! old male- Seuure Policy Admission date of 03/17/13. Diagnoses 0' UNSpecflled 2 Tram sun on rhe Search and Seuure Policy pm, in 5, Spectrum at Other Disoldels. 12713 Disordel With Anxious Distress. Tm" 3.an me DMH pepunmg ADHD, Intermittent Exploswe Disorder. Other "ml [0 repomns of mm, and Specilied Disruptive Mood Disorder, Impulse mm madam 4721718 Control Disorder, Autism Disorder and Intellectual Development Disability, Moderate. Mmsurm in place In prevent or PCP dated 03/03/17 revealed. 'He threatens to he mum, mom's dog Sheflses as a SSWICB dog 1 Comm :1 monrronng oflhe slnfiand provide and other lamrly pets.,.hrstory ol twisting morn mm," mm gne ,mmedm needs constant supermsion,.,lack ol 0" om remorse, his behaviors scare her (mom). He 3 3 stole his lather's truck and wrecked 2 Con'mued renew or med", mom one" ensure any nered meldems a bee re; ended it: a motel and bullies, threatens intimidates others, frequent ep'oned 3mg] . Followup in surf meetings Lind/0r individual 0" 04/05/13 Chem "am" MPSl'uhlons with mini wmamed Ongomg You go to the time out room cause not behavmg, stall [stall mu] said I had a bad anilude." . . . J'[Stall went into my pocket and took my lPod 22:53::3'v'v'fl1'f0723mf" has" Drreeror/LPC Interview on 04/1 on a start #9 stated: "j'f'edMWW'Mf'D "One stalt allowed him (client to have cell phone lPhone or something like that and I told him. he couldn't have it. ltold him he couldn't have it and ltold himl or Healrh Service Repolanon STATE FORM BZNHI sneer s4 Division of Heallh Service Reaulallon D. 04/25/2013 FORM APPROVED STATEMENT oE nEErclENclES rm AND FLAN or coAAEchoN loENTlErcATloN NUMBER MNL018-31E < D. 04/25/2013 FORM APPROVED Division ol Health ServiceRem/latlon STATEMENT OF (Xi) MULTWLE txai DAVE SURVEY AND new or uunese A BUWNG 1/11th13413 WING omalzma NAME OF nooeess crrv. sure zre CODE -- NEW nomzon GROUP HOME, LUMBER amass. NC "351 (x4y in summxv iD run or rxsy (EACH DEFlclEch uusr er onscreen ev run mm (EACH SHOULDEE COMPLETE rec m; we aeoxoeemr one DEFlclENch 512 Continued From page as 5'2 necessary to repel or secure a violent and 512 aggressive client and which is permitted by governing body policy. The degree of force that is necessary depends upon the individual Mmsurm in place In toned the deficiency: characteristics ol the client (such as age. size lcuent Righh was provided nil 4721er and physical and mental health) and the degree ten, of aggressiveness displayed by the client. Use ol intervention pmoedules shall be compliance with 2 memg was completed with all staff H418 Subchapter 10A NCAC 27E orthisChapter. See Any violation by an employee ol Paragraphs through o1 this Rule shall be grounds lor Completed relevant lo "how u) dismissal ol the employee. ornplere internal lnveshgnuons" during the' 21 I 8 netdenr Repumng Manual Also. ornplered renew training regarding the This Rule is not met as evidenced by: Standard 01 Operation rer lnerdenr Repumng Based on record review and interviews. two 01 six has s|eps for completion of rotemdl audited stall 1:6) subyected two o1 five audited "mums. clients :17) to harm and abuse. The lindings 5% Repunmg mummy are. Mmsurm in place In prevent o1 Finding be problem. Review on 04/09/13 0' client W's record 1 Continued ddowmg and revealed- 11 order lo provide trnroedtate reedbuek '4 Yea! Old male- behavior modifications, Admission date of 03/14/13. "gums Diagnoses 0' Comm" Disordeh 2 Review or medical record ducumemnuon to Disruptive Mood Disorder and Cannabis Llse mm "med madam was Dismder- andled and reported hmely. Pelsan Centered Plan (PCP) dated 12/14/17 and assessment dated 03/1411 3 revealed. Founwmp any "mm mugs m" nee-us 'loved Wee! life" gang banging smoking meetings dnd/ormdludual super/1510M. marijuana. history ol IVC due to threats to kill farmly and others, his larmly is alraid_ol him.,.he Who is and how one" .0 mm can become extremely angry. easily rrntated and he problem will no. "mum "gums argumentative and often blarnes others. he 1mm, Duecwruc deliberately annoys others and attempts to umfied "Memo", intimidate them threats ol violence. hlsloiy "my Mmeemem Dmm, of berng spiteful and as well as destruction ol property. lying and leaving home without teachers to 'bluw dr Healrn Sen/Ice Regularron STATE FORM on Elm" ll continuation sheet 86 Division of Heallh Service Reaulallon D. 04/25/2013 FORM APPROVED ineir brains oul' and has also inrealened nis molner on several occasions inal he was galng to kill ner.., has inrealenerl 1o 'beal down' home slall will provide a safe and slable envimnmem ior [cllem 1:7] provide supervision and slruclure, utilize behaVloi managemem lechnigues, and creale and implemem corieclive inlervenlions lo iacrlilale [cliem #71'5 improvemenl in demonslralion oi respem, managemeni of anger and elieciive coping skills. [oliem will receive an indiwdualized educalion based on needs, inslrucuon in core curriculum and independenl living skills, social skills, leisure skills, nealln and wellness lraining, and vocalion skills inrougn recrealion five limes per week..,will provide inleracuon to build compelence and slabiliiy inrougn evidence based indiVldual inerapy mommy iamily inerapy wiin guardian. Review on 04/05/15 oi a worm Carolina Incidem Response lmprovemenl Syslem (IRIS) repon compleled by me Operalion Manager/Group Home Manager revealed. Dale of incidem, 03/31/13. lncideni Commems. daled 04/03/15 [operalions manager/group home manager] received a call lrom staff member [slalr #10] a1 approximalely 9pm on 3/31/18 reponing lhal consumer [cliem was allegedly choked by slalr member [slarl relieved [slalr of his dimes unlil me inlernal invesligalion can be compleled,bu1a11nis1ime neilner me consumer nor lne mher slall member [slarr 1:13] on duly indicaled any knowledge oi are alleged incidenl reponed by [salt 1:10]. There were no visible marks on me consumer and me consumer repealedly indicalerl inal lie was line and nad no complainls, Even when lollowing up wilnlhe smenw or rm recviormurenexcru (x2) nurme coNsIRuchoN (x3) one sum/Ev one mm or concierge A mama--:15 WING 04/13/2013 NAME OF srkeer nooerss cirv. sme zre cone NEW "0mm" GROWN, ch -- LUMBER BRIDGE. NC 28357 lx4) in summer/Tor in mm or prey rem (EACH nusr er mecca; av FULL mm EACH CORREWVEWION SHOULDEE comm me m; me we 512 From page as 5'2 ol Healm Service Regulancn STATE FORM azmu comrnuanen sheet sr Division 0! Heakh ServiceRem/Iallon D. 04/25/2013 FORM APPROVED consumer on mday he indica1ed mere was no incideni, Invesfigalion is currendy ongoing as DSS was onsile 1ooay and we are awaking meil findings as well." me cause of mis mcidem. mmpleled on 4/3/13 s1all rnember accused anolner member o1 physically abusmg a consumer (cliem lmernal inves1igauon is being conducled as well as DSS having come ou1 1o conouc1 Ihelr own inves1igatlon, "Ineldem Plevemion: comple1eo on 4/3/13 A1 mis lime we are nm sure wna1 could have been done dilferendy and are sfill invesiigaling me manerlunner, The managemem 1eam will be rel/law policy 3 procedures 1o de1ermine il 1ney need 1o be upoa1e.' 7N0 internal inves'lgafion was pmvided fol the incident on 03/31/13 lor review on the completion of me sulvey pmcess on 04/13/18. lnlen/iew on 04/05/13 and 04/11/13 and observamn a1approxima1ely 3:15 pm a me local hospi1al cllem 1:7 stated. 4/05/13 "no s1all hi1 me. pushed me. nolning Io talk about" 4/11/13 while Chem 1:7 was under lnuolunlary (IVC) order a a local nospnal. 1ell you (DHSR surveyors) diey (group home s1alf) 1ney were going 1o me place (lamlky) down and send us 1o level four or five." rlncidem on 03/31/13, "[s1alf came in wiln adilude around 7(pm) we were eafing. +1e said don't 1 "k wiln me mday. +1e picked me am onhe bunch and Said wnal me f"k you laughing at. +1e said he had an ammde because he oculom go home wiln lamily, +1e1old rne 1o go 1o my room,1nen he said go 1o sum/w or (x1) paewomsueeusmru coNsIRuchuN 1x31 one suRva AND em or camcncu nuneze consume . WING 04/13/2013 NAME OF srezsr nooeess sure Zip code NEW HORIZON GROUP HOME. LLC LUMBER BRIDGE. NC 28351 (x4y in SUMMARY sum/Euro; 1D PRuleERs run or prey (EACH uusr 3E eezczoeu av run mm (EACH muwai comm rec m; ME one 512 Conunued From page 70 5'2 o1 Healrn Service Regulancn STATE FORM 3le11 11 sneer so: Division of Heallh Service Reaulallon D. 04/25/2013 FORM APPROVED ihe liVlng loom. he said why alen'l you going lo youl room, he pushed me againsnhe wall. He wasn't huning me so I laughed. he was hlning me, ihen he choked me and I was yelling ior help," rObseNallon of olieni #7 ai 3.15pm he demonsiraied a choke hold io his neck wiih ooih hands around ihe ironi oi his neck, JlSiaii Mu] iold [siaii lo gei me. {Staff iold him ihai only i siaii need lo be in ihe room and [siafi #10] said no nm in a like ihis, <Division of HeaItn Service Reaulatlon PRINTE D. 04/25/2013 FORM APPROVED [Client said [staff slapped him and I believe him. [Start was in his (client we) room." Interview on 04/05/15 Client #4 stated. . heard some stair. But [stall mo] told meto stay in myroom, 7| heard [client yelling, maybe around Easter Sunday, didn't see anything don't know why he was arguing with [start Stair raise their voice a little bit to get through to the clients." . Start #9 and stair #10 only stair on duty during incident, Interview on 04/05/15 Staff #2 Slated, . came in on Easter Sunday morning (04/01/15) and [cIient said he and [start got in a confrontation, argument. [Client got out or hand and [start had to put him in his plaoe. [Client said [staff was cursing at him and he may have lelt intimidated by [stair 'Cause [staff is big in is 300 to 400 pounds and 5' and would intimidate any ohild.,.rio one told me anything. rNo weapons allowed here." Start ms was not available during interview survey process and no contact iniormation was provided by the Licensee. Interview on 04/09/15 Staff #1 Slated, . On 3/31/15, he began work at aam andstarl its was going oft shitt. "no other stair but me there with 7 was still only stair on at 4.30 to 5 on 03/31/13." . lncident on 03/31/13 . [Start came in a to 5.30 his wire dropped him oli, [Start #13] came in at 4.30 to 5 on 03/31/13. swarm or paowomsuperizmiia txzi MULTIFLE coNsrRuchoN txai suavev AND mm or NUMBER covetzreo A BUILDING MltLun-zts WING 0411312013 NAME OF eraser cirv ewe zre CODE -- LUMBER BRIDGE. NC 2am lxt) ID summon SYATEMENTOF DEFICIENCIES ID mm or ixs, max (EACH MUST es eazczoeo av FULL emix CORRECWE ANION SHOULDEE comm roe m; ms APPROPRIATE we 5t2 Continued From page 72 5'2 MSion at Health Service Regulation STATE FORM azmtt ri coininuarioi. sheet 70 Division of Heallh Service Reaulallon D. 04/25/2013 FORM APPROVED {Staff yelling, I'm gonna bea<< youl 3's and goes [cliem ms room and I hear, boom. 7| go [cllem ms room, [slall is doing <Division of Heallh Service Reaulallon D. 04/25/2013 FORM APPROVED sem me a text at 10.157 10.15 and said don't come in Easlel Sunday al BA(am) and was scheduled, 7| looked on line and law says lo repon ii, 7| had no Ilalning on whai Io is going around lelling slall nol in say aboullhe incident." . Three slall on 5th during lhe incidenl 7 clienls in lhe lacilily. Interview on 04/09/15 Staff #9 slated, rlncidem on 03/31/15 "4.30 lo 5.00 I came in and [clienl declined his meds, he was agilaled nm his sell, he was combaiive sail and chenls and [Former op] and [slall look lhe TV from <Division of Heahh Service Reaulallon PRINTE D. 04/25/2015 FORM APPROVED rNo slap across rhe race, I have big hands and rm a big man, if I would have done any1hmg a1 all Ihe markings would slill be me on Monday 104/0215) 1o rell me I'm suspended aoou1 a allegalion ol 7| am a oonviored lelon mysel1, firealm, don't own a firearm. 7| pul everylhing 1" my sweal pam's poeke1s, rha1 day in ouesrion, where would I have pul ii, no hols1erwould have fallen oul. 7| don't carry hrearms or knives. 7| do carry in my bag, a box cuner, I carry one of Ihose lo rhe laoiliry because onhe Inrerview on 04/05/151he speralions Managel/Gmup Home Manager slared. . He had walked al rhe 1aoili1y 1or oneweek, . He was aware elienr #7 had madeaoose allegarions agains1 sla/l #9 on 03/31/15. . He had begun Ihe inrernal invesliga1ion ol rhe abuse allegarions on 03/31/15. Interview on (14/10/15 and Licensee slated, . She was unsure as lo operaiions manager/group home manager had not oomplered 1he imemal inves1igahon lor inordenr on 03/31/15, "maybe he didn't wme 11 all up." . s1a/l #3 will be rerrninaled lrom his posmon as a lesuh of rhe allegalion on 03/31/15. Finding 1:2 Review on 04/13/15 ol ihe IRIS sysiem revealed. rNo IRIS repor1 /or inoiden1 on 04/03/15 was available fol review a1ihe oomple1ion o/ ihe survey process on 04/13/13, swam/r or oerroienoies coNsiRuchoN 1x31 oars suavev our; mm or common iozmirroanou nor/sea oowizreo A surroruo mum-:15 WING 0411312013 NAME OF srazer orrv. sure zre NEW NORIZON GROUP HOME. LUMBER BRIDGE. uc 25:51 1x4) 1o summon SYATEMENTOF DEF1C1ENC1ES 10 paovlnzas mm or 1x5) max 15/05 uusr es eazozoeo av mm mm IEACH ANION comm roe assumoavoaisoiowirvworuroamnom m; ms removal/re we 512 Continued From page 75 5'2 o1 Healih Sen/Ice Regulanon STATE FORM 5mm 11 sheet 73 Division of Health Service Reaulallon D. 04/25/2013 FORM APPROVED rNo internal investigation was provided fol the incident on 04/09/15 for review at the completion of the survey process on 04/13/13. Interview on 04/11/15 at the local hospital under IVC order client #7 stated. lncident on 04/09/13 was in [client ms room she (513" 5) would come in and stan stult with us, . She would cuss like cut the alighlofl. {Client m] had a phone, I called my mom and telling her what was happening, 7| think [stall heard me calling my mom. . I was playing with a soccer ball, it was loud. {Staff said give me the Farmball. She put her fingels in my lace and pushed me against the wall. al was mad. . I kept throwing the ball hard against thewall. {Staff said I wish you would hit me as hard as you throw that ball. 7| went in [client #11'5 room and he was on the phone. 7| retused meds that night, because I didn't know what she was going to do. . ltalkeo to [operations manager/group home manager] but he took up lor [slaff {813mm} came in [client #11'5 room [operations manager/group home manager] came in andtold me to go to bed. . She (start came in and threw water on me, a big cup with ice and water, all got on [client #11'5 bed and it was wet. . blanked out, she started swinging and hit me on the shoulder. 7| went to punch and I hit her, {Staff #14] came in and told me to go to bed. . [Stall came back in with a big pole. rTheylook my bed out of my room and a rolling closet thing. smenw or rm (x2) MULTWLE coNsYRuchoN txai one suavev nun mm or ioeunncanou cowtereo it mums--:15 WING 0411312013 NAME OF may cirv. sure Zip code NEW "0mm" GROWN, LLC -- LUMBER BRIDGE. NC 28357 ixt) in summon io mm or 0(5) max (EACH MUST ea paeceoeo av FULL omit EACH CORREWVEWION SHOULDEE comm no m; ms maopaim on: 512 Continued From page 76 5'2 ivision at Health Service Regulation STATE FORM BZNHI continuation sheet 74 Dlvision of Heallh Service Reaulallon D. 04/25/2013 FORM APPROVED rShe lried lo hri me wilh iI (pole), she swung al me. She called lhe police and med In press charges. {Staff slaneo when rhe pollce came." aThe police look him to the hospilal. Imeview on 04/13/18 client #1 slaled, "[Cliem was bored and was bouncing a ball on rhe wall. {Staff Sald, won't you hri me wilh lhal ball, He came lo my room lo gel away from [slall and she lollowed him imo my room and said lo [cliem go lo your P'mg room and when he slood up she lhrew a cup of me warer on him and on my bed everywhere, He punched her in lhe face, She grabbed a pole and lried lo hri him, swinging al him. [Operalions Manager/ Gloup Home Manager] was holding her back and lhe police came, {Staff always cuss al us and al said (to clienr I'll Wk you up lime boy and lried lolhrow his clmhes nulSldef' Interview on 04/09/15 Staff #1 slated, "[Slall a cerlaln slafl agilales the kids, yells and culses at them. [Slall would also poke al [cliem and upsel him, make angry." Interview on 04/12/15 Staff #6 slated, I was assaulled lhere allhe group home, Two women on slall 7 boys gehing our of comrol (incioem On 04/09/15). [Clienr caughl ahilude, cussing, Ihrowmg his slulr agalnsl rhe wall, gm in my laoe. I called [operalions manager/group home manager] In come In rhe group lell unsale 7 boys. [Clienr reluseo his meds (medicahons) andl iolo [clienr oohle ol swarm or DEFlclENclEs (x0 paovromsumrzmua (X2) numne coNsYRuchoN lxal oars suayzy AND mm or NUMBER couprzreo a mum-:13 WING 0411312013 NAME OF eraser aooazss ewe cooe NEW NORIZON GROUP HOME. -- LUMBER BRIDGE. uc 2s357 lx4) lo summon lo mm or 9(5) max (EACH DEFlclEch nusr as pazczozo av rum mm CORRECWE ANION SHOULDEE comm rac m; ms Appaoparm we 512 Conllnued From page 77 5'2 ol Healm Sen/me Regulanon STATE FORM BZNHI camlnuallnn sheet 75 Division of Heallh Service Reaulallon PRINTE D. 04/25/2013 FORM APPROVED waIer In my hand and wayrng my hands and he said don't pour waler on me, some ol Ihe waler spilled on his leeI and [slall called me (dale unknown) and asked me why I poured waler on him. They pul me in a unsafe place, I-leIclienI w) punched me in Ihe lace and injured my lelI eye, me wiIh a closed lisI and broke my glasses and I gol gashes on my face around my and opIical bone is fracmretL, [Slall came Io see my lace and Iodo IVC order on [chem mm [Operalions managel/group home managerllold [slarl I poured waler on him (clieni and in his lace,., {Operalions manager/group home manager] Iackled [cllem aher [olienl ahacked me. We look [chem ms bed om and olosel 'cause [cllem was Iearrng hup. A bar, broke ofl Ihe closeI, a melal olosel piece, Ididn'l do noIhing Io him wiIh no meIal pole Islall #6 laughed), I Just reamed on pure emolron, Ijuslwenl Io gel him and Ihey had Io hold me back em I didn't hit him, couldn't gel Io him, nevel hit him, couldn'l gello him, [operahons manager/group home manager] held me back." was cursing aI him (cllem well generally, because I was Finding #3 Review on 04/09/15 OI client #85 lecord revealed. 17 year old male. Admission dale of 03/17/15. Diagnoses ol Unspeoihed Schizophlenla Specvum Oiher Disordels, Cyclolhymic Disorder Anxious ADHD, lnIermhIenI Exploswe Disorder, Oiher Specilied Drsruphye Mood Disorder, Impulse or rm peovromsumrzmun < D. 04/25/2013 FORM APPROVED Division ol Health ServiceReuulation STATEMENT OF (le MULTWLE txal DATE SURVEV AND pm or houses cowtmo a WING -- 0411312013 NAME OF Aooszss cirv. sure Zip code NEW HORIZON GROUP HOME, LLC -- LUMBER BRIDGE. NC 2azs1 (x4) in SUMMARY surmsmor io mm or coRREcmN ixsy max (EACH MUST es passion; av mu PREFIX (EACH CORRECWE ACTION SHOULDEE comers no m; ms APPROPRIATE one 5t2 Continued From page 79 5'2 Control Disorder, Autism Disorder and intellectual Development Disability, Moderate. PCP dated 03/03/17 revealed, "He threatens to hun mom's dog that she uses as a service dog and other family pels.,.hismfy ol twisting mom's needs constant supemsion,.,lack of remorse, his behaviors scare her (mom). He stole his father's truck and wreckeo not see the danger.,.cfuelly to people or animals, often bullies, threatens intimidates others, freouent interview on 04/05/13 client tie stateo. rYou go to the time out rooin 'cause not behaving, staff [staff ma] saio I had a bad ammde," JlStaft went into my pocket and took my IPod." interview on 04/10/13 staff #9 stated: +te had not receiveo any NCI onh Cafolina intervention) training at the laci y, "One stall allowed him (client to have cell phone, IPhone or something like that and I told him. he couldn't have it. told him he couldn't have it and Hold him needed to get it from him. He got oombative therapeutic hold and put him. walked him to time out room to calm down; torts inin (minutes) holo was left arm up aho intohis back. Can't explain, nothing life threatening, just a restraint. Early March (zeta), Never been tolo to write up anything at all about arestraint.,." Multiple interview attempts were madeto interview the Operations Manager/Group Home Manager in regards to the allegation on 04/09/13. there were no response from the Operations Managef/Gmup Home Manager at the completion of the survey process oho4/t an a, ivision or Health Service Regulation STATE FORM can win. it sheet 77 in Division of Heahh Service Reaulalion PRINTE D. 04/25/2013 FORM APPROVED inierview on 04/09/15 ihe Licensee siaied. She was aware of an NC for chem #7 due io an assauii on Siaff #6 on 04/09/15. . The IRIS reporis were in process iobe compieied ior ihe incidenis. . No IRIS reporis were compieied by ihe oi ihe survey prooess on 04/13/15. Review on 04/10/15 oi ihe Plan of Proiechon daied 04/10/13 compieied by ihe Licensee reveaied. Whai immediaie aciion wrii ihe iaciIiiy rake io ensure ihe saieiy oi ihe consumers in your care7 "All siaii will be irained and rerlrained in cIieni rrghis by improvemeni) wiih poieniiai hire oi LP (Licensed meessmnal by 4/30/15. Wrii expiore impiemenirng video for ihe iacihiy by 4/30/15 by ihe Licensee and I am recrurhng more siaii wiih adolscem expeiience by 4/30/15," Describe your plans io make sure ihe above happens. scheduie siaii io be irianing wrih siaii, I'm expiorrng companies video equipmenno be ai ihe I'm in process oi more siaii." The inc1dems of abuse on cliem #7 ocurfed on 03/31/15 by staff #9 and on 04/09/15 by sIafl #6 and on ciiem #6 by staff #9 on 03/2015, On 03/31/13 Siaii #3 abused cIieni 1:7 by grabbing him byihe shin hoiding him up againsi a waiI and hining/slapping/choking him. And on anmher occasmn (03/201 5 exaci daie unidenirried) siaii 1:9 piaced cIieni #5 In a hoid (siaii #9 was nm irained on Norih Camlina iniervenironsiwcm which included havmg ihe client's arm behind his back and pushed upinio swam/r or (in peovromsumrzmua (X2) humor; cousreucrroh susvzv AND mm or comcrroh Nor/ego comerzrso A surrorhc MuLun-zis WING 0411312013 NAME OF crrv. zre coo; NEW NORIZON GROUP HOME. LUMBER BRIDGE. NC 20:51 1x4) Io sum/my Io mm or rxs, max 1mm musr es eazczozo av mm mm IEACH ANION SHOULDEE comm rac m; ms remover/ire on: 512 Conirnued From page so 5'2 oi Heaim Service Reguiarrcn STATE FORM BZNHI comrnuanor. sheet 703 Division of Health Service Reaulallon D. 04/25/2013 FORM APPROVED Ahemalive 10A NCAC 27E .0101 LEAST RESTRICTIVE ALTE RNATIVE Each lacility shall provide services/supports that promote a sale and respectlul environment. These include. using the least restrictive and most appropriate settings and methods (2) promoting coping and engagement skills that are allemallves Io injurious behaviol to sell or mhers, (3) providing choices ol activities meaninglul to the clients served/supported, and (4) sharing ol control over decisions with the client/legally responsible person and stall, The use ol a restrictive intervention procedure designed to reduce a behavior shall always be accompanied by actions designed to insure dignity and respect during and alter the intervention, These include, using the intervention as a last resort, and (2) employing the intervention by people trained in Rs use. srarsniw or rm (X2) MULTWLE coNsTRuchoN txa) oars suavzv nno mm or NUMBER cometzrso A MuLun-zts WING 0411312013 NAME OF eraser aooazss cirv. sure Zip code NEW "0mm" GROUP HOME, LLC -- LUMBER BRIDGE. NC 2am lxt) io summon srarmsmor io mm or 0(5) max (EACH MUST es eazczozo av FULL CORRECWE ACTION SHOULDEE comm rec m; on: 5t2 Continued From page 61 5'2 his back while stall escorted the client to the Isolation TimenOuI room. On 04/09/15 stall #5 abused client #7 by throwing water on him and putting her lingers in his lace and pushing him and attempting to hit him with a metal pole. Stall had to intervene and "hold her back." The actions of the stall resulted in serious harm and abuse to clients #2 and This deficiency constitutes a Type Al rule violation fol serious harm and abuse, 51 27E .0101 Client Rights Least Restictive 513 ivision at Health Service Regulation STATE FORM BZNHI continuation sneer 79 Division OI HeaIth ServiceReuulatlon STATEMENT uE DEFICIENCIES AND pun or CORRECTION IDENTIFICATION NUMBER a D. 04/25/2013 FORM APPROVED <Division 0! Heakh ServiceReuulallon PRINTE D. 04/25/2013 FORM APPROVED and imerviews, The {Milky lailed mainlarn a limerom/Isolamn roorn used lor behavioral Comrol In a sale and harmlree manner and according <Division 0! Heakh ServiceReuulallon PRINTE D. 04/25/2013 FORM APPROVED the wrinen approval loe designee ol ine governing body. alleciing 2 ol 7 Clients Cross Reference. 10A NCAC 27E .0104 SECLUSION. PHYSICAL RESTRAINT AND ISOLATION TIMEOUT AND PROTECTIVE DEVICES USED FOR BEHAVIORAL CONTROL (V525). Based on obselvalion, record reviews and imerviews, ine laileo maintain a me uul/lsolafion roam used lor benavioral connol In a sale and narmlree manner and according <Division of Heallh Service Reaulallon PRINTE D. 04/25/2013 FORM APPROVED erlecIiveness, affecilng 2 of 7 clienis Cross Reference. 10A NCAC 27E .0107 TRAINING ON ALTERNATIVES TO RESTRICTIVE INTERVENTIONS (V536). Based on record reviews and inIerview, Ihe laciliiy larled Io implemenl policy Io ensure Six or Six audiled Slaff #10 and lhe Operations Managel/Gmup Home Manager) received ranral Iraining in allernalives Io inIervenIions. Cross Reference. 10A NCAC 27E .0105 TRAINING IN SECLUSION, PHYSICAL RESTRAINT AND ISOLATION TIMEOUT (V537). Based on record reviews and inIerview, Ine racilin railed 1o ensure six of SIX audired sIalr 1:10 and Inc OperaIions Managel/Gmup Home Manager) received Iraining in SecluSIon, pnysical leslraim and isolaIion Iimeoul only by Slafl who have been Irained and demonsllaled oompeIence and prior In providing direcI care 1o people with disabiliIres, Review on 04/10/10 ol Ine Plan or ProIecIron dared 04/10/13 compleled by me Licensee revealed. WhaI immediale acIion w1l| Ine racilin lake 1o ensure me salely ol Ine consumers in your care7 J'Trainrng Will be given Io all Slafl Inai lime will nm be used, by GA (qualrly assurance) Irainer by 4/14/ and 4/21 (201a)1raing all Irained." Describe your plans Io make sure Ihe above happens. NWill coniacl 0A Slafl lor Irarning on lime room, will noi be utilized." A nine year old clienI #3 who has diagnoses ol Bipolar Disorder, RosdraumaIrc Siress Disorder (PTSD), ADI-ID, Drsruplrve Mood Disorder, swarm or (XI) peovrozmumrzmua 1x2) numm cousreucnou 1x3) oars suRva AND mm or coasscnou NUMBER COMFLETED a surLoruc MNLun-m WINC 0411312013 NAME OF may aooezss snare ZIP code NEW NORIZON GROUP HOME. LUMBER BRIDGE. NC 211357 Ix4)1o SYATEMENTOF DEFICIENCIES ID PROVIDERS mm or coRREcrloN rxs) max (EACH nusr es eazczozo av FULL mm IEACH CORRECTIVE ACTION snouwez comm rec m; ms Aeoxoperm oar: 513 ConIrnued From page as 5'3 o1 Health Service Regularron STATE FORM 02mm 1) conrrnuanen sneer Division oI Heakh ServiceReuulalion D. 04/25/2013 FORM APPROVED STATEMENT OF nEEiciENciEs (xii pauvroER/sumiEx/cm AND FLAN or cuRAEcTiuN NUMBER a ixzi MULTWLE coNsTAucTiuN A gimme a WING ixai DATE SURVEY COMFLETED 04I1 ("201 3 NAME oE STREET AD NEW HORIZON GROUP HOME. LUMBER DRESS ciTv. ZIP CODE BRIDGE Nc 23:51 my in TAG SUMMARY DEEiciENciEs iEAcn nEEiciEch MUST BE FRECEDED av FULL nEEiciEchr TD FLAN or cuRAEcTiuN prey PREFIX AcTioN snuumeE COMPLEYE TAG CROSS-REFERENCEDTD THE APPROPRIATE DATE V513 v52 Conirnued From page as Encopresis and Rule Om Conduoi Disoroer and a 14 year oid eiieni :i7 who has diagnoses oi ADHD, Conduei Disordei. Disrupiive Disorder and Cannabis Use Disorder were in an unapproved iimeoui room and unahendeo by siaii ior up io ai ieasi i5 on ai ieasi 7 difleiem doournemed occasions, Boih siaii and oiienis repon ihe use oi ihe unapproved iimeoui room. oiienis were locked in ihe room. This room was noi approveo as a hmeoui room ouring iroensure, Siaii used ihe room as a punishmem ano ihreaiened io use ihe room in an ahempno ooniroi and deier behavmrs. None oi ihe siaii have been irained ihe use oi resirieiive imeivenlions including use oi iimeoui Siaii Iailed io doeurnem ihe use oiiheiirne om room, physioai assessmeni/psyehoiogieai wellrbeing oiihe eiieni. raiionai ior use, doourneniahon iog. ano anaiyze daia. ooiarn rneoroai orders, maimain siaii in aiiendanoe. ensuring saieiy and harm iree use while ihe iime room, reqmremems, reporis and reviews requiremenis loe use oi ihe iime om room ano esiaoirsh ihe reqmred poiiey and pmceduies ior ihe use oi a me room. Due io cliems being locked in an unapproved iimeoui room by siaii who were noi irained in hs use, lack oi monimiing while in ihe hmeoui room, lack oi cliems' welkbeing. lack oi required doournemairon on use oi a iime om room ihis deficiency conslimles a Type ior serious harm ano abuse. 27E .0104 (as) Client Rights Sec. Rest. ITO 10A NCAC 27E .0104 SECLLISION, PHYSICAL RESTRAINT AND ISOLATION TIMEVOUT AND PROTECTIVE DEVICESLISED FOR BEHAVIORAL CONTROL V513 520 Ivisinn dr Heairh Service Reguianon STATE FORM BZNHI caminualiun sheet I34 Dlvision of Heaiih Service Reaulallon D. 04/25/2013 FORM APPROVED Within a lacili(y where res(ric(iue lmervemions may be used, (he pulley and procedures shall be in accordance wi(h (he lollowing provismns. any room used lor seclusion orisola(ion ilmeroul shall mee( (he lollowrng crr(eria. (A) (he room shall be deslgned and cons(ruc(ed (o ensure (he heal(h, sare(y and welirbeing or (he clien(, (he floor space shall nm be less (han 50 square lee(, wr(h a ceiling heigh( or no( less (han eigh( leeh (C) (he floor and wall coverings, as well as any conlen(s ol (he room, shall have a onerhour ilre ra(ing and shall nm produce (oxic fumes rr burned (in) (he walls shall be kep( comple(elylree of objects (E) a lrx(ure, equipped wi(h a minlmum ol a 75 wah bulb, shall be moun(ed in (he ceiling and be screened (o prevem (amperrng by (he clien(, (F) one door of (he room shall be equipped wi(h a window moun(ed in a manner which allows inspec(ion orlhe en(ire room, (S) glass in any windows shall be impac( resis(an( and shallerproofi (H) (he mom (empera(ure and yen(ila(ion shall be comparable and compa(ible wi(h (he res( or (he racili(y, and in a lockable room (he lock shall be interlocked wi(h (he fire alarm sys(em so (ha( (he door au(oma(ically uniocks when (he lire alarm ls ac(iya(used lorseclusion. This Rule ls not met as evidenced by. Based on observation, record reviews and interviews, the lacilily falled Io malnialn a lime Uni/isolation mom used for behaVloral comml ln a safe and harmfree manner and according i0 ihe swarm or DEFlclENclEs (x0 peovromsupensmo (x2) nurms coNsrRuchoN (xal one sum/Ev (no new or coRREchoN NUMBER concierge A eonoruc a WING 0411312013 NAME OF NEW NORIZON GROUP HOME. LLC LUMBER BRIDGE. NC 28357 lx4) lo summon lb pmulnzas mm or (x5, max (EACH Musr ea mczoeo av mo mm (EACH CORRECWUUION SHOULDEE comm ms m; ms one 520 Continued From page 87 520 o( Healrh Sewlce Regularron STATE FORM azmu camlnuamn sneer as D. 04/25/2018 FORM APPROVED Division ol Healih ServiceReoulahon STATEMENT OF (Xi) (le MULTWLE (xal DAVE SURVEV AND em or lDENilFchiloN i 5 M132013 NAME OF sure ZIPCODE NEW HORIZON GROUP HOME. LLC LUMBER BRIDGE. NC 28351 my lD run or prey (EACH DEFlclEch uusr ea ev FULL mm (EACH SHMDEE comm TAG m; ME one 520 Conhnued From page as 520 reqmred provisions affeciing 2 ol 7 clienis (d3. The findings are: Review on 04/05/13 ol clieni was record revealed. 9 year old male. Admission dale oi 03/17/13. Diagnoses ol Bipolar Disorder, Poshraumaiic Siress Disorder (PTSD). Allemion Delicii Hyperactivity Disorder (ADHD). Disruptive Mood Disorder. Enoopresis and Rule om Conduci Disorder. Peisan Cemeied Plan (PCP) daied 04/26/17 revealed. "What's noi walking sechon; "Nothing is walking, he coniinues Io be aggressive and nonrcompllanl. He is siealing food. his aggressive behaviors, mood swings, defiamrwon'l lollow diieciiuns and rules and sexual hehaviors/geshires. need consiam supervision. medications noiworking. and he is nm sleeping." 'He hulhes oiher reponed ihai [chem has pushed and hn her ..moiher expressed major concern ahoui [cliem muching his sisierinappropriaiely, Mom ieporled mat [cliem siuck an object up his sisier's huh. Mom and [cheni :ia] ieporled ihai [clieni #31'5 laiher used to iouch him inappropriaiely, [Clieni siaied he did mat in his sisier so she can feel how he leels,.,rnom leels fol ihe girls saleiy. Mom repons mat [cliem has choked her and his younger sisier on more ihan one ohen has major iernper iamrums. he screams, yells. slam doos and oihers [clieni was involuniary on 12/11/17 aher a physicalaliercahon ihe school siall. As a resuli ol his aggressive behaviors he has pending charges Depi, (depanmeni) oi Juvenile Jusiice fol disorderly conduct and assauli on a goveimem olhcia ,h was ieporled he is aggiesswe wiih stall 520 Measum in place no toned ihe deficiency: 1 (uliemuuve io resinoiive inieneniionsl raining wus provided for ilie sinii. See ii-iining 2 The siaii will he named on ihe New Homon Resincuve Imervemlon Policy renecung no use fiSOL'fllon or use oi hmeruul. See Resinoiive lnlenenuon Policy Chem Rights wus provided |o ihe See ii-iining cemficnle 4 Redo. neil rhe morn ilioi had been wrongly used a. 11 "Inseam room The mom has been re Eemgned d- smdy area wrili compuiers [or rhe onsiin-iers use. Measum in place no preveni reoccureence oi he prohleni, Coniiniied monironng and shadowing oi ihe iuiiro provide immediuie regarding behavior n-ioiliricduons 2 Followeup any i: iies in siuii meeungs aniuor individual supem ons. ~wurranied Who is monitoring and how onen to ensure he problem will noi re-oculr: linicul Director/LPC Eudhly Managemenl Halli-led Prof onul Hus Pi-icr ic seize ix $721718 Coniplered pi-ior io une IX ngcing ngcing ngcing MSIOH in Healin Service Regulanon STATE FORM BZNHI sneer as in Division of Heaiih Service Reaulallon D. 04/25/2013 FORM APPROVED allhe was released irom lhe hbspilal alier so days.,cbnlinues 1b be aggressive loward o1hers.,.grbup home 515" will suppbn use ol CBT behavioral [clienl 1:3] and family on relapse prevenlibn,.leach lechniques such as progressive relaxalion, or biofeedback, leach behavioral aliernalives deSlgn a loken economy.,.develop a cbnlingency cont/am lo impmVe [clienl 1131's social skills.,.use a reeling chan,.,' Medical Physician nme daied 04/06/15, Assessmem. needs higher level ol care such as PTRF Residenlial Trealmeni Facilhy). Review on 04/05/15 oi sialf notes in! cliem #3 revealed. Pm in iime out mom, 3/20/18, Pm in isolation environmem, 3/24/15. Pm in lime out room, 04/03/15, Sent in lime out room, 04/04/13. Review on 04/09/15 ol clienl #B's record revealed. 17 year old male. Admission dale of 03/17/15. Diagnoses oi Unspecilied Schizophrenia Specvum Oiher Disorders, Cyclolhymic Disorder Anxious Dislress, ADHD, lnlermhleni Explosive Disorder, Oiher Specified Disruplive Mood Disorder, impulse Conlrol Disorder, Aulism Disorderand Inleilemual Developmenl Disabilhy, Moderale. PCP daled 03/03/17 revealed, 'He lhreaiens 1o hun mom's dog lhal she uses as a service dog and olher iamily pels.,.hislory ol lwisling mom's needs consiani supewlsion..,lack oi remorse, his behaviors scare her (mom). He slole his ialher's truck and wrecked nm see ihe smeuw or [x0 reoVioee/sureriemo 1x2>> coNsYRuchoN ixai one sum/Ev Add new or coRREchoN couplereo ii mama--:13 a we 04/13/2013 NAME OF i NEW NORIZON GROUP HOME. LLC LUMBER BRIDGE. NC 28357 1x4) io SUMMARY summer/Tor DEFiciENciEs iD mm or ixsi ram (EACH MUST ea pagceoeo av ruo mm EACH CORRECWUUION SHOULDEE comm me m; me we 520 Continued me page 89 520 ivision oi Healm Service Regulaiion STATE FORM azmu coininuarioii sheer E7 171 Division of Heallh Service Reaulallon D. 04/25/2013 FORM APPROVED danger.,.cruel1y lo people or animals, ohen bullies, lhrealens inlimidales olhers, flequenl lying .collabolale wilh lheraprsi. Therapisi Will lac iiale group [chem and peers in order lo increase posnive communicahon and problem solving skills. is recem behaviors requires a locked sening .level iv residemial 1rea1mem, 24 hours a day, 7 days a Review on 04/05/13 o/ DHSR (Division o/ Healih Sen/ice Regulahon) records revealed lhe was no1 licensed/approved lor a lime oul room a1 innial licensore on November 1 2017. Observaiion and inlerview on 04/05/15 al approximalely1000 am while 1he walk lhrough of lhe lacilily was oonducled lhe Operahons Managel/Gmup Home Manager revealed. rThe speraiions Manager/Group Home Manager idenlihed 1he room as 1he hme oul room, which was no1 in use a1 lhe lacilily. . A small room on 1he bedroom hallway a window in 1he door and deadboli and no handle 1o emer/exil 1he room. . A client's personal i1ems,a ball and slippers were on 1he lloor onhe lime oul room. . The lloor space/dimensions of 1he room was undelermined. Interview on 04/05/15 Chem #3 slated. . He was onen plaoeo in 1he lime ou1 room ovlhe slalf, . "Lasl week (03/25/13 . 03/31/13, exacl dale could nol be pm me in lhe lime 001 mom. . liusl smeared oodo all over 1he lime oul walls and 1he window, . I was spelling cuss words dardo, 'cause I was aming up and 513" locked me door and go away, 15720730 minutes. i1 doesn'l maner if you smeuw or DEFlclENclEs reovromsurerrzmo (x2) coNisuchoN (x3) one sum/Ev mo now or comcnou Nor/ere coverereo A sorrows mama--:13 a wine 04/13/2013 NAME OF may aooerss clTv. sme zre CODE NEW NORIZON GROUP HOME. LLC LUMBER BRIDGE. NC 28357 lx4) lo SYATEMENTOF lo mm or rxs, max (EACH DEFlclEch MUST er paeczoro av r011 mm CORRECWUUION SHOULDEE comm ms m; me maorerm we 520 Conhnued From page 90 520 o1 Healih Service Regulahon STATE FORM 02mm eonhnuanon sheer as Division of Heaith Service Reaulation D. 04/25/2013 FORM APPROVED do something bad like kicking the door then you get more time. The door is made for kicking, can't bust it," Interview on 04/05/15 Client #6 stated. he had been in the time out room by the stair. J'You go to the time out room, 'cause nm behayrng, Stair said i had a bad sent me to the time out room and the door is locked when you go in with the key, rThey don't want anyone to bother us in there, so they lock it With a key, {Client goes in time out room an the trme and he's a iittie kid." Interview on 04/05/15 Client #4 stated. He has not been in the time out room' He "tries to stay out oithere." [Client goes in time out room themost' [client one or two times. [Client in the time out room sorta on a dairy thing, can't seem to stay out or time outroom. [crienmsi absoiuteiy bad, hurting peopie, way out, steais stun, A couple or weeks ago he smeareo, you know #2 (feces) everywhere in the trme out room, he had to clean it up by hrmseit." Interview on 04/05/15 Client #7 stated. he has not been in the time out room, "just [client "He takes crying and Just sits in time outroom crying, cussing and sailing peopie the word, foul mouth. Sometimes he goes in 2 times a day." Interview on 04/05/15 staff #3 stated, she has not used the time out room at the swarm or rm peovroemupenemo 0(2) nutme coNsrRucrioN 0(3) one sum/Ev we now or iDENriFIcArioN nausea connetereo eunorne MNLun-zts a WING 0411312013 NAME OF swear sooness cirv. snare zre cooe NEW NORIZON GROUP HOME. LLC LUMBER BRIDGE. NC 28357 IXA) ro summon DEFiciENciEs ro mm or 9(5) max (EACH nusr ea eneceoeo av FULL new EACH CORRECTWEWION SHOULDEE comm me m; ms nepkoperm we 520 Continued From page 91 520 Msion at Health Service Reguiarron STATE FORM cammuarinn sheer as Dlvision of Heallh Service Reaulallon PRINTE D. 04/25/2013 FORM APPROVED laoilily. I would (use me lime oul room) if Iney were causmg halm Io sell ol others," Interview on 04/05/15 Staff #2 slated, The lime oul room is nol ulillzed al all. use iI (lime oul mom) as a delenenl, I say man you could go in mere, pm I don'l pul anyone in mere,- Interview on 04/12/15 Staff #6 slated, pul one olienl in lime oul room, [cliem and maybe [client Nobody ever Iold us howlo use me lime oul mom." Interview on 04/09/15 Staff #9 slated, V"[Clienl was in lime oul loom cleaning up feces in Ihe me am room when I came in (dale undeleimined) leoes all over Ihe floor and walls, hm sure who had pm him in me lime oul loom." in Ihe Ilme oul mom (speeihe dale unknown 03/2015). One slafl allowed him Io have a cell phone, IPhone or somelning like Inal. 7| Iold him he couldn'l have gol oombahye Iherapeulio hold and walked him Iolime oul loom Io calm down lor 1015 minutes,.." Interview on 04/09/15 Staff #1 0 slated, JTne lock up room (lime oul mom) is Io be used ll any problems, (wilh Ihe clients). Room is nol padded. 7| had Io pul [olienl in me lime oul room 03/31/15, he walked and Ihe door was looked. {Staff Sald Io lock Ihem (cliems) in Ihe quiel room il Ihey needed ii or needed Io be Iaken down (Inerapeulio hold). 7No one Iralned me on lake downs or how Io use smenw or DEFICIENCIES (in paowomsupeuemm (le MULTIFLE coNisuchoN (x3) one sum/Ev Add new or ioemmoknou oowiereo A eunoiwe mama--:13 a WING 0411312013 NAME OF may soosess my. ewe Zip NEW "0mm" -- LUMBER BRIDGE. NC 28357 W) In SUMMARY DEFICIENCIES lo PROVIDERS mm or my max (EACH DEFICIENCY MUST ee av mu max IEACH CORRECTIVE ANION SHOULDEE comm no m; me maopaim we DEFICIENCY) 520 Conhnued me page 92 520 wision ol Healm Sen/Ice Regulahon STATE FORM BZNHI camlnuallnn sheet en PRINTE D. 04/25/2013 FORM APPROVED Division oi Heaiih Service Reaulalion STATEMENT OF DEFICIENCIES (in (X2) MULTIFLE CONSTRUCTION 0(3) DAVE SURVEV mo mm or coaaecnoN IDENTIFICATION NUMBER COMFLETED a BUILDING MNLu1a-31s WING -- 0411312013 NM or eaoyiozaoasumiea srazer CITY. snare Zip code NEW NORIZON GROUP HOME. LLC LUMBER BRIDGE. NC 28357 0(4) Io SUMMARY STATEMENTOF DEFICIENCIES Io PROVIDERS mm or pa, ram (EACH oerrcimcy nusr as eazczoeo av FULL mm coaaecnveacnoN SHOULDEE comm rac "a me maopaim one DEFICIENCY) 520 Continued From page 93 520 ihe duiei roorn foi ihe iirne ouis," Interview on 04/05/15, 04/09/18 and 04/10/18 Ihe Licensee siaied. rThe iime room was nm in use ai ihe She had given siaii instrumions nmio use ihe Iime 0m room. This deficiency is crossed referenced inio 27E .mui LEAST RESTRICTIVE ALTERNATIVE (V513) ior a Type A1 roIe szi 27E .0104(e?) Chem Righis Sec. Resi. ITO 521 NCAC 27E .0104 SEOLLISION, PHYSICAL RESTRAINT ANO ISOLATION TIMEOUT AND PROTECTIVE DEVICESUSED FOR BEHAVIORAL OONTROL Wiihin a iaciIiiy where resiriciiye Imervenlions may be used, ihe pohcy and procedures shaII be in accordance wiih ihe provismns. (9) Whenevera resiriciiye Intervention is uhiized, shaII be made In ihe cheni record io incIode, ai a minimum. (A) nmalion of ihe ciieni's physioai and wellrbeing' nmalion oi ihe frequency, iniensny and duraiion oi ihe behaVIOr which Ied io ihe inieryenhon, and any precipitating Circumstance coniribuhng io ihe onsei oi ihe behavior, (C) ihe rationale iorihe use of ihe inieryeniion, ihe posniye Or Iess resinciiye inieryeniions conSIdered and used and ihe inadequacy of Iess resiriciiye Imervenlion techniques ihai were used, (D) a descripiion oi ihe inieryeniion and ihe daie, me and duraiion oi iis user (E) a descripiion oi accompanyingposmye meihods or inieryeniion, ivision oi Heairh Service Reguianon STATE FORM BZNHI bi bi Division at Heaith ServiceReuulatlon D. 04/25/2013 FORM APPROVED restraint or isolation timeout to eliminate or reduce the probability at the future use ol restrictive interventions: (G) a description of the debneting and planning with the client and the legally responsible person, it applicabie, for the planned use ol seclusion, restraint or isolation timeout. if determined to be clinicaily necessary: and (H) Signature and title ol the employee who initiated, and ol the employee who lunher authorized, the use ol the intervention. This Rule is not met as evidenced by. Based on record reviews and interviews, the tailed to maintain a time outfisolation room used lor behavioral control to include documentation, notation at client's and weilrbeing, rational for use and description ol the intervention, debriehng and planning. allecting 2 ol 7 clients (we, Reta! to tag V520 tor speleic details. ReVlew on 04/09/13 of client #3 and #85 records revealed. No evidence at documentation ol all times the time out room was utilized for behaVloral control, no notation of the client's physical and well being and rationai lor use and description ol the intervention, debriehng and planning. Interviews on 04/05/13 through 04/12/13 the audited staff stated they had used the time out mom fol negative behaviors or would use the time out mom if needed and had not documented swarm or (Xt) tle coNsTRuchuN out one suRva AND em or cometsreo a WING 0411312013 NAME OF i NEW HORIZON GROUP HOME. LUMBER BRIDGE. tic 2a351 (x4) in lD FLAN or prey (EACH nusr es ev FULL PREFIX (EACH CORRECWE ACTION SHOULDEE COMPLETE rec m; me heexoeeme one 521 Continued From page 94 521 511>> Mmsurm In place In correct the deficienc (F) a description ol the debriefing and planning with the client and the legally responsible person, I hid tulternuute to restrictive Imenenuum) il applicabie, for the emergency use ol seclusion. was pmudea [or the Sign ngmn' I that umerum and lsulflhun would not he used See trtunmg certificates 2 The start will he trained on the New to Sell Restncute intervention Policy reflecting no use"? or use or hmEruuL Client Rights wad pmuded to the toll. See trtunmg cemficnle dezlelx 4 Rede. ned the mom that hud been wrunegComplelcd used a. a timeout mm The mom has been rerPnor to Moe Eemgned a- study area computers [or theIX onsumers use. Mmsurm in place In prevent reorenrrenre or he problem, 1 Continued monuonng and at the tail to feedback regarding appropnute behavior modificfluom Ongomg 2 Followup any is Mes In Muff meeungs author supervisions. - warranted Ongomg Place additional starfon shift [0 meeting the behavioral needs or the con, mer. mauled, Ongomg Who is monitoring and how onen to ensure he problem will not re-oeenr: Ethical Dueclor/LPC Ongomg ualuy Management Director ualtrted Professtonnl gulallull STATE FORM Cami/Malta" sheet 52 Division of Heallh Service Reaulallon PRINTE D. 04/25/2013 FORM APPROVED IDA NCAC 27E .0104 SEOLLISION, PHYSICAL RESTRAINT AND ISOLATION TIMEOUT AND PROTECTIVE DEVICESUSED FOR BEHAVIORAL CONTROL Wilhin a Iaciliry wnere reslricrive rnlervenlions may be used, rhe policy and procedures shall be in accordance wirh lhe following provismns. (10) The emergency use of inrervenlrons shall be Irmiled, as follows, (A) a Iaciliry employee approved lo adminrsler emergency inlervenlions may employ such procedures Ior up lo 15 minules wirhour Ionher aulnorizalion, lhe oonlinued use of such inrervenlrons shall be aulhorized only by < D. 04/25/2018 FORM APPROVED Division ol Health ServiceReuulallon STATEMENT OF (X1) (le MULTWLE (xal DATE SURVEV AND we or wuuece commerce WING -- 04/13/2013 none or eecvtocecesumtce sreccr tooecss ctrv. sure are CODE NEW HORIZON GROUP HOME. LLC LUMBER BRIDGE. NC 28351 but in sumwxv lD run or txsy (EACH DEFlclEch uusr ec ev FULL PREFIX (EACH muwai comm rec m; one 522 Continued From page 96 522 concurs that the intervention is justified alter discussmn with the laCllin employee, continuation of the intervention may be verbally authonzed until an onrsile assessment ol the client can be mad a verbal authorization shall not exceed three hours after the time of initial employment ol the intervention; and (E) each wntlen order lor seclusmn, physical restraint or isolation timeout ts limited to tour hours lor adult clients: two hours lor children and adolescent clients ages nine to 17; or one hour fol clients under the age ol nine. The original order shall only be renewed in accordance with these limits or up to a total of 24 hours. This Rule ts not met as evidenced by: Based on observation, record reviews and interviews. the lacility lailed to maintain a timeout/isolation mom used lor behavioral control in a sale and harmlree manner and according to the required policy and procedures and the required provisions as an emergency use of a intervention. approved stall to administer intervention, conduct assessment which includes the and we eing of the client and obtain a written order fol timeout allecting 2 of 7 clients The findings are: Relel Io lag V520 lor spemfic details. interviews on 04/05/13 through 04/12/13 the audited facility stall stated they had used the time out room fol negative behaviors or would usethe time out room if needed. All stall reported they ahd not been trained on the use of the time out room including no training on receiving authorization lor use ol the time out procedures, 522: Measum in place In correct the deficiency: (alternative to restrictive mlervenuufl) raining was provided [or the stud agum that timeout and isolation would not he used See |rtul||l|g oemfioutes {isolation or use or hmeruul. tun. See |rtul||l|g cemficnle med a, a museum mot-n, The room has been re onsumers me. Measum in place In prevent reoccnreence oT he problem, 1 Commued monllonng and shadowing or the toll to provide unmedtute feedback regarding appropnute behavior modifications 2 Followup any i: ues sturr meetings and/or supem ons. ~wurranted Place additional stair per shirt. depending on he needs oltlte consumer Who is monitoring and how onen to ensure he problem will not A's-occur: ltnteul Du'eclor/LPC ualtty Director ualtrted Professtonnl 44th 2 The starl will he trained on the New Honaunpnur |u 57 Restrictive Imervemlon Policy reflecting nu Cllem Rights was pcottded to |he4721718 nor to 4 ned the mom that hud been wrunegEompleled Eestgned a- study area computers [or the orig Ongomg Ongomg Ongomg Ongomg dr Health Service Regulation STATE FORM BZNHI it continuation sheet 54 Division of Heallh Service Reaulallon PRINTE D. 04/25/201 3 FORM APPROVED STATEMENT 0E rm FLAN or CORRECTION loENTlErcATloN NUMBER MNL018-31E 1x2>> MULTIFLE CONSTRUCTION A eulLorNs 5 WING 1x3>> DATE SURVEY COMFLETED 04l1 3201 3 NEW NORIZON GROUP HOME. NAME 0E PROVIDERORSUFFLIER STREET A0 LUMBER DRESS clTv. STATE ZIP 005E BRIDGE. Nc 25357 1x4) 15 PREFIX TAG SUMMARY (EACH 5EErclEch MUST 5E FRECEDED 5v FULL DEFICIENCY) 10 PROVIDERS FLAN or CORRECTION 0(5) PREFIX rEAch CORRECYIVEACYIONSHDULDEE COMPLEYE TAG CROSS-REFERENCEDTD THE APPROPRIATE 522 V52 Conhnued From page 97 Review on 04/05/151hrough 04/1215 oi cliem #3 and chem <Dlvision at Health ServiceReuulatlon STATEMENT uE mu FLAN or (Xt) NUMBER a D. 04/25/2013 FORM APPROVED tle MULTWLE txal DAVE SURVEY A COMFLETED 5 MW 0411 3I201 a NAME oE NEW HORIZON GROUP HOME. STREET no erss clTv. STATE ZIP conE observation shall be documented in the client record; and (C) physical restraint and may be subiect to injury: a facility employee shall remain present with the client continuously. This Rule is not met as evidenced by: Based on observation, record reviews and interviews. the tailed to malntaln a time outfisolation room used ior behaVloral control in a safe and harmiree manner and according to the reqmred policy and procedures and the ieqmred pmvismns to include periodic observation oi at least every 15 minutes, provision to the use oi the on. See mulling cenrficnre used as a timeout room The mom has been re Eestgned as study area computers ior the onsume use. Measnm in place In prevent oi he problem, 1 Commued monnonng anti shadowing oi the on to pruvnie feedback regarding LUMBER BRIDGE. Nc 23:51 my in SUMMARY SYATEMENTOF lD run or cuRREchuN nay max nusr BE av run (EACH SHOULDEE COMPLETE TAG m; CROSS-REFERENCEDYD YHE Apoxopeme DATE 523 Contlnued From page 98 523 523: Measnm In place In correct the deficient necessary, to assure the saiety oi the client, 1 Nci. nliemnuve to restrictive intervention, attention shall be paid to the oi regular was pmuded mg m" flgmuux meals, bathing and the use at the toilet. and such emphasmng that timeout and isolation would observatlon and attentlon shall be documented in not be used the client record; See certificates (B) isolatlon timeout: there shall be a iacility employee attendance with no other immediate 2 The star! will be trained on the New Hon/.tm responsro ty than to monitor the client who rs Remune immennon you" mnecrmg m, mapt-ior 57127 placed ln isolation timerout. there shall be {isolation or use ultimeruul. '3 continuous observation and verbal inteiaction With the client when appropriate. and such cuent Rights tnunmg wax provided to the 21 I 8 4 Rede gned the mom that had been prior to Mar IX 0 me behfl or mod full one toilet, documentation in the client record and a facility stait with no other immediate responsibility 2 Fouuwp any, m" memg' mm other than to monitor client who is placed in time, gupem' on; provide continuous observation and verbal 'V'elacm" allec'mg 2 7 Chem The Place additional staff per depending on findings ale>> he needs unite consumer "gums Reter to tag V520 ior speleic details. Who is "mum: and how on" mm Review on 04/09/13 oi client #8 and #85 records revealed. rNo documentation oi observation by staii when Eff? ngolng the time out room was used fol behavioral '3 control. or Health Service Regulallnn STATE FORM sheet 96 Division of HeaIth Service Reaulatlon PRINTE D. 04/25/2013 FORM APPROVED STATEMENT oE nEElclENclEs AND FLAN or CORRECTION MNL018-31E (le loENTlEchTloN NUMBER MULTIFLE CONSTRUCTION A BUILDING a WING TxaT DATE SURVEY COMFLETED 04l1 3201 3 NAME oE PROVIDERORSUFFLIER NEW NORIZON GROUP HOME. LUMBER BRIDGE. Nc 28357 Ix4) ID PREFIX SUMMARY DEFICIENCIES ID nEElclEch MUST BE FRECEDED av FULL TAG TAG PREFIX DEFICIENCY) PROVIDERS FLAN or CORRECTION sz, IEACH CORRECTIVE AchoN SHOULD BE CROSS-REFERENCEDTD THE APPROPRIATE 523 Continued From page as Violation. ITO 10A NCAC 27E .0104 FOR BEHAVIORAL CONTROL obiained. Subparagraph (emu) oT This Rule, Staff interviews from 04/05/15 through 04/11/15 revealed no sTafi had been Trained in The use oi resTricTiue inTeryenTions lncIuding use oT a time ouT room and The speCIfic requirements Tor such, Interview on 04/05/15 the Licensee stated she was unaware staff had used the time out mom for behaT/lor contmI for cIient #3 and client This deficiency is crossed reTerenced inTo 10A NCAC 27E .mm LEAST RESTRICTIVE ALTERNATIVE (V513) Tor a Type A1 [The 524 27E CIient Rights Sec, Rest. SECLLISION, PHYSICAL RESTRAINT AND ISOLATION AND PROTECTIVE DEVICESLISED Within a laciliTy where resTricTiue lnteiventions may be used, The policy and procedures shall be in accordance wiTh The IoIlowing provismns. (12) The use or a inTeryenTion shall be discontinued immediater aT any indicaTion oT risk To The cIient's healTh or saleTy or immediately aher The clienT gains behavioral oonTrol. lTThe clienT is unable To gain behaVloral conTrol erhrn The Time frame specified in The authorization oi The intervention, a new auThorizaTion must be (13) The wnTTen approval or The designee oTThe governing body shall be required when The original order lor a restrictive intervention is renewed Tor upTo a ToTal oT 24 hours in accordance The limhs specified In iTem (ET oT 523 524 Mslon oT Heelrh Service ReguIallon STATE FORM BZNIH cenhnuanon sheer er PRINTED: 04/25/2018 FORM APPROVED Division of Health Service Regulation V 524 Continued From page 100 V 524 (14) Standing orders or PRN orders shall not be used to authorize the use of seclusion, physical restraint or isolation timeout. (15) The use of a restrictive intervention shall be considered a restriction of the client's rights as specified in G.S. 122C-62(b) or (d). The documentation requirements in this Rule shall satisfy the requirements specified in G.S. 122C-62(e) for rights restrictions. (16) When any restrictive intervention is utilized for a client, notification of others shall occur as follows: (A) those to be notified as soon as possible but within 24 hours of the next working day, to include: (i) the treatment or habilitation team, or its designee, after each use of the intervention; and (ii) a designee of the governing body; and (B) the legally responsible person of a minor client or an incompetent adult client shall be notified immediately unless she/he has requested not to be notified. This Rule is not met as evidenced by: Based on observation, record reviews and interviews, the facility failed to maintain a time out/isolation room used for behavioral control in a safe and harmfree manner and according to the required policy and procedures and the required provisions to include the required documentation, required notification, an order for the use of the restrictive intervention and the written approval of the designee of the governing body, affecting 2 of 7 clients (#3, #6). The findings are: Refer to tag V520 for specific details. 2.The staff will be trained on the New Horizon Restrictive Intervention Policy reflecting no use of isolation or use of time-out. It also reflects the circumstances under which a restrictive Prior to 512-18 intervention can be used i.e., restrictive hold. 3.Client Rights training was provided to the 4-21-18 staff. See training certificate 4.Re-designed the room that had been wronglyCompleted used as a time-out room. The room has been re- prior to 4designed as a study area with computers for the 30-18 consumers use. Measures in place to prevent reoccurrence of the problem: 1.Continued monitoring and shadowing of the staff to provide immediate feedback regarding appropriate behavior modifications. 6899 Ongoing 2.Follow-up any issues in staff meetings and/or Ongoing individual supervisions, as warranted. 3.Place additional staff per shift, depending on Ongoing the needs of the consumer. Who is monitoring and how often to ensure the problem will not re-occur: Clinical Director/LPC Quality Management Director Qualified Professional Review on 04/09/18 of client #3 and #6's records revealed: Division of Health Service Regulation STATE FORM V524: Measures in place to correct the deficiency: 1.NCI, alternative to restrictive intervention, training was provided for the staff again 4-14-18 emphasizing that time-out and isolation would not be used. See training certificates 8ZNI11 Ongoing If continuation sheet 98 of Division of Heallh Service Reaulallon D. 04/25/201 3 FORM APPROVED nErlclENcV) or 1x21MuLTleE 1x3) one suRVEv we now or Nuneze COMFLETED mama--:15 a WING 04/13/2013 NAME OF may noosess sure zrpcooe NEW NORIZON GROUP HOME. LLC LUMBER BRIDGE. NC 28357 1x4) lo summon SYATEMENTOF 055101540155 10 pom/inane mm or 1x5, max (EACH nusr ea av FULL emu EACH CORRECWEWION SHOULDEE comm rac m; ms rppnopem no: 524 Continued From page 101 7N0 leqmred documenlallon oflhe use of the lime om room including an order for lhe use of such. Review on 04/05/15 . 04/13/15 oi racimy reooros revealed no documenlalion o1 nolillcalion lo reqmred persons including ll1e lrealmem learn, designee oi lne governing body nor are legally responsible person. lnierviews on 04/05/1a1nrougn 04/1z1a1ne audi1ed faciliiy sla/r s1aled iney had used me time our room fol negative cllem benaviors. All slai/ reponeo ll1ey had no lraining in me use or use or time our procedures. s1a/r reponed iney did nol provide cominuous rnonrloring for elienis while in me lime out mom, This deficiency is crossed rerereneeo imo 10A NCAC 27E .0101 LEAST RESTRICTIVE ALTERNATIVE (V513) ror a Type A1 rule violaiion. 525 27E Chem Rights Sec. Rest. ITO 10A NCAC 27E .0104 SECLLISION, PHYSICAL RESTRAINT AND ISOLATION TIMEOUT AND PROTECTIVE DEVICESUSED FOR BEHAVIORAL CONTROL Within a iaciliiy wnere res1rie1ive rnlervenlions may be used, are policy and shall be in aeoordanee wiin the iollowing provismns. (17) The racilny shall condum rel/laws and repons on any and all use of reslriclive rnlerveniions, including. (A) a regular review by a oesignee of me governing body, and review by me Clieni Rignls in compliance wim conrioen1ialrly rules as speciired in 10A NCAC 28A, 524 525 o1 Health Service Regulanon FORM 02an Cami/maxim: sham so 01 D. 04/25/2013 FORM APPROVED Division 0! Heakh ServiceReuulallon STATEMENT uE nEErclENclEs lxu lx2l MumnE lxal DAVE SURVEV AND new or NUMBER COMFLETED a surname 5 mm; 04I13IIU13 NAME oE pauleanasuqua NEW HORIZON GROUP HOME. STREET no DRESS clTv. STATE ZIP conE (vi) durauon ol eacn inlervenllo (Vii) reason use of me inlervemion. posiuve and less reslriciive akernalives mar were used or lhal were considered bm nm used and why inose akernalives were nm used; (ix) debliellng and planning conducled me clieni, legally responsible person, il applicable, and slall, as specilied in Pans and (G) of <DlVision of HeaIIh Service Reaulallon PRINTE D. 04/25/2013 FORM APPROVED STATEMENT oE DEFICIENCIES AND FLAN or CORRECTION ioEuTiEchTioN NUMBER MNL018-31E 1x2>> MULTIFLE CONSTRUCTION A BUILDING a Wide 1x3>> DATE SURVEY COMFLETED 04l1 3201 3 NAME oE PROVIDERORSUFFLIER NEW NORIZON GROUP HOME. LUMBER STREET ADDRESS ciTv. STATE ZIP conE BRIDGE. Nc 211357 1x4) ID PREFIX TAG SUMMARY DEFICIENCIES (EACH DEFICIENCY MUST BE FRECEDED av FULL DEFICIENCY) ii; PROVIDERS FLAN or CORRECTION ixs, PREFIX iEAch CORRECTIVEACYIONSHOULDEE COMPLEYE TAG CR055-REFERENCEDTD THE APPROPRIATE 525 525 Conllnued From page 103 physical and weIIrbeing orlhe cIiem aflecting 2 ol 7 clienis The lindings are, ReIer Io lag V520 for spemfic deiails. Review on 04/09/15 lhrough 04/13/15 ol faciIin records and sham records revealed no documenlalion rhe use ol lhe lime our mom was reponed lolhe necessary persons including a Cliem Righls Commihee. Review funher revealed no documenlailon reviews were conducted on < D. 04/25/2013 FORM APPROVED Division 0! Health ServiceReuulaliorl STATEMENT pE uEEicrENcrEs peovruEe/suppuEx/cm tle MULTWLE txal DATE SURVEY mu FLAN or rcEnrrEicATroN NUMBER COMFLETED a eurmins 5 mm; 04I13IIU13 NAME oE NEW HORIZON GROUP HOME. STREET no DRESS chv. STATE ZIP couE alternatives corTSidered and effeciiverless. affecting 2 ol 7 clients The findings are: Relel Io lag V520 lor speCific details. Review on 04/09/13 OI facility lemlds and client Who is monitoring and how oileu to ensure he problem will not A's-occur: Mdnagemenl Wealth-Set gulallull STATE FORM Dll'eclor/LPC ualrfied azmtt LUMBER BRIDGE. tic 2azs1 my in swunxv SYATEMENTOF cEErcrENcrEs Tu mm or ixst (EACH uEErcrEnev MUST eE eeEchEu ev FULL emu (EACH SHOULDEE comm TAG m; CROSS-REFERENCEDYD rnE aepxopeure we 526 Continued From page 104 526 516= Mmslu'm to place to toned the delimuc Within a lacility where restrictive intelvemions NCI. ultemuuve lo restrictive may be used, the policy and procedures shail be retiring was provided [or the sun ugum in accordance with the loilowing provisrons. emphasulng umeuut and isolation would4rlc18 (la) The facility shail coilect and analyze data on no| be used the use of seclusmn and physical restraint, The See data coilected and analyzed shall reliect fol each incident: 2 The surf will be mulled ou the New Hun/.un (A) thetype at procedure used and the iehgth at Reunite Policy refleclmg .u use time employed: {isolation or use or limeeuul It also reflects (B) allematives considered oi employed. and he mummnees werer wind. memetnepuur in 57 (C) the effectiveness of the procedure or can be used Le . Immune hold. 12718 alternative empioyed. The lacility shali analyze the data on at least a my." "mums muded to .he quarterly basis to monitor ellectiveness, .en, determine trends and take corrective action See .mmng cemmre 4721718 where necessary. The shail make the data available to the Secretary upon request. 4 Reue, gned the mom um bed been Mengly (19) Nothing in this Ruie shali be intelpleled to med '5 mm, The mm he; been .e ompleled prohibit the use of voiuntary restrictive ensued 35 emery area Wm. to, iheErrur iv interventrons at the client's Tequesl: however, the Somme" we. 18 procedures in this Rule shah apply with the in place to prevent or exception ol Subparagraph (3) cl Ruie, he problem, 1 Conllnued mourrouug and shadowing ui the unto rmmedure feedback regarding This Rule is me} as evidence? by: ppropnute behavior modificfluom LPC, le. ungaing 0" "men/av?" 'ew'd re'l'ews a"d_ are pluee lo sun wuh interviews. the larled to maintain a lime dd, "g me Manual new onhe outfisolation room used for behaworal control in a mummy safe and harmlree manner and according to the reqmred poiicy and procedures and the leqmred 2 Fouuweup any mm m" "mung; Mo, to include, larled to collect and ndludlml Superman '5 "mm" Onsoms analyzing data on the use ol the restrictive Imewenmnr documen' We 0' Pmcedme Place additional surf per depending on used and length at trme employed, document he needs 0me consumer Onsoms anomg sneer toz HE Division 0! Heakh ServiceRem/Ialion PRINTE D. 04/25/2013 FORM APPROVED Im, 10A NCAC 27E .0107 TRAINING ON ALTERNATIVES TO RESTRICTIVE INTERVENTIONS Eacihhes shaII impIemem pcIicies and practices 1ha1 emphaSIze 1he use 01 aherna1ives 1u res1ric1ive in1ervemiuns. (0) Rricr1u providing services 1c people wiih staff including sen/Ice providers, empIuyees, smdems cr vqumeers, shaII demons1ra1e cumpeience by successIuIIy ccmpIeIing flaming In ccmmunicaiiun skills and mhei strategies fol creaiing an envirunmem In which 1he likelihood of imminem danger oi abuse or iruury 1c a person disabilkies cr u1hers cr prupemy damage is pievenled. Rruvider agencies shaII es1a01ish haining based on s1a1e onmpelenmes. murmur Icr imernaI and demons1ra1e1hey seed on data ga1hered. The hairnng shaII include measurable leaming uuiecIives, smeuw or DEFICIENCIES 1x1) cousreucncu 1st one suRva mu pm or ccaeecncu iceunricunou Nuusee cavemen . BUILDING mamas": a WING 04/13/2013 NAME OF eecviceeoesuwuea srxzer success CITY. sure zw CODE NEW HORIZON GROUP HOME. LLC LUMBER BRIDGE. NC 28351 my ID SUMMARY sum/Euro; DEFICIENCIES 10 PROVIDERS mm or CORRECTION 1x5} max (EACH DEFICIENCY uusr ea paeczeeu sv mu mm (EACH cuxeecnveucnuu SHMDEE comm rec m; me Apexureure we DEFICIENCY) 526 Conunued page 105 526 records reveaIed nc documemaIicn 1ha1 daIa had been chIecIed and anaIyzed 1c murmur and de1ermine1he errecuveness of such procedures, Imerviews cn 04/05/131hrcugh 04/12/131he audi1ed IaciIin staff s1a1ed Ihey had used 1he1ime cm ruum fol negauve chem behaviurs, AII s1aII repumed1hey had received no Iraining in 1he use of res1ric1ive Imervemions including use uI1ime cm prucedures. This deIiciency is crussed Tefeienced in1u 10A 27E .0101 LEAST RESTRICTIVE ALTERNATIVE (V513)foi a Type A1 ruIe vicIaIicn. 535 27E .0107 oiiem Righ1s . Training on An 1u Res1. 535 d/ Heairh Service Reguianun STATE FORM sheermd mus Division of Heallh Service Reaulallon D. 04/25/2013 FORM APPROVED measurable lesling (wrihen and by observalion of behavmr) on lhose objectives and measurable melhoos lo delermme passing or failing the course, Formal relresherlraining musl becompleled by each sen/ice provider periodically (minimum annually). (I) Conlem of the training lhar (he service provider wishes lo employ musl be approved by lhe Divismn ol porsuanr Io Paragraph of this Rule. man shall demonsrrale compelence imhe following core areas. (1) knowledge and underslanorng ollhe people being selvei (2) recognizing and inlerpreling human behavior, (3) recognizing the ellecl oi inlernaland exlernal slressors lhal may alrecl people disabilihes, (4) slralegies lor building posrlive relalionships wirh persons wirh orsabrlnies (5) recognizing culrural, envilonmemal ano organizarional lacrors lhal may arrecl people disabilihes, (is) recognizing the imporlance of and in (he person's involvemenr in making decisions aboul (heir life (7) skills in assessmg individual risklor escalaling behavior, oommunicahon slralegies fol delusing and derescalaling polenhally dangerous behavron and (9) poskive behaworal suppons (providing means (or people lo choose aclivrlies which directly oppose or replace behavmrs which are onsale). Service providers shall malnlaln documenlalion oi inllial and refresher training (or or (x1) paovrozmureuzmoa (x2) murnm coNsYRuchoN (x3) oars susvzy who now or coRREchoN homers coverzrzo MuLun-zls WING 0411312013 NAME OF may aooazss zip code NEW "mm" GROUP HOME, LLC -- LUMBER BRIDGE. uc 2am lx4) lo summon lo mm or 0(5) max (EACH musr es eazczozo av rum mm (EACH CORRECWE ANION SHOULDEE comm me m; ms we 536 Continued From page 106 535 ol Healih Service Regulancn STATE FORM azmu sheelim ems Division of Health Service Reaulallon D. 04/25/2013 FORM APPROVED at least three years. (1) Documentation shall include. (A) who participated inthetraining and the outcomes (pass/tail), when and where they attendedand (C) instructors name, (2) The Division or may reVlew/requesl this documentation at any time, instructor Qualilications and Training Requirements. (1) Trainers shall demonstrate competence by scoring 100% on testing in a training program aimed at preventing, reducing and eliminating the need lor restrictive interventions. (2) Trainers shall demonstrate competence by scoring a passing grade on testing in an instructor training program. (3) The training shall be include measurable learning objectives, measurable testing (written and by observation ol behavior) on those objectives and measurable methods to determine passing or failing the course, (4) The content of the instructor trainingthe service provider plans to employ shall be approved by the Division of pursuant to Subparaglaph of this Rule, (5) Acceptable instructor training programs shall include but are not limited to presentation ol. (A) understanding the adult learner, (3) methods (or teaching content olthe course, (C) methods (or evaluating trainee perlormance and (in) documentation procedures. Trainers shall have coached experience teaching a training program aimed at preventing, reducing and eliminating the need (or restrictive interventions at least one time, with positive or [x0 (X2) MULTWLE coNsTRuchoN txa) one suavev AND mm or coRREchoN ioeunncanou coimerso it MNLun-zts a WING 0411312013 NAME OF i NEW NORIZON GROUP HOME. LLC LUMBER BRIDGE. NC 28357 lxt) in summaxv srarmsuror in mm or 0(5) ram (EACH MUST as paeceoeo av FULL omit (EACH CORRECWUUION SHOULDEE comm no m; his we 536 Continued me page 107 536 ivision at Health Service Regulation STATE FORM BZNHI sneeitos ems Division of Heallh Service Reaulallon D. 04/25/2013 FORM APPROVED reVlew by the coach, (7) Trainers shall (each a (raining program aimed al preyenling, reducing and eliminaling lhe need lor reslrielrye inlervemlons al leasl once annually. (3) Trainers shall eomplele a relresher insirumor 1rainrng at least every 1woyears, SeerCe providers shall mainlain documemalion ol inrlial and rerresher vaining lor a1 leasl 1hree years. (1) Documenlahon shall include, (A) who inlhelraining and me ooloomes (pass/rail), when and where ahendeu, and (C) insvuclol's name, (2) The DiVlsion ol may requesl and review lhis documenlalion any lime. Qualilieahons of Coaches. (1) Coaches shall mee1 allpreparalion requrremems as a lrainer. (2) Coaches shall leach a1 leasl lhreelrmes lhe course which is being coached. (3) Coaches shall oemonslrale compelence by complelron of Coachingol vainrlherlrainer instrumlon. Doeomenlaiion shall be (he same preparalion as flamers. This Rule is not rnel as evidenced by. Based on record reviews and inleryiew, 1he raeiliiy lalled 1o ensure six ol six auorled slafl #10, and the Operations Managel/Gmup Home Manager) reoeiyeo inilial vaining in allernaliyes lo inleryenlions. The lrnuings are, he problem, he problem will nol Queluy Management nireeror Ieosm-es in place In torml 1he deficienc NCI. oliemome |o munclne rnleryenlruns. been provided 1o Lhe slafl by a cemfied neruuor using An oppmed cumculum. See mulling cemficmea and meer's ererlenuah Iensures in place 1o prevem reoccurreuoe ol 1 New Horizon Group Home a rim base oi all required and due dines. The UHEUME CEO is gnen a oi needed mulling evenh ezm one moorh in Advance onlre due dale moniloring and how onen 1o ensure swemw or (x1) paovrumsumremuu (x2) coNsTRuchoN (x3) oars suayey mu new or coRREchoN Numeea comerereo eurruwc MuLun-zls WING 0411312013 NAME OF eraser clTv. srare zre NEW NORIZON GROUP HOME. LUMBER BRIDGE. uc 211351 lx4) lu summon srarmemor lo mm or coRaEcrloN 0(5) (EACH musr es paeceueu av rum emu ream CORRECWE ACTION SHOULDEE COMPLETE rae m; caossaereaewceuro me upeaoparure we 536 Continued From page 108 536 536= 4714718 Ongoing o1 Healrh Service Regularron STATE FORM azmu sheerms ems Division of Hea1tn Service Reaulatlon D. 04/25/2013 FORM APPROVED Review on 04/10/15 at me Approved Currier/1a for me Use of DerEsca1alion Strategies and Reslrielive Effective January 22, 2015 revealed. rThe lrainer idemiired on all the staffs' training oerliiroales was not listed as an approved lrainer/inslruclor. Review on 04/10/15 at 315/1 #35 personnel file revealed. Date of application on 02/20/15. North Carolina Interventions (NCI) training 1n alternatives to restrictive imervenlions training certificate dated 0217/13. Interview on 04105/15 staff #3 siated, She did not remember the trainers/instructors, Review on 04/10/15 01 Staff #Z's personne1 file revealed. Date of application on 02/20/15. lraining in allernalives 1o restrictive imervenlrons lraining certificate dated 02/17/15. Imerview on 04105/15 staff #2 slated, He did not remember the trainer/instructor. Review on 04/10/15 01 slal/ #6'5 record revealed. . Date of application, 02/17/15. . NCI training in alternatives lo restrictive imervenlrons lraining certificate dated 02/17/15. Imerview on 04112/15 staff #6 slated, She had received no NCI training in alternatives to restrictive interventions, "never." Review on 04/10/15 at slai/ #S's reeord revealed. . Date or applica1ron. 02/02/15. lraining in allernalives 1o restrictive imervenlrons lraining certificate dated 02/17/15. amen/w or DEFlclENclEs (x11 coNsrRucrloN our one suRva m; Rum or coRREcrloN NUMBER cowrzreo A Burrows mum-:15 5 WING -- 0411312013 NAME OF eraser moazss errv. ewe le cone NEW NORIZON GROUP HOME. -- LUMBER BRIDGE. uc 25:57 1x4) 1D summer/r0; DEFlclENclEs 10 mm or coRREcrroN 1x5) max 15/05 MUST es pazczozn av mm mm CORRECWE mm 55001555 comm me m; ms we 536 Continued From page 109 535 51 Health Service Regularrorr STATE FORM 5mm 11 55221107 51 11s Division of Heallh Service Reaulallon D. 04/25/2013 FORM APPROVED swam/r or rm paevrdemupenemna coNsTRuchoN 1x3) dare suavev AND mm or common leer/memes comma a surmise mum-:15 WING 04/13/2013 NAME OF may sneaess clTv. swe zre cone NEW NORIZON GROUP HOME. -- LUMBER BRIDGE. uc 25:51 1x4) in SYATEMENTOF DarlclENclEs ll: mm or 1x5) max (EACH nusr es passion; av FULL mm EACH CORRECWE dunes snoumez COMPLETE ms m; messenger/seem ms wearer/ire we 536 conirnued me page 110 535 Imerview on 04/09/15 staff #9 slaled, "All my trainings wele on the job, noNCl.' Review on 04/10/15 oi slal/ #105 record revealed. . Dale of applicahen. 02/13/15. lraining in allernalives re reslriehve inrervenhens lraining eerhrieare da1ed 02/17/15. Interview on 04/09/15 Staff #1 slated, . He had hm recall/ed anylrarning in NCI, "no lraining a1 all. none." Review on 04/10/15 oi lhe sperarions Managel/G/oup Home Managers personnel /ile revealed. rDale e1 applrealion on 02/20/15. lraining in allernalives re reslriehve inrervenhens lraining eenrrieare da1ed 02/17/15. lnrerview on 04/05/151he speralion Managel/G/oup home manager sialed. He had only worked for one week a1 1he laciliry. . He he had received NCI. lnrerview on 04/10/151he Licensee slaled. She was aware slarr should have he required lraining. She had paid for MCI lrarning. She was unsure why sla/r would say lhey had nm been lrained, She did nm have oonlaer in/errnarion available for he 1rainer, This de/ieiency is crossed rerereneed inla 10A NCAC 27E .0101 LEAST RESTRICTIVE ALTERNATIVE Tag ms 01 reviewed defimenmes iar a Type A1 rule vrelahen, o1 Healrh Service Regularron STATE FORM 5mm sneerma ems Division of Heallh Service Reaulallon PRINTE D. 04/25/2013 FORM APPROVED 27E .0105 Cliem Rights Training in Sec Rest ITO 10A NCAC 27E .0103 TRAINING IN SECLUSION, PHYSICAL RESTRAINT AND ISOLATION TIMEEOUT Seclosion, physIcal reslrainl and isolarion limeroul may be employed only by slarl who have been trained and have demonslraled compelence In rlIe proper use ol and ahemalives lo Inese procedures, shall ensure Inal slalr aorlIorIzed lo employ and lerminale Inese procedures are relrained and have demonslraled compelence a1 Ieasr annually. PrIorlo providing dilecl care lo people will whose irealmenI/IIabIliralIon plan includes reslriciIve inrervenlIons, siall including service providers, employees, sludenrs or volumeers slIall complele lrainIng in me use of and shall nol use Inese Imervenlions um die lraining is oornpleled and cornpelence Is demonslraled. A prerequisite lor lakIng ilIis training Is demonslraling compelence by cornplelIon ol lraining in prevenling, reducing and elIminaring lne need fol resrrIclive inlervenlions. The lrainIng shall be include measurable leamlng objectives, measurable leslIng (wrmen and by observalion of behavmr) on lhose objectives and measurable melnods lo delermme passing or failing rlIe course, (9) Formal relresnerlraining rnusl becompleled by each servIce provider periodically (minimum annually). (I) Conlem of ihe lrainIng <> DAYE suava AND mm or CORRECTION IDENYIFICAYION NUMBER COMFLETED A BUILDING WING 04113I2013 NAME or eaovIoanasumEa STREET aoanss cIrv STATE zw cooE NEW NORIZON GROUP HOME. LUMBER BRIDGE. Nc 211357 1x4) In summon SYATEMENTOF Io PROVIDERS mm or CORRECTION pray PREFIX (EACH DEFICIENCY nusr eE FRECEDED av rum new IEACH CORRECTIVEWION snourer COMPLETE no m; APPROPRIATE DAYE DEFICIENCY) ConlInued From 3 e111 537 9 537 IvIsrcn o1 Healm Service Regulancn STATE FORM sheexms one Dlvision of Healm Service Reaulallon D. 04/25/2013 FORM APPROVED Paragraph of (his Rule. Accep(aole (raining programs shall include, bm are nm limhed presenla(ion or. (1) relresher inlorma(ion on al(erna(ives (o (he use of res(ric(ive inlervemions( (2) guidelines on when (o in(ervene (unoerslanding lmminem danger (o selland mhers) (3) emphasis on sale(y and respec( lor(he righis and digni(y of all persons involved (using concep(s ol leasl res(ric(ive lmervenlions and inclememal s(eps in an inierven(ion), (4) s(ra(egies lor (he sale implemen(a(ion of res(ric(ive in(erven(ions, (5) (he use or emergency sare(y inlervemlons which include coniinuous assessmem and moni(oring of (he physical and wellrbemg of (he clien( and (he sale use ol res(rain( (hroughounhe duraiion orlhe res(ric(ive in(erven(ion, prohibhed procedures, (7) debrieling s(ra(egies, includinglheir imponance and purpose, and oocumen(a(ion ine(hods/procedures. Service providers shall inaimain documenla(ion or ini(ial and reflesher (raining for ai Ieasi ihree years. (1) Documen(a(ion shall include. (A) who panicipaied in(he(raining and (he ouicomes (pass/rail), when and where (hey adenoedand (C) lnsvuclol's name, (2) The Division or may reVlew/requesl (his documen(a(ion ai any lime, lns(ruc(or Qualilicaiion and Training Requiremenis. (1) Trainers shall demons(ra(e compe(ence by scoring 100% on (es(ing in a (raining program aimed ai preven(ing, reducing and elimina(ing (he smenw or lx() peovioemuperizncro (x2) MULTWLE coNsTRuchoN (x3) one sum/Ev (no new or comcnon ioenrincnrion NUMBER commerce mums--m a WING 0411312013 NAME OF i NEW NORIZON GROUP HOME. LLC LUMBER BRIDGE. NC 28357 lx4) in summon in pmvinzas mm or 0(5) max (EACH DEFlclEch MUST ea mceoeo av mo 7)::le (once CORRECWUUION SHOULDEE comm rec m; his one 537 Cominued From page 112 537 (vision o( Heelrh Sen/me Regularicn STATE FORM azmu oi Division of Health Service Reaulallon D. 04/25/2013 FORM APPROVED need lor restrictive interventions. (2) Trainers shall demonstrate competence by scoring 100% on testing in a training program teaching the use of seclusion, physical restraint and isolation limeroul. (3) Trainers shall demonstrate competence by scoring a passing grade on testing in an instructor training program. (4) The training shall be include measurable learning objectives, measurable testing (written and by observation ol behavior) on those objectives and measurable methods to determine passing or failing the course, (5) The content of the instructor trainingthe service provider plans to employ shall be approved by the Division of pursuant to Subparaglaph of this Rule, (5) Acceptable instructor training programs shall include, but not be limited to, presentation of. (A) understanding the adult learner, (3) methods (or teaching content olthe course, (0) evaluation of trainee perlormance and (in) documentation procedures. (7) Trainers shall be retrained at least annually and demonstrate competence in the use of seclusion, physical restraint and isolation limeroul, as specilied in Paragraph ol this Rule. (3) Trainers shall be in CPR, (9) Trainers shall have coachedexperience in teaching the use ol restrictive interventions at least two times with a positive review by the coach. (10) Trainers shall teach a program onthe use ol restrictive interventions at least once srarenw or (xi) (X2) MULTWLE coNsTRuchoN txa) one suavev mm or coRREchoN ioeurincarion nuusea conntereo a mums--:13 a WING 0411312013 NAME OF NEW NORIZON GROUP HOME. LLC LUMBER BRIDGE. NC 28357 lxt) in summon iD mm or 0(5) (EACH MUST as paeceoeo av FULL omit CORRECWUUION SHOULDEE comm me m; his appaopaim we 537 Continued From page 113 537 ivision at Health Service Regulation STATE FORM BZNHI it sneer ct D. 04/25/2013 FORM APPROVED Division ol Heahh ServiceReoulalron STATEMENT OF (X2) MULTWLE (x31 DATE SURVEV AND pm or cowmeo a 31111.0le WING -- omalzma rows or srxzer nooeess sure zre cone NEW HORIZON GROUP HOME. LUMBER BRIDGE. NC 2azs1 (x4) 1D summon lo mm or (x5) max (seen nusr es pezczoeo av mu PREFIX (EACH CORRECWE ACTION SHOULDEE COMPLETE rec m; me one 537 Continued From page 114 537 537= annually. Trainers shall complele alefleshel instructol training at least everymo years, Service providers shall malntaln documemalion ol innial and refresher (raining lor a1 leasl 1h ree years. (1) Documenlahon shall lnclude. (A) who pamcrpaled in (he (raining ano the omcome (pass/rail); (B) when and where (hey adenoeo:and (C) name, (2) The DiVlsion ol may reVlew/lequesl (hrs documenlafion 31 any lime, Qualifications ol Coaches. (1) Coaches shall rneel allpreparalion requirements as a Trainer. (2) Coaches shall leach a1 leasnhree hmes, (he course which is belng coacheo. (3) Coaches shall oernonslrale compelence by cornplehon of coachingol Trainrmerflainer Documentation shall be (he sarne prepalafion as lor lrarners, This Rule ls nol rnel as evioenced by: Based on record reviews ano inlerview. the lacilily lalled Io ensule six ol six audlted staff #10 and The Opelamns Managel/Gmup Horne Manager) received (raining in seclusmn, physical leslraim ano isolation lirneom only by staff who have been (rained ano demonsllaled compelence ano providing direcl care In people wilh disabi The hndings are: lor res, Review on 04/10/13 OI The Appmved Cumcuia lor The Use OI DarEscaiafion SflaTegies and Measnm in place In toned the deficiency: 1 New Human only rmplemenrs nrervenhons in rhe case 0le snunnon 11ml eeuhl esull buddy harm, per New Honmn Reslncuve lnlervenhon Policy. be pmuded 10 lhe 514" 2 The room in quesuon lhar bu|l| a |1merou| mom when lhe was burh, as our miended 10 use as such by New emon's CED Since rhe survey, me more has een redesigned by remoung lhe door, mble compnlers for lhe consumer's use or academics and/or Llc|1v1|y1 Measnm in place In prevent or he problem, 1 The "room" has been redesigned and equlpped [or lhe consumers and acuvrues, 2 Licensed slal'l in place lo sl rhe d1rec| cure inn w1|h behnvrem1 henhh needs or lhe onsume New Harmon's |o Add addrhonnl .1 Shin lu - 1 behavior mnnagemeni Who is monitoring and how onen to ensure he problem will nol A's-occur: Drreclor/LPC uallfied Prof .. onnl Pnur in Se 12718 ner 10 0718 Eompleled ompleled ner 10 0718 4725718 4723r18 Ongomg Ongomg or Heahh Service Regulanon STATE FORM BZNHI o) Division of Health Service Reaulallon D. 04/25/2013 FORM APPROVED Restrictive E/reotive January 22, 2015 revealed. rThe trainer identitred on all the staffs' training oertitroates was nm listed as an approved trainer/instructor. Review on 04/10/15 ot Staff #35 personnel file revealed. Dale of application on 02/20/15. North Carolina interventions (NCI) training in seclusion, restlalm and isolation timeout training certitroate dated 02/17/1a Interview on 04105/15 staff #3 sialed, She did nm remembef the trainers/instructors, Review on 04/10/15 ot Staff #25 personnel file revealed. Dale of application on 02/20/15. . NCI training in seclusion, physical reslialm and isolation timeout training oertitroate dated 02117/1 Interview on 04105/15 staff #2 slated, He did nm remember the Irainer/lnsimclor. Review on 04/10/15 o1 slat/ #6'5 record revealed. . Date of application, 02/17/15. . NCI training in seclusion, restrarnland isolation tirneoutlraining dated 02/17/15. Interview on 04112115 staff #6 slated, She had received no NCI training, "never." Review on 04/10/15 ot stat/ #S's record revealed. . Date of application. 02/02/15. training in seclusion, physical restraint and isolation timeout training oertitroate dated 02117/1 B. smenw or DEFlclENclEs rm paovroemuppuemm (X2) norms coNsiRuchoN 0(3) one suRva mo Rum or nut/sea countereo Burrows mums--:13 a we 0411312015 NAME OF sraeer crrv. sure le cooe NEW NORIZON GROUP HOME. LLC LUMBER BRIDGE NC 28357 1x4) 1o summer/Tor DEFlclENclEs 10 mm or 1x5) (EACH DEFlclEch nusr 5E paeceoeo av FULL EACH CORRECWUUION SHOULDEE comm me m; me amoral/re we 537 Continued me page 115 537 at Health Service Regulation STATE FORM 52N11t umnonvmonsneemt: e1 Division of Heahh Service Reaulallon D. 04/25/2013 FORM APPROVED Imerview on 04/09/15 staff #9 slated, "All my trainings wele on the job, noNCl,' Review on 04/10/15 o1 slai/ #105 record revealed. Da1e of applicahon. 02/13/15. lraining in seclusion, physical res1rain1 and isolarion limeoul lraining oenihoale daled 02/17/1 B. Interview on 04/09/15 Staff #1 mated, He had nm received anylrarning in NCI, "no lraining a1 all, none." Review on 04/10/15 o1 lhe sperarions Managel/G/oup Home Managers personnel /ile revealed. rDale o/ applroalion on 02/20/15. lraining in seclusion, physical res1rain1 and isolarion rimeoullraining oenihoare daled 02/17/1 B. lnrerview on 04/05/151he speralion Managel/G/oup home manager slaled. He had only worked for one week a11he1aci y, He he had lecelved NCI. lnrerview on 04/10/151he Licensee s1a1ed. She was aware s1arr should have 1he required lraining. She had paid for MCI lrarning. She was unsure why s1a/r would say lhey had nm been lrained, She did nm have oon1ao1 in/orrnarion available for 1he 1rainer, This de/iciency is crossed rererenoed in1o 10A NCAC 27E .0101 LEAST RESTRICTIVE ALTERNATIVE Tag V513 o/ reviewed deriorenoies 1or a Type A1 rule vrola1ion, swarm or rm peovromsumrzmo coNsTRuchoN 1x3) one sum/Ev mo mm or coRREchoN Nuneeo cowrereo A mama--:15 a WING 04/13/2013 NAME OF PRoleERoRsi/Wuzfi may ewe zrpcooe NEW NORIZON GROUP HOME. LLC LUMBER BRIDGE. NC 28357 1x4) lo sum/15v summer/Tor mammals in mm or 1x5) max 1am nusr ea oneceoeo av FULL mm EACH CORRECWUUION SHOULDEE comm rac m; ms remover/re one 537 Continued me page 116 537 o1 Healrh Service Regularron STATE FORM 52mm o1 PRINTE D. 04/25/2013 FORM APPROVED Division oi Heahh STATEMENT OF DEFICIENCIES (Xi) (XZI MULTWLE CONSTRUCTION (xai DATE SURVEV AND ms or ceaeecnen A cewlereo WING 0411312013 NAME OF NEW HORIZON GROUP HOME. LUMBER BRIDGE m: 23:51 (X4) In DEFICIENCIES ID PROVIDERS FLAN OF CORRECTION as} (EACH DEFICIENCY MUST es easceoee av mu eegnx (EACH ceaeecnveacrres swuwfii comm TAG m; me one DEFICIENCY) From page 117 735 736 27G Faciliiy and Glounds Maimenanee 7351 10A NCAC 276 .0303 LOCATION AND EXTERIOR REQUIREMENTS Mfism'm in place in toned rhe deficiencyfin'I'iy d' hllo 111. [b beg a mainiained in a sale, clean, amacfive and orderly eplnced. manner and shall be kepi Iree Ircm ohensive odor. 2 The leaiher like mieml sofa is being repmred 18 replaced This Rule IS as BVidenCed by: The "(Lark Mum" on the WAS from Based on observaiicns and Imen/Iew, the IaciIiiy me bleed Wm, mommg All Me," was not malmain in a clean and ahrachve mh and hm been replaced Wm mm ,mm 712718 manner. The findings are. flange chm.>> Observaiicns oi me Iaciliiy on 04/05/13 a 10:15 4 Some gm, ,s heme placed the mm 712718 am revealed: TV/Livrng area oi the Iacihy had me fablic soias MEWS in mm mm" rears on me cushions and ihe inner ma'elial he mum, A "Safely Review" walk ihmugli area of ihe had a Ieamer like he complemd [m one um per monlh by me maierial and me maienal was Irayed and peeling Group Hume Manage, my" Qunhfied oh the cushions and arm Ies's oi ihe sofa. "new" Comma" [0m be onihly and Cliem #6 bedroon linens/pillow case had awarded the Gamma mm be ngumg da'ken evlewed by ihe leily Mmgemem Drrecrer Second bamroom irile flow on mam bedroom hallway had a clack in ihe Iile less ihan 2 lee' in 2 An Independm "my Renew be omplered eiery firmunlhs by a nonrempluyee. 5 . . libs ritho Imervrew on 04/05/131he Licensee siaied: 5:20 [h :23; ?Ch:ckm Eunihs She would address < D. 04/25/2013 FORM APPROVED Division of Health Service Reaulatlon STATEMENT oE nEElcrENcrES [x0 tle MULTWLE coNSTRucTroN txa>> DAVE SURVEY AND mm or coRREcTroN NUMBER COMFLETED 5 mm; 04I1SIZO13 NAME oE NEW NORIZON GROUP HOME. STREET on DRESS chv. STATE ZIP conE l! 283!7 each client, This Rule is not met as evidenced by. Based on observation, record review, and interviews, the lacility failed to minimum furnishings for client bedrooms. The findings are. Review on 04/05/15 ol the DHSR (Division 0t Health Service Regulation) license erlective on 11/01/17 revealed the raoilrry was licensed lor capaClty or 9 clients. Observation in the facility on 04/05/15 at 1050 am revealed. . Seven clients were residing at the laorlity. rThele were no bedside rabies in any of the bedrooms. rThe only storage the clients had were small shared closets lor clients personal clothing and personal items and a metal hanging closet With wheels for client #7'5 room. During lnteerew on 04/05/15 the Licensee stated, She was nm aware she needed to have bedside iabies in each of the clients' bedrooms. Iensures in place to prevent reoccurrence or he problem i A month!) Safety Review" walk through will he completed at leoat one tone per month b3. the Group Home Manager And/or Qualified Prolaanonal. Completed ronn will be forwarded to the Corporate omee to he eviewerl b3. the Quality Management Director 2 An independent Satety Renew will be \umpleted every firmomha by a nonremployee. Report will be given to the CED See cup). or the Salety Wh monitoring and how onen to ensure he problem will not re-occnr: ronp Home Manager uallfietl Management Director uallfietl Prolessional nrlepenrlent Consultant for Safety Review lx4) in Summon STATEMENTOF oEErcrENcrES lo mm or coRREcTroN rxs, (EACH DEFlclEch nusr er narcroro av row new law CORRECWUUION SHOULDEE COMPLETE no m; me one V774 Continued From page no 774 square footage requirements in elfect at that 77': hme. Unless othenIl/lse plowded in these Rules, residential lacilities licensed after October 1, 1955 shall meet the following indoor space reqmremems Iensures In place to correct the deficiency: (7) Minimum furnishings lor client hedrooms shall l-Bedside ables. storage bin_s. and comp-"er "'de include a separate hed, bedding, prllow, hedside ables have been placed In each of ""Enor 57 lahle, and storage for personal belongings lor bedroom "4713 onthl). and ngomg Ever). 5, ontha Ongoing ol Heelrh Service Regulerron STATE FORM azmtt or Attachment #2 Confirmation for Disaster Drills: The Group Home QP and/or Group Home Manager is responsible for implementing the disaster and fire drills at the group home. Drills of emergency procedures are conducted at least quarterly during varying times of operation in the group home and reflect realistic events. Group home drills must be completed at least monthly and during both day and night shifts. By the end of the quarter, a fire drill and a disaster drill should have been completed on each of the shifts. Information including the date and time of the tests, number of persons involved, time involved in the tests, and assessment of the process is documented by the QP. A copy of the disaster drills and fire drills will be forwarded to the Corporate Office for review. The drill is held with no person served knowing that it is about to happen. Use the Emergency Operation Plan to see how to carry out each of the drills. A copy of the drill shall be forwarded to the Corporate Office upon completion. The original drill form and this Confirmation Form shall be maintained at the Group Home location. Quarter 1 Complete one of these per month; one on each shift for the month Fire Complete one type of disaster drill from this list per month. Complete one of these per month; one on each shift for the month Fire Complete one type of disaster drill from this list per month. Hazardous Materials January February March Quarter 2 April May June Hazardous Materials Severe Weather: Hurricane, Tornado Threat of Violence or Harm: Bomb Threat Utility Power or Mechanical Failure Severe Weather: Hurricane, Tornado Threat of Violence or Harm: Bomb Threat Utility Power or Mechanical Failure Quarter 3 Complete one of these per month; one on each shift for the month Fire Complete one type of disaster drill from this list per month. Complete one of these per month; one on each shift for the month Fire Complete one type of disaster drill from this list per month. Hazardous Materials July August September Quarter 4 October November December Hazardous Materials Severe Weather: Hurricane, Tornado Threat of Violence or Harm: Bomb Threat Utility Power or Mechanical Failure Severe Weather: Hurricane, Tornado Threat of Violence or Harm: Bomb Threat Utility Power or Mechanical Failure New Horizons, LLC Subject: Incident Reports Policy No.: C-14 Page 1 of 5 Effective Date: 01/01/09 Revised Date: 05/03/18 Policy New Horizons, LLC immediately reports all incidents or unusual occurrences. Procedures 1. The Director ensures that Level I, II or III incidents are responded to be assigning staff directly involved with the consumer and the Qualified Professional to: a. Immediately attend to the health and safety needs of consumers involved in the incident; b. Determine the cause of the incident; c. Develop and implement corrective measures; d. Develop and implement measures to prevent similar incidents, which will be monitored by the Human Rights Committee; e. Be responsible for implementation of the corrections and preventative measures; and f. Maintain documentation of a-e above. 2. The Director responds to any Level III incident that occurs while a consumer is in New Horizons, LLC care or on it’s premises by immediately securing the consumer’s record by: a. Obtaining the consumer’s record; b. Making a photocopy; c. Certifying the copy’s completeness; and d. Transferring the copy to a peer review team. 3. The Director if designated appoints a peer review team to convene with 24 hours of the incident. The peer review team: a. Reviews the copy of the consumer’s record; b. Gathers other information needed; c. Issues a report concerning the incident to the Director and to the consumer’s home area authority/LME to facilitate the monitoring of services as required by G.S. 122C-111 and other State statutes; and d. Immediately notifies the following: • The local area authority/LME; • The consumer’s legal guardian, as applicable; and • Any other authorities required by law. 4. The Director assures that Level II or Level III incidents are reported to the local area authority/LME within 72 hours of the incident. The report is New Horizons, LLC Subject: Incident Reports Policy No.: C-14 Page 2 of 5 Effective Date: 01/01/09 Revised Date: 05/03/18 submitted on the DHHS Incident and Death Reporting Form approved by the Secretary of the Department of Health and Human Services (DHHS). The report may be submitted via mail, in person, facsimile or other electronic means. The report includes the following information: a. b. c. d. e. f. New Horizons, LLC contact person and identification information; Consumer’s identification information; Type of incident; Description of incident; Status of the effort to determine the cause of the incident; and Other individuals or authorities notified or responding. 5. Any missing or incomplete information is explained and by the end of the next business day, the Director ensures that staff update the report by: a. Notifying the local area authority/LME when it has reason to believe that information provided in the report may be erroneous, misleading or otherwise unreliable; and b. Submitting to the local area authority/LME information required on the incident form that was previously unavailable. 6. The Director or designee submits, upon request by the local authority/LME and proper consent of the consumer or legally responsible person, other information obtained regarding the incident, including: a. Hospital records including confidential information; b. Reports by other authorities; and c. New Horizons, LLC response to the incident. 7. The Director designates an employee who is responsible for sending a quarterly report to the local area authority/LME on a form provided by the Secretary of DHHS, via electronic means. The report includes summary information as follows: a. Medication errors that do not meet the definition of a Level I or Level II incident; b. Searches of a consumer or his/her living area; and c. Seizures of consumer’s property or property in the possession of a consumer. 8. The Director assures that a copy of all Level III incident report is provided DMH/DD/SAS and/or DHRS for Category A providers and DMH/DD/SAS for Category B providers immediately upon receipt of the report. New Horizons, LLC Subject: Incident Reports Policy No.: C-14 Page 3 of 5 Effective Date: 01/01/09 Revised Date: 05/03/18 9. All incidents/accidents are reported to the Director, as soon as possible, and no later that (1) hour of the incident becoming known. a. An employee completes and submits the reporting form within 24 hours to the Director or designee who reviews, signs, files the form and initiates any necessary action. b. The Director or designee verbally reports all incidents to the County Program/LME, as appropriate, within that 24-hour period and provides a copy of the form within 72 hours. If the incident is over a weekend or holiday, the form must reach the Program/LME at the beginning of the next work day. 10. The Director reviews each incident and takes any additional corrective actions, as indicated, to prevent future occurrence of similar incidents. 11. Examples of incident/accident reports for documentation include, but are not limited to: a. Any accident or injury, including self-injurious behavior, which requires treatment by a physician. First aid provided by a nurse or other facility staff would not be included in this category; b. Any medication error, including lack of administration of a prescribed medication, which causes the consumer discomfort or places his or he health or safety in jeopardy; c. Use of any hazardous substance which requires treatment by a physician. First aid provided by a nurse or other facility staff would not be included in this category; d. A consumer’s elopement (escape, run away from or abscond) lasting more than 3 hours; e. A consumer’s death; f. Suspension or expulsion of a consumer from services or supports; g. Any case of abuse, neglect or exploitation against a consumer which is under investigation or has been substantiated by a county Department of Social Services (DSS) or the DHRS Health Care Personnel Registry Section; h. Any suicide attempt which results in injury or places the consumer in jeopardy; i. The arrest of a consumer for violations of state, municipal, county, or federal law; or j. Any fire or equipment failure that places the health or safety of a consumer in jeopardy. New Horizons, LLC Subject: Incident Reports Policy No.: C-14 Page 4 of 5 Effective Date: 01/01/09 Revised Date: 05/03/18 12. Reporting of incidents and unusual occurrences includes: a. a description of the event; b. actions taken on behalf of the consumer (corrective actions taken); and c. the consumer’s condition following the event. 12. If the incident involved any suspicion of abuse, neglect or exploitation of a consumer, the staff witnessing the event or suspecting such must report it to the county Department of Social Services and a Health Care Registry report completed within 24 hours. 13. Incident Reports which include the administrative review must not be referenced or filed in the consumer record but filed in administrative files. Opinions, conclusions, or personnel actions relative to the event must not be included in the consumer’s record. The occurrence of an incident is recorded in the service record. 14. The Quality Improvement Committee reviews aggregate reporting of incidents and unusual occurrences. The Director reviews each incident and takes any additional corrective actions, as indicated, to prevent future occurrence of similar incidents. 15. Incidents that are not routinely reported to DMH/DD/SAS or DHSR include: communicable diseases, infection control, vehicular accidents, biohazardous accidents, and unauthorized use or possession of licit or illicit substances. These incidents should be documented on the DHHS Incident Reporting form and given to the Director immediately upon an occurrence. The Director takes the proper action of reporting, if necessary. 1. Communicable disease are reported to the person’s private physician and/or Public Health Department 2. Infection control are reported to OSHA, Public Health, private physician and others, as appropriate 3. Vehicular accidents are reported to law enforcement and insurance carrier. When person served are in the vehicle, legal guardians are notified and the DHHS Incident Report is completed. 4. Biohazardous accidents are reported to OSHA, private physician and others, as appropriate. 5. Unauthorized use or possession of licit or illicit substances by staff results in disciplinary action, the severity depending upon the circumstance as determined by the Director. Illicit substances are referred to the public law enforcement agency and staff dismissed. New Horizons, LLC Subject: Incident Reports Policy No.: C-14 Page 5 of 5 Effective Date: 01/01/09 Revised Date: 05/03/18 6. Unauthorized use or possession of licit or illicit substances by persons served result in action, the severity depending upon the circumstance as determined by the treatment team and Director. Illicit substances are referred to the public law enforcement agency and staff dismissed. 16. Following any critical incident, staff debriefs with the people involved and documents the findings. Referrals are made for more intensive follow up/treatment, if indicated. State Definitions “Incidents” means any happening which is not consistent with the routine operation of a facility or service or the routine care of a consumer and that is likely to lead to adverse effects upon a consumer. [10 NCAC 27G .0103(b)(32)] 10 NACA 27G .0602 (5-7) includes: • • • Level I incident – does not meet the definition of a level II incident or a level III incident. Level II incident – results in a threat to consumer’s health, safety; or a threat to the health, safety of others due to consumer behavior and does not meet definition of a Level III incident. Level III incident – results in: (a) a death, permanent physical or psychological impairment to a consumer; (b) a death, permanent physical or psychological impairment caused by a consumer; or (c) a threat to public safety caused by a consumer. “Provider category” means the type of facility in which a consumer receives services or resides. The provider category determines the extent of monitoring that a provider receives and is determined as follows: Category A – facilities licensed pursuant to GS 122 C, Article 2. Category B – G.S. 122C, Article 2, community based providers not requiring State licensure. [10 NCAC 27G .0602 (10)] Standard of Operation: Incident Reporting Purpose: Outline of the steps needed in reporting an incident regarding scenarios constituting the need for a report, timelines for submission, and follow-up. Internal Steps for reporting oversight: 1. CEO is notified by the staff person(s) involved in the incident and/or the Director or Manager of the service immediately; 2. Operations Director will notify the Quality Management Director and Compliance staff person via email immediately upon notification of the incident; 3. Operations Director will forward the passcodes for the incident, via email, to the above two staff immediately once the incident report has been entered into the IRIS System; and 4. Quality Management Director and Compliance staff person will review the incident in the IRIS System for details and to ensure quality of care was adhered; and 5. Quality Management Director will log the incident report onto the electronic Incident Report Log at which time all timelines are ensured to be within requirements. What is an incident? Per DMH Incident Manual, an “incident”, is any happening which is not consistent with the routine operation of a facility or service or the routine care of a consumer and that is likely to lead to adverse effects upon a consumer. All Category A and B providers are required to report any adverse event that is not consistent with the routine operation of a facility or service or the routine care of a consumer. Under Your Care: • The definition for “a consumer under the care of a provider” refers to a consumer who has received any service in the 90 days prior to the incident. • Reporting of incidents is required for purposes of communication and timely response. Individuals receiving Residential or Assertive Community Treatment Team (ACTT) services are considered under the provider’s care 24 hours a day. Individuals receiving day services or periodic services are considered under the provider’s care while a staff person is providing services of if the consumer received any services from the provider in the 90 days prior to the incident. Standard of Operation: Incident Reporting When to File? Type Incident of Report to Host LME Report to Home LME Report to DMH/ DD/SAS (all providers) Report to DHSR Complaint Intake Unit (122C-Licensed providers only) No report No report except for Opioid providers Level II IRIS report incident within 72 hours (including death from natural causes or terminal illness) If required by contract Level III Verbal report incident (other immediately than IRIS report death) within 72 hours Verbal report immediately IRIS report within 72 hours IRIS report No report within 72 hours Death from Verbal report suicide, immediately accident, IRIS report homicide, other within 72 hours violence Verbal report immediately IRIS report within 72 hours IRIS report IRIS report within 72 hours within 72 hours Death from Verbal report unknown cause immediately IRIS report within 72 hours Verbal report immediately IRIS report within 72 hours IRIS report No report within 72 hours Death within 7 IRIS report days of immediately seclusion or restraint IRIS report immediately IRIS report immediately IRIS report immediately A provider must submit an initial incident report within 72 hours of learning about an incident (this includes any incident occurring on site or while the consumer is on therapeutic leave relevant to residential services), even if the provider does not have all of the facts about an incident. This report should contain all of the information that the provider knows at the time of submission. When provider obtains or is informed about new or additional Standard of Operation: Incident Reporting information related to the incident, the provider must update the original report and submit the update information by the end of the next business day after becoming aware of the information. If the cause of death is initially unknown and later determined to be a result of suicide, accident, homicide, or other violence or occurs within 7 days of seclusion or restraint, file a Level III incident/death report within 72 hours of receiving the additional information on the cause of death. The provider must submit the updated report even if the new information does not change the level of the incident. Providers are further required to submit, “upon request by the by the LME, other information obtained regarding the incident, including: • hospital records including confidential information; • reports by other authorities; and • the provider’s response to the incident.” When updating an incident report, the supervisor of a provider agency needs to provide information regarding the reason for the resubmission of incident report in the boxes on the Supervisor Action section of the incident Report. Reporting of Abuse, Neglect and/or Exploitation: • Must be reported to the appropriate agencies within the required timelines • Report to the New Horizon CEO immediately • Verbal report to the Host MCO immediately • IRIS System upload within 72 hours • Begin internal investigation immediately reflecting: o Person interviewed o Date and time the interview was completed o Complete conversation that transpired during the interview, with each individual o Person’s name completing the investigation • If the incident is alleging a staff person is the accused, a Health Care Registry report must be completed within 24 hrs. Note: Reports to DHSR Health Care Personnel Registry regarding an allegation against an unlicensed staff in a licensed or unlicensed facility should be submitted within 24 hours of the agency becoming aware of the incident. FOR FURTHER INFORMATION REGARDING REQUIREMENTS SEE THE DMH INCIDENT MANUAL (online and in the agency office) PCP review and revision following an incident: Standard of Operation: Incident Reporting In addition to the requirement related to the completion of incident reporting, the following steps shall be followed: 1.The service Director or Manager or responsible QP will collaborate with the Operations Director regarding the determination whether a revision of the consumer’s PCP is warranted. a. If warranted, meet with the Child & Family Treatment Team relevant to the incident. b. If warranted, immediately revise the present PCP goals, or develop a new goal related to addressing the new need. c. The consumer and the consumer’s guardian shall always be involved with the Child & Family Treatment Team meeting and the review/revision of the PCP. 2. Operations Director will email Quality Management Director and Compliance staff person with the decision regarding warranted PCP revisions. 3. Quality Management Director and Compliance staff person will review the decision related to the need to revise the PCP goals compared to the incident details. 4. Additional follow-up will be completed by the Quality Management Director and Compliance staff person, if warranted. Dev. 3-20-18 NEW HORIZON, LLC EMERGENCY DRILLS Site: New Horizon Group Home Address: Lumber Brid NC Date: April 28 1018 Time Started: Time Completed: 7:10 am Type ofDri rii-e _Natural Disaster _Power Failure _Vio|ence Boluh Threat Describe Simulation (How. What, When, Where): The phone rung in the Level IV facing and when Stall answered it the caller stated, "There is a bomb at that place". Slzt'l' asked where the bomb was while motioning to other Staff to remove them from the Home. While guestioning the caller Staff assisted other Staffwith directing all exiting the front door. Staff asked caller if he had placed the bomb. Staff asked caller his name. Staff received no resmnses from caller to call 911 to report was told Staffover bl Ihe caller. Staff was asked by 9" to cross the slrcel from the Home and remain in an area that's safe until assistance arrives, Staff called the Director to inform of the situation. After :heckingiuside and outside the facl Itv it was discovered that the call was a nranlL Staff were allowed Io return to the facility. Staff called the Director to inform of the outcome. Participants in drill(s): Staff Name ofPerson Conducting Drill: _Mellia Conley Was the building evacuated? .3 Yes No ii no explain: Were the individuals moved to a safe location and accounted for? Yes 7 No If no explain: Were the emergency procedures followed? 5 Yes No If no which procedures were not followed? Responses to drill(s): Cooperative. Recommendations for improvement following drill simulation (if applicable): None during this drill. Report Completed Date: Li NEW HORIZON, LLC EMERGENCY DRILLS Site: New Horizon Group Home Address LumberBrid NC Date: APREL 28K 2018 Time Started: NJ Time Completed: 10:00 am Type ofDrill: x_ Fire Natural Disaster il'ower Failure _Medieal ivinlence *Bomb Threat Describe Simulation (How, WhatV When, Where): Staffwas assembled in the hallway ofthe Level IV Group Home to learn each route to be taken in the event ufa fire. Staffwas explained the importance of Staff remaining calm to prevent evervonc from becoming overwhelmed and/or naniefl and able to ensure that all are accounted for. How to exit the building in a safe and timely manner with evegone was demonstrated. At each exit Stafl' was instructed on how to lead us out into the farthest sections of the yard to include' the left side of the the backyard. Staff when assembled outside was asked to call 911 and to follow the 911 instructions. Staff was also asked to eall the Director after the 911 call to inform ofthe situation. Participants in drill(s): New Horizon Staff. Name ofPerson Conducting Drill: Melba Conlev Wasthehuildingevaeuated? Yes No If no explain: Were the individuals moved or a safe location and accounted for? Yes No If no explain: Were the emergency procedures followed? 5 Yes No If no which procedures were not followed? Responses to drill(s): Coo erative. Recommendations for improvement following drill simulation (if applicable): recommendations durin this drill. Report Completed By: (438% Date: 4/93" /18/ New Horizon Group Home, This is to Certify that Dorre? Bailey has com [eted VJ, - Date Signature New Horizon Group Home, LLC This is to Certify that Nyshella Smith -Mu1 (@9460 4a Ed CPN Date I Signature New Horizon Group Home This is to Certify that Shaunda Smith I LLC I 4th CM Signature New Hori20n Group Home, LLC This is to Certify that La keshaw Bea rega has comPleted ,1 @ch Signature New Horizon Group Home, LL This is to Certi?/ {hat Wendy Chavis mgiet 93,20 I aimeu?ys (40129)] puma/mp Mp 1914493 9551 game AL. I (ML) Aaluog quaw 42qu 29.14493 0542/ Date New Horizon Group Home, LLC This is to Certi?/ that Sean Evans has comglg?ce .5 Sir}; SignatIEI/re 292 I GINO: 96% I030 Ch .15 a +0 ?ows? >399? mama Em nOBE?mm S?m?a New Horizon Group Home, LLC This is to Certify that Darrell Baley Tim, I x?jg??a?cure Horizon Group Home, LLC This is to Certify that Nyshella Smith has comgle?cgd? New Horizon Group Home, LLC This is to Certi?/ that Shaunda Chappel has com [eted New Horizon Group Home, LLC This is to Certify that Wendy Chavis 4/41; [ac/y Date Sig?ature New Horizon Group HomeCerti?/ that Lakeshaw Beauregard Ed, Cream" - vz? (I Signature 9mg AQIUOD 3,12an @1449) 04 5! Wu DTI uozuoH MQN am - I. New Horizon Group Home, LLC This is to Certify that Cleveland Kealon Signature Ina/W 93,20 (Squ) I 94 mm 615 1ch "57/7 (WI) ?73?7" sum; wees #2an @1449) 04 5! Slqi DTI ?atuoH anJD uozuoH MQN 995/ 91/ {ciao/K Date New Horizon Group Home, LLC This is to Certify that Anthony Bears has com leted A/(ngd, jSignature New Horizon, LLC 4989 Rock?sh Rd Raeford, NC 28376 Phone: (910) 848-1080 Fax: (910) 848-1819 RESIDENTIAL LEVEL IV LICENSED PROFESSIONAL JOB DESCRIPTION Provider Requirements: New Horizon Group Home, LLC is certi?ed as a Critical Access Behavioral Healthcare Agency (CABHA) provider through NC Division of and is credentialed by Sandhills Center and Eastpointe Managed Care Organizations. New Horizon Group Home also is nationally accredited by Commission on Accreditation of Rehabilitation Facilities (CARP). The agency meets all the provider quali?cations established by Division of Medical Assistance, Division of and the Managed Care Organizations (MCO). Residential Treatment Level IV is an intensive residential treatment facility that is a 24-hour residential facility which provides a structured living environment within a system of care approach for children or adolescents whose primary diagnosis is mental illness, some of whom may also have co-occurring diagnoses, and for whom removal from home is essential to facilitate treatment. The needs of the children/adolescents require more intensive treatment and supervision than would be available in a residential treatment facility offering only a staff secure setting. Primary Purpose of the Position: New Horizon Group Home, LLC offers and relational support, behavioral modeling of interventions, and supervision to the consumer residing in the facility. These preplanned therapeutically structured interventions occur as required and outlined in the consumer?s service plan. Staff also monitor, treat, and assess the emotional, and behavioral needs of this population, and assist with coordinating service needs. The Licensed Professional (LP) will assist in the development of and behavior management skills; include intensive, frequent, and pre?planned crisis management; provide containment and safety from potentially harmful or destructive behaviors; promote involvement in regular productive activity, such as school or work; support the consumer in gaining the skills needed for reintegration into community living; and coordinate with other individuals and agencies within the consumer?s system of care. The LP will work with the Qualified Professional team and all other facility staff to assist consumers in unlearning maladaptive behaviors and develop more appropriate relationship skills. Duties are performed primarily in the residential facility but may also include other areas in the community. The Licensed Professional is a full?time licensed position in the facility being involved with the clinical and administrative aspects of the consumers services, to include but not limited to: Supervision of direct care staff; Oversight of emergencies; Provision of direct clinical services to consumers and their families; Participation in treatment planning meetings; and Coordination of each consumer?s treatment plan. Licensed Professional Job Description New Horizon, LLC Edition 4-20-18 page 1 of 4 New Horizon, LLC 4989 Rock? sh Rd Raeford, NC 28376 Phone: (910) 848-1080 Fax: (910) 848-1819 Accountability: The Licensed Professional position works as an integral part of the clinical and administrative team at the facility. Quali?cations: Licensed Professional means an individual who holds a license or provisional license issued by the governing board regulating a human service profession in the State of NC. For substance related disorders this shall include a Licensed Clinical Addiction Specialist or a Certi?ed Clinical Supervisor. Staf?ng Requirements: Residential Treatment Level IV requires a minimum of three direct care staff per six consumers; four direct care per seven, eight. or nine consumers; and ?ve direct care staff per ten, eleven, or twelve consumers, always. During consumer sleep hours. three direct care staff shall be present of which two shall be awake and the third may be asleep. In addition to the minimum number of direct care staff, more direct care staff may be required in the facility based on the consumer?s individual needs as speci?ed in the treatment plan. Special Knowledge, Skill, Physical Requirements, and Training: 0 Knowledge of State and Medicaid requirements as they relate to the provision of Residential Treatment services. - Expertise with Sex Offender techniques to provide service as well as supervise the staff in this subject matter. - General understanding of behavioral patterns and attitudes common in varying degrees with children/adolescents in the populations; Ability to deal patiently and fairly with staff, consumers, families, and others; Ability to maintain effective and ef?cient working relationships and present an atmosphere of teamwork; Consistently aware of health and safety needs for all consumers and staff; Demonstrate good oral, written, and documentation skills; Regular and predictable job attendance; Ability to accept and respond positively to change; 0 Training/certi?cation in the following: I General Organization Orientation Licensed Professional Job Description New Horizon, LLC Edition 4-20-18 page 2 of 4 New Horizon, LLC 4989 Rock?sh Rd Raeford, NC 28376 Phone: (910) 848-1080 Fax: (910) 848-1819 I Client?s Rights I HIPPA Laws and Con?dentiality I Person Centered Planning I Person Centered Thinking I Cultural Awareness I Speci?c Population characteristics of consumers being served I Documentation requirements and skills I Crisis Intervention I Incident Reporting I Supervision Techniques I Aid/Blood Borne Pathogens I NCI or equivalent I Sex Offender training, if required to meet consumer?s needs Equipment Regularly Used: 0 Computer Phone Cell Phone Copier machine Fax machine Agency vehicle and personal vehicle Licenses or Certi?cations Required: 0 License or Provisional license issued by the governing board regulating a human service profession in the State of NC. 0 Sex Offender training, if indicated in the consumer?s treatment plan Valid North Carolina Driver?s license, which is clear of violation re?ecting a poor driving record 0 Personal vehicle insurance as required Minimum Quali?cations: The employee must have the ability to read and analyze/interpret journals, technical procedures, and government regulations. The employee must have the ability to assess and develop the Person-Centered Plans and communicate effectively both in writing and orally. Employee must also have the ability to write reports, business correspondence, and procedure manuals. The LP must be able to present information to participants and their families, community support groups, other quali?ed professionals, paraprofessionals, and the public. Licensed Professional Job Description New Horizon, LLC Edition 4-20-18 page 3 of 4 New Mia?. LLC 4989 Rex?klish Rd RaeR??i? 233 76 Phone; \Qit?t) 848?1080 Fax: (?no SIS-1819 inM-J ?we Skills: Misuse must have the mito- to read, analyze am! interpret general business periodicals, pmliesshmal jewels. technical, mediates or governmental restdations. Employee must also have the ability to write tetanus, business cutesptutdence, and pmoedmc manuals. Make! Demand/Work linimnment: Banana? and reasonable- may nude to enable individual with disabilities to pettimn casein-uni functions. (m Requirements/Cul?iemiality: limpbyee must adhere to the Health Insurance and Accountabilio Act (HIPPA). AM ?0 "Oil-.2011 Group ?01le i I C. Policies and Perform other duties that may be mm In the supemsor, Director oi?Operations. and 3 \m?ntit'ex?CEO. Ethics and Compliance: Horizon Group ?cute 2 i t? (?ode of Ethics ex needed to prevent. and correct violations of WM ?1133 311d POlik?is?s employees. The slates of the Code of lithies include a continuum no its: dignity. well-being, aw: self xi members served. Statl?ot?NHGH will titanium? the lunacy. con?dentiallt) it?si? tights of member-.1: vc?wx?l. New Horizon Group Home 1 t? seeks to 1111?va emp?fm eVide?W?Mml services, treatment and asserts in a manner that :s respectful of the sud worth of eve-11V itniix-idual (and their {amides} mm a mental health than-isms New Horizon ?Hz-one Eionte. LLC holds cattplopees to certain summits ot?mtuhtct that require then: to use a clear set at wines which guide their decision-making pmess and was they approach consumes. No employee. toot 01? management t?s-?mm of New Horizon Gimp Home LLC has the authotiu to direct any other seahorse to act or do muthittg that violates conuwo? policies and procedures Neal, state. or federal Laos or regulations or the Ne Horizon Group Horne Whale. of Conduct. \exx Horizon Group Home will take prompt and action, to at.? imm?ng termination of man?umcnt, and ?ling taste or criminal charges leading to the adimiioatim in a wart of competent minority. t: lune read and understand the Licensed Fromm Job Description. I that from this point Mold 1 will be WW tior complying with these guidelines. Failure to comply may result in a action up and including tenninatiok ?he- - I 1 We Othcensed Date arenas ?ll/Ines :5 Mat} kw Mistrial Job Deacon?s? 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Add), -m'min April 15, 2018 Renewal April 30, 2019 .I alums!- ?Ll-Liming 7-K 2 .. ..- Charlene Ross IN COMMUNITY FACILITIES A FOR SATISFACTORY COURSE COMPLETION OF MEDICATION ADMINISTRATION FOR UNLICENSED PERSONNEL "av ?(qr in; hid-u" Certi?cate of Achievement INSTRUCTOR SHARON KNOTTSVan-'1Iu?lrlha J: I . I 31.1.1Ful?l? I. I Iftn?irnl .1.nme .51. . 1.3? 333.1 I kxux .thz..ux . 3 . x: I a . af?x-Kw. ?\ur?lfx. Uri . .. . 72-. .. 21m 2' 527;: i. NSIN NH NOHVHS HOLDOHLSNI uo1ueD pJeme k. ..A . :35: OJ. GELLNEISEIHJ SI NOLLEHJWOC) EISHHOC) 210:1 8102 6102 ?02 ?Jdv lemauag 30:1 NOLLVDIGHW mm?- 3?5.an .-. .4335. c. up. . . .Il.Va \rx Ara,? . thbuiuunwnmuu aw?vbmm?ar impEarmy>w??kf .. .. mug inn (UK, .. v.31). .. THIS CERTIFICATE IS PRESENTED TO Monty Little FOR Ul l" Ht MEDICATIUN IURL \l KT PERSONNEL IN \t I [[58 x. Apnl IS. 2018 INSTRUCTOR SHARON moms RN th Renewal Apnl 30. 2019 - a; w? 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(?L?mhun?b 22* . . 1-11- New Horizon, LLC 4989 Rock?sh Rd Raeford, NC 28376 Phone: (910) 848-1080 Fax: (910) 848-1819 RESIDENTIAL LEVEL IV QUALIFIED PROFESSIONAL JOB DESCRIPTION Provider Requirements: . New Horizon Group Home, LLC is certi?ed as a Critical Access Behavroral Healthcare Agency (CABHA) provider through NC Division of and is credentialed by .Sandhills Center and Eastpointe Managed Care Organizations. New Horizon Group Home also is nationally accredited by Commission on Accreditation of Rehabilitation Facilities (CARF). The agency meets all the prov1der quali?cations established by Division of Medical Assistance, Division of and the Managed Care Organizations (MCO). Residential Treatment Level IV is an intensive residential treatment facility that is a 24-hour residential facility which provides a structured living environment within a system of care approach for children or adolescents whose primary diagnosis is mental illness, some of whom may also have co-occurring diagnoses, and for whom removal from home is essential to facilitate treatment. The needs of the children/adolescents require more intensive treatment and supervision than would be available in a residential treatment facility offering only a staff secure setting. Minimum Staf?ng Requirements for the Facility: The minimum number of direct care staff required when children or adolescents are present and awake is as follows: Three direct care staffshall be present for up to six children or adolescents; Four direct care staff shall be present for seven, eight or nine children or adolescents; and Five direct care staff shall be present for 10, 11 or 12 children or adolescents. During child or adolescent sleep hours three direct care staff shall be present of which two shall be awake and the third may be asleep. 0 More direct care staff may be required in the facility based on the child or adolescent's individual needs as speci?ed in the treatment plan. Primary Purpose of the Position: New Horizon Group Home, LLC offers and relational support, behavioral modeling of interventions, and supervision to the consumer residing in the facility. These preplanned therapeutically. structured interventions occur as required and outlined in the consumer?s service plan Sta?? also monitor, treat, and assess the emotional, and behavioral needs of this population- and as51st With coordinating service needs. The Quali?ed Professional (QP) will provide individualized, intensive, and constant supervision and structure of daily living designed to minimize the occurrence of opposrtional behaVior, to ensure safety and maintain optimum level of functioning. The QP will work With the Licensed Professional team and all other facility staff to assist consumers in 111116311]ng Quali?ed Professional Job Description New Horizon, LLC Revised Edition 4?20-18 page '1 of 7. New Horizon, LLC 4989 Rock?sh Rd Raeford, NC 28376 Phone: (910) 848-1030 Fax: (910) 848-1819 maladaptive behaviors and develop more appropriate relationship skills. Duties are performed primarily in the residential facility but may also include other areas in the community. Accountability: . The Quali?ed Professional position is under the supervision and guidance of the Director of Operations and/or Clinical Director and is subject to a performance review and appraisal at least once per year. Requirements of the Quali?ed Professional Position: The Quali?ed Professional is a full-time employee with two years of direct consumer care experience. The Quali?ed Professional parameters: a shall perform clinical and administrative responsibilities a mininmm of 40 hours each week; and 75% shall occur when children or adolescents are awake and present in the facility. shall be available by telephone or page. A direct care staff shall be able to reach the facility within 30 minutes always. Quali?cations: "Quali?ed professional" means, within the system of care: an individual who holds a license, provisional license, certi?cate, registration, or permit issued by the governing board regulating a human service profession, except a registered nurse who is licensed to practice in the State of North Carolina by the North Carolina Board of Nursing who also has four years of full-time accumulated experience in with the population served; or a graduate of a college or university with a master?s degree in a human service freld one year of full-time, post?graduate degree accumulated experience with the population served, or a substance abuse professional who has one year of full-time, post-graduate degree accumulated supervised experience in alcoholism and drug abuse counseling; or a graduate of a college or university with a bachelor?s degree in a human service ?eld and has two years of full-time, post-bachelor?s degree accumulated experience with the population served, or a substance abuse professional who has two years of full?time, post- bachelor?s degree accumulated supervised experience in alcoholism and drug abuse counseling; or a graduate of a college or university with a bachelor?s degree in a ?eld other than human services and has four years of full?time, post?bachelor?s degree accumulated experience With the population served, or a substance abuse professional who has four years of full-time, post-bachelor?s degree accumulated supervised experience in alcoholism and drug abuse counseling. Quali?ed Professional Job Description New Horizon, LLC Revised Edition 4-20?18 pageZ or 7 New Horizon, LLC 4989 Rock?sh Rd Raeford, NC 28376 Phone: (910) 848-1080 Fax: (910) 848-1819 Provider Requirements and Supervision related to the service: The minimal requirements are (depending on the position): 0 a high school diploma or GED, associate degree with one year of experience, or a four-year degree in the human service ?eld, or a combination of experience, skills, and competencies that is equivalent, plus: 0 Skills and competencies of this service provider must be at a level that includes structured interventions in a contained setting to assist the consumer in acquiring control over acute behaviors. - Sex Offender Speci?c Service Provision: In addition to the above, when the consumer requires sex offender speci?c treatment, as outlined in their treatment plan, special training of the caregiver is required in all aspects of sex offender speci?c treatment. Implementation of therapeutic gains is to be the goal of the placement setting. AND 0 Supervision is provided by a Quali?ed Professional with sex offender speci?c treatment expertise is on-site per shift. Must meet requirements established by state personnel system or eqmvalent for Job classi?cations. Supervision provided by quali?ed personnel as stated in 10 NCAC 27G rules regarding Professionals and Paraprofessionals. Minimum direct care staff to children/adolescents of two direct care staff per six consumers always, including sleep hours. Special Knowledge, Skill, Physical Requirements, and Training: 0 Knowledge of State and Medicaid requirements as they relate to the provision of Residential Treatment services. 0 Expertise with Sex Offender techniques to provide service as well as supervise the staff in this subject matter. 0 General understanding of behavioral patterns and attitudes common in varying degrees with children/adolescents in the populations; Ability to deal patiently and fairly with staff, consumers, families, and others; Ability to maintain effective and ef?cient working relationships and present an atmosphere of teamwork; Consistently aware of health and safety needs for all consumers and staff; Demonstrate good oral, written, and documentation skills; Regular and predictable job attendance; Ability to accept and respond positively to change; Training/certi?cation in the following: . General Organization Orientation I Client?s Rights Quali?ed Professional. Job Description New Horizon, LLC Revised Edition 4-204 8 page 3 of '7 New Horizon, LLC 4989 Rock?sh Rd Raeford, NC 283 76 Phone: (910) 848-1080 Fax: (910) 848-1819 HIPPA Laws and Con?dentiality Person Centered Planning Person Centered Thinking Cultural Awareness Speci?c Population characteristics of consumers being served I Documentation requirements and skills . Crisis Intervention Incident Reporting I Supervision Techniques I Aid/Blood Borne Pathogens I NCI or equivalent Sex Offender training, if required to meet consumer?s needs Equipment Regularly Used: 0 Computer Phone Cell Phone Copier machine Fax machine Agency vehicle and personal vehicle Licenses or Certi?cations Required: 0 Sex Offender training, if indicated in the consumer?s treatment plan 0 Valid North Carolina Driver?s license, which is clear of violation re?ecting a poor driving record 0 Personal vehicle insurance as required Job Duties and Responsibilities: 1. Management ofthe day to day operations of the facility; Supervision of paraprofessionals regarding responsibilities related to the implementation of each child or adolescent's treatment plan; Participation in treatment planning meetings; and Provision of basic case management functions. Actively involved in program development, implementation, and service delivery. Coordinates the assessment and reassessment of the consumer?s clinical needs. Convening the Child and Family Team for person-centered planning. Assessing the child?s/adolescent?s needs for additional service needs. Completing the initial development and ongoing revision of the Person-Centered Plan and ensuring its implementation. 10. Consulting with identi?ed collateral contacts and natural supports and including their input in the person-centered planning process. 11. Ensuring linkage for any additional evaluations/assessments for the consumer. Quali?ed Professional Job Description New Horizon, LLC Revised Edition 4-20-18 page 4 of 7 New Horizon, LLC 4989 Rock?sh Rd Raeford, NC 28376 Phone: (910) 848-1080 Fax: (910) 848-1819 12. Monitoring the provision of services and supports, and documenting the status of the consumer?s progress and the effectiveness of the strategies and interventions outlined in the Person-Centered Plan. 13. Assisting with crisis interventions; 14. Collaborate with the Local Education Authority and other service providers as needed for the consumer?s service provision. 15. Provide interventions designed to reduce improve behavioral functioning, increase the consumer?s ability to cope with and relate to others, and promote recovery. 16. Ability to provide healthy and appropriate adult role models. 17. Administer medication as prescribed using safe medication administration practices. 18. Ability to document relevant and signi?cant observations regarding consumer behaviors as they relate to actualizing therapeutic and treatment plan goals. 19. Remain cognizant of consumer rights and con?dentiality always and during all interactions with the consumers. 20. Attend all mandatory trainings, in-service trainings, and other conferences that relate to assigned and direct care duties. 21. Responsible for the care and development of the consumers. Assist consumers in the development of self-help skills classroom activities, social skills, etiquette and social relationships, and other activities). 22. Transport consumers to appointments and other events as indicated on the activity list and/or the consumer?s treatment plan. 23. Maintain positive relationship in interpersonal dynamics which typically provoke rejection, hostility, anger, and avoidance. 24. Maintains composure in intense situations that may arise when grossly inappropriate behaviors occur and effectively calm consumer through verbal non-aggressive techniques or protective interventions. 25. Guides and instructs consumers toward accomplishment of goals within the consumer?s Person-Centered Plan. 26. Assess and monitor a consumer?s progress and stability. 27. Assist consumers with necessary treatment and service needs. 28. Providing education and support to consumers and families related to the of the mental health and other possible co-occurring diagnoses the consumer is experiencing. 29. Provide intensi?ed structure and supervision to consumers. 30. Maintain accurate and timely documentation of the services interventions and the outcomes relevant to the consumers treatment needs. 31. Attend and participate in scheduled administrative staff meetings. 32. Serve on internal agency committees such as I Cl' committees, etc. 3 lent and employee 33. Provide. special consultation in consumer and stakeholder satisfaction studies and other quality nnprovement activities. 34. Participate in scheduled and unscheduled clinical and administrative supervisions. Quali?ed Professional Job Description New Horizon, LLC Revised Edition 4-20?18 page 5 of 7 New llorimn. Lu: 4W9 MM Rd Mind. NC 11316 Hm, (Old) 14340.0 Fl: (Gill) It'll-l3? and enhance clinical skills "trough professional tending: and utterulence at recommended training events. 36. Other activities. rel-to to job title duties. Mini-U. Wits-n: The must have the ability to read and analyze/interpret journals. technical procedures, and covemnm regulations. the employee must have the ability to assess and develop the Person-Centered Plans and clloctiwl) both in writing and orally. Employee must also have the ability to write reports. business and moccdure manuals. The OP must be able to present informatim to mximts and their families. community support groups. other quali?ed professionals, and the public Lennon Skills: Employee must hate the in read. and interpret general business periodicals, professioml journals, lul'mltill, ur emernmentul regulations. iimploycc must also have the ability to write returns, prwedure manuals. Physical ortt nt Equitable and JL wmnu ~.l.tl:Htl- rim he nude In enable individual with disabilities to perform essential l?mtt?llutts Other Requirements? Employee must adhere lu [munmte and Accountability Act (HIPPA). Adhere to Net-t lloriwn tiruup llumc. Policies .utd Procedures. Perform other duties that may be 838in b) the supcnisor. Diteemr at .tnd or l~ \ec?utitelCliU. Ethics and Compliance: Neu Horizon (iruup Home, Code of lithies is intended to prevent, detect, and correct violations of the law. rules, and policies by employees. [he core values of the Code of Ethics include a commitment to the dignity. well-being and sell-determination of the members served. Staff of NHGH will maintain the privacy. con?dentiality and rights served. New Horizon Group Home, LLC seeks to provide competent evidence-based services, treatment and supports in a manner that is respectful of the dignity and worth of every individual (and their families) with a mental health diagnosis. New Horizon Group Home, LLC holds employees to certain standards of conduct that require them to use a clear set of values which guide their decision-making process and way they approach consumers. No employee, supervisor or management person of New Horizon Group Home, LLC has the authority to direct any other employee to act or do anything that violates company P011016 and WIRES. local. state. or federal laws or regulations or the New Horizon Group Home Standards of Conduct. New Horizon Group Home will take prompt and complete action, up to and Quali?ed Professional Job Description New Horizon, LLC Revised Edition 4-20-18 page. 6 of 7 New Horizon, LLC 4989 Rock?sh Rd Raeford, NC 28376 Phone: (910) 848?1080 Fax: (910) 848-1319 including termination of employment, and ?ling of civil or criminal charges leading to the adjudication by a court of competent authority. Agreement: I have read and understand the Quali?ed Professional Job Description. I understand that from this point forward I will be responsible for complying with these guidelines. Failure to comply may result in a disciplinary action up to and including termination. WMQ Wigs ,p Signature of uali?ed Professional Date a 7 . 11/. 0 ?&i7gnature #Xis/A? Day! Quali?ed Professional Job Description New Horizon,_LLC Revised Edition 4?20-1 8 page 7 of 7 I 53333333233333: response 355:3 f3): (33333333331 133533733303? (73333. I?m tin n. (13:13 1-17 154.5 333335.333 3: {333 "333533333 3333331333 333:![ 32333333133332 M. - MM. m. .. hm". f3 3 L333{333.3 ?z?i?ffecf 331T 38333333333333.3333 ?33? swig/3373233033 333331315 gz3g3f3?cd 30 33333313 {3 "3 3 [33333333333330335 3' ?33333 333333333333 3 3335 3 33-3233? 33+ ?53333333333ro?0333333333 33313337353333733333'33333333 ?a 7}?333133?33331?33333?33 333333333333 5333: 3 v" 33333533333 33?: 333333333! 3372-33 33353333332333? $335333: 33333? 5?3 533533 S33 333337313 3 Tmm?r 53333233133333?? 5 (1333333333333 33;. va 1331 through has er! Expiration Date hi' "Vf'z ?137,3 1? 3 :yifr/j New Horizons, LLC Policy No.: P-1 Page 1 of 5 Effective Date: 01/01/09 Subject: Personnel Revised Date: 07/08/15; 09/01/15; 4/30/18 Policy New Horizons, LLC employs and retains qualified personnel. Procedures 1. The agency complies with all EEO and ADA requirements. The agency hires and maintains the most qualified person for a position and does not discriminate against race, gender, disability, ethnicity, nation of origin, sexual orientation, or religion. 2. Employees/Contractors meet all requirements specified in rules and regulations governing MH/DD/SA Services. Employees/Contractors are currently licensed, registered or certified in accordance with applicable state laws for the services provided and meet basic requirements for respective positions as outlined in the job descriptions, rules and regulations and personnel policies. 3. Employees/Contractors or any other person who provides services to consumers on behalf of New Horizons, LLC: a. are at least eighteen years of age; b. are able to read, write, and understand and follow directions; c. meet the minimum level of education, competency, work experience, skills, and other qualifications for the position; and d. has no substantiated findings of abuse or neglect listed on the N.C. Health Care Personnel Registry. 4. All applicants for employment or volunteer must disclose any criminal convictions and prior to hiring sign a release for information to be obtained. Criminal background and Health Care Registry checks are conducted on all new employees, contractors, and volunteers. Updates are conducted “for cause” and/or per request of the CEO whenever there is an indication of possible changes. a. Applicants who have been a resident of North Carolina for less than five years must have a State and National criminal history check. National criminal history record checks include a check of the applicant’s fingerprints. b. Applicants who have been a resident of North Carolina for five years or more have a State criminal history check. c. All criminal history information received by New Horizons, LLC is confidential and may not be disclosed, except to the applicant under the New Horizons, LLC Policy No.: P-1 Page 2 of 5 Effective Date: 01/01/09 Subject: Personnel Revised Date: 07/08/15; 09/01/15; 4/30/18 following condition: If New Horizons, LLC disqualifies an applicant after consideration of the relevant factors, the agency may disclose information contained in the criminal history record check that is relevant to the disqualification but may not provide a copy of the criminal history record check to the applicant. d. The fact of a conviction of a relevant offense alone does not bar employment; however, factors are considered by New Horizons, LLC. If an applicant’s criminal history record check reveals one or more convictions of a relevant offense, New Horizons, LLC considers all of the following factors in determining whether to hire the applicant: • level and seriousness of the crime; • date of the crime; • age of the person at the time of the conviction; • circumstances surrounding the commission of the crime, if known; • criminal conduct of the person and the job duties of the position to be filled; • prison, jail, probation, parole, rehabilitation, and employment records of the person since the date the crime was committed; and • subsequent commission by the person of a relevant offense. e. New Horizon, LLC may employ an applicant conditionally prior to obtaining the results of a criminal history record check regarding the applicant if the following conditions are met: • New Horizons, LLC does not employ an applicant prior to obtaining the applicant’s consent for criminal history record check or the completed fingerprint cards as required in G.S. 114-19.10 and the request for the criminal history record check must be within five business days of the offer of conditional employment. • The employee/contractor is not allowed to be alone with consumers. f. New Horizon, LLC does not fingerprint nor require staff/personnel to be fingerprinted. 5. A written job description is developed for all employees, which: a. specifies the minimum level of education, competency, work experience, and other qualifications for the position; b. specifies the duties and responsibilities of the position; and c. is signed by the employee/contractor and the supervisor. 6. Personnel files are the property of New Horizons, LLC. All personnel records are maintained in a designated, locked file cabinet and access is only by the CEO or designee. Employees/Contractors who want to review their files must arrange review with the CEO and only have access to allowed information. New Horizons, LLC Policy No.: P-1 Page 3 of 5 Effective Date: 01/01/09 Subject: Personnel Revised Date: 07/08/15; 09/01/15; 4/30/18 7. A file is maintained on each employee/contractor that includes: a. application for employment; b. signed job description that identifies the required educational, licensure credentials, and other qualifications for the job; c. in-service training; d. verification of experience, credentials, and other qualifications for the position, including transcripts, and current licensure/registration/ certification; e. the results from the criminal background checks, driving and Health Care Registry checks, and verification that sanctions from professional boards and/or health care registry have been reviewed; f. clinical supervision and documentation of clinical supervision plans and activities, when supervision is required; g. performance evaluations (at least annually); h. evidence of orientation; and i. verification of current automobile insurance coverage. 8. All continuing education relevant to employment is documented. 9. At least one staff person is available at all times that is trained in basic first aid including seizure management, currently trained to provide cardiopulmonary resuscitation and trained in the Heimlich maneuver or other first aid techniques such as those provided by Red Cross, the American Heart Association or their equivalence for relieving airway obstruction. 10. When an employee/contractor is unable to work as scheduled, he/she informs the supervisor in order for coverage to be arranged if needed. a. The supervisor takes into account all available staff, their primary responsibilities, and any special circumstances in filling absences. b. Every effort is made to assure that staff who act as back-up are trained to the specifications required for the consumer for whom they are providing services, including any specific training. 11. New Horizons, LLC ensures that back up staff is available when the lack of immediate care would pose a serious threat to the consumer’s health and welfare and formal providers are unavailable. New Horizons, LLC documents who provides services in the absence of the direct service employee/contractor. Credentials New Horizons, LLC Policy No.: P-1 Page 4 of 5 Effective Date: 01/01/09 Subject: Personnel Revised Date: 07/08/15; 09/01/15; 4/30/18 The employee/contractor is responsible for providing information in order for verification of credentials and maintaining current copies of any license, registration or certification. The employee/contractor must provide initial verification from the primary source, e.g. an original educational transcripts or verification of school/degree completion, prior to hire or when obtained. In the event a potential staff member holds a license from a state other than North Carolina New Horizon will follow the standards set for the specific licensure board as well as all state and federal guidelines. The CEO will contact the primary source if there is any question or concern about authenticity. The CEO or designee verifies license/certifications directly by contacting the granting organization. In the event credentials cannot be verified, the person is not employed. Grievance Employees may file a grievance or appeal personnel actions taken to the CEO. The grievance or appeal must be in written format with specific information noted to assist the CEO in the investigation. The CEO provides written response to the employee within 15 working days of receipt of the report noting actions taken on the grievance/appeal. The CEO has final decision. Dismissal Persons are employed “at will” by the CEO. An employee and/or contractor may be dismissed from the agency by the CEO for just cause, e.g. subjecting the persons served to harm or fraudulent documentation. The CEO may contact the agency’s attorney to obtain legal clarification prior to dismissal. Dismissal by the CEO is not appealable. Performance Evaluations Performance evaluations for all personnel are conducted at least annually that are: 1. Based on job functions and competencies identified; 2. Evident in personnel files; 3. Conducted in collaboration with the immediate supervisor with evidence of input from the personnel being evaluated; and 4. Used to assess performance related to objectives established in the last evaluation period and establish objectives for the next year. Hiring, Promotions and Work Assignment The CEO is responsible for recruitment and hiring of staff members. Vacant positions are shared during staff meetings and filled internally if staff is qualified. Applications are received and screened for appropriate credentials/requirements New Horizons, LLC Policy No.: P-1 Page 5 of 5 Effective Date: 01/01/09 Subject: Personnel Revised Date: 07/08/15; 09/01/15; 4/30/18 and experience by the CEO. The CEO selects the qualified candidates who are interviewed by the CEO and others as requested by the CEO and the position is offered to the most qualified candidate. Monetary compensation is based on the local market and qualifications/experience of the employee and/or representative. Work assignments are based on the service definitions requirements, expertise of the employee/contractor and needs of the persons served. New employees/contractors are not provided a full workload until the supervisor reports that the employee/contractor is capable of providing qualified work to more persons. At no time does the workload exceed state requirements. The CEO makes promotions based on the employee and/or representative attaining the experience/training required in the job description, e.g. Associate Professional being moved to a Qualified Professional. New Horizon Group Home, LLC Service: Intensive In-Home/Personnel Requirement: 1. Job application indicating Disclosure of Criminal convictions 2. References verifying past employment with population 3. Copy of highest degree earned 4. College transcript for QP 5. Job description with all of the service required elements 6. Orientation 7. Training on meeting the consumer’s MH/DD/SAS needs (training on diagnosis/review of PCP goals and strategies, etc) 8. Client Rights 9. Confidentiality 10. Blood Borne Pathogens 11. CPR 12. 1st Aid 13. Med Adm 14. NCI or CPI 15. Criminal background checks (including DMV) (if lived outside of NC within the past 5 years – need national)-prior to hire 16. N C Health Care Registry – prior to hire 17. Meets the competency level for the position: Licensed or Provisionally Licensed with one year child mh/dd/sas Qualified Professional with two years exp child mh/dd/sas At least AP level with one year exp child mh/dd/sas Review Review Review 18. Supervision Plan 19. Supervision documentation per plan 20. Copy of license: professional, if applicable 21. Drivers license 22. PPD Service required training within timelines: All staff: 30 days 23. 3 hrs Intensive In-Home service definition 24. 3 hrs Crisis Response Team Lead & QP: 30 days 25. PCP Instructional Elements Team Leads: 90 days or 3-31-11 26. 13 hrs Motivational Interviewing 27. 12 hrs Person Centered Thinking 28. 11 hrs SOC Team staff: 90 days 29. 13 hrs Motivational Interviewing 30. 12 hrs Person Centered Thinking 31. 11 hrs SOC All staff 32. CBT Training: To ensure the core fundamental elements of training specific to the modality** selected by the agency for the provision of services are implemented a minimum of 24 hours of the selected modality must be completed. Team Leads and/or supervisory level 33. All supervisory level training required by the developer of the designated therapy, practice or model with a minimum of 12 hours must be completed. All staff annually 34. Follow up training and ongoing continuing education required for fidelity to chosen modality** (If no requirements are designated by developers of that modality, a minimum of 10 hours of continuing education in components of the selected modality must be completed.). 10 hrs CBT Model Approval Rate: Comments on back side Rev 3-11-17 Attachment #1 NEW HORIZON GROUP HOME Orientation Checklist Employee Name _______________________ Hire Date__________________ COMPLETED Initials- Employee/Designated Agency Staff DATE ***Warning: no staff person can be put onto a shift schedule until having completed NCI/CPI and Medication Administration, Client Rights, Confidentiality, Documentation training. Prior to First Day ***Warning: the below paperwork items MUST be completed prior to hire offer! No potential employees can be offered a job without CEO having received evidence the prior to hire paperwork has been completed. ***A copy of this form, reflecting the prior to hire paperwork completion, must be forwarded to the CEO/Owner prior to job offer ***The Criminal Background Check must be requested at least five business days prior to the offer of conditional employment. Administra tive Assistant I. Paperwork Complete Criminal re cord check NC Health Care Registry NCI or CPI DMV report _______________ _______________ _______________ _______________ _______________ ___________ ___________ ___________ ___________ ___________ _______________ ____________ NH Policy Manual ______________ ____________ Review Personnel Policy Manual ______________ ____________ Sexual harassment _______________ ____________ Ethics _______________ ____________ Cultural Diversity _______________ ____________ Review Confidentiality Manual _______________ ____________ Review Client Rights Manual _______________ ____________ Documentation Manual _______________ ____________ NCTOPPS _______________ ____________ First Day of Work Quality Management Director Mission, Values, Vision statement Review Records Management and Administra tive Assistant Workers Comp. Procedures ________________ ____________ Hours of operation ________________ ____________ Lunch breaks ________________ ____________ Signing in/out ________________ ____________ No overtime (unless given permission) ________________ ____________ Holiday Schedule ________________ ____________ Travel/reimbursement for appointed staff ________________ ____________ Reporting sick or leave to personnel ________________ ____________ Transportation (car/vehicle logs/care) ________________ ____________ Mileage reports ________________ ____________ Use of center vehicles _________________ ____________ Use of seat belts _________________ ____________ Transportation adaptive equipment _________________ ____________ Emergency situation preparation _________________ ____________ Emergency information on vehicles _________________ ____________ Tour facility/introductions _______________ ___________ Discuss work areas _______________ ___________ Emergency Operations Plan _______________ __________ Adverse Weather _______________ __________ Fire Extinguishers _______________ __________ Fire drills _______________ __________ Evacuation Route _______________ __________ Written Fire Plan _______________ __________ Area Wide Disaster Pla n _______________ __________ Health & Safety Plan _______________ __________ Location of fuse/breaker panels _______________ ___________ Maintena nce Concerns _______________ ___________ Cleaning Concerns _______________ ___________ Location of first aid kits _______________ ___________ Provide copy of tra nsportation _______________ ___________ log Receive Ke y to Facility _______________ ___________ Location of cabinets for vehicles _______________ ___________ ______________ ___________ Team mobile phone #’s and use ______________ ___________ Open door management (chain of command) _______________ ____________ keys NH employee contact info & Agency phone numbers/fax Personal phone use Dress Code _______________ ____________ Drug Free environment _______________ ____________ Resignation _______________ ____________ Supervisor/Clinical Director Review job description Develop Supervision contract ______________ ________________ ___________ _____________ -Monthly supervisions ________________ _____________ -Discuss employee evaluation ________________ _____________ Review service notes/documentation ________________ _____________ Documentation in medical records ________________ _____________ Training in meeting the MH/DD/SAS needs of the consumer(s) based on diagnosis ______________ ____________ Review Service Definition/Policy ________________ _____________ On-call schedule (if applicable) ____________ ___________ ________________ ______________ Second Day of Work process Administrative Assistant Review appropriate Systems Protocols Third Day Training by licensed/certified contract trainer CPR First Aid Bloodborne Pathoge ns/OSHA _____________ _____________ _____________ ___________ ___________ ___________ _____________ ___________ Fourth Day Medication Administration Fifth Day Quality Management Director Review of Incident Reporting Policy and forms ________________ _____________ Review of DMH rule (computer) ________________ _____________ Review of Quality Improvement Policy ________________ _____________ Review of current QI Plan ________________ _____________ Review process request for training and cost ________________ _____________ Individual Training Plan Development ________________ _____________ Training Director Sixth Day Supervisor Introduction to Team ________________ _____________ Shadowing ________________ _____________ Over the next few weeks Supervisor and/or Clinical Director Shadowing ________________ _____________ 45 Days after hire date Training Director Monitoring of training ________________ _____________ _______________ _____________ ______________ ______________ Supervisor -Mid probation evaluation 90 Days after hire date Training Director Evaluate training performance Supervisor End of probation evaluation Key: NH = New Horizon Revised 4-29-2018 ______________ _______________ NEW HORIZON GROUP HOME, LLC RESIDENTIAL SERVICES LEVEL IV CEO MEDICAL DIRECTOR CLINICAL DIRECTOR SENIOR TEAM LEADER/QUALIFIED PROFESSIONAL SHIFT TEAM LEADER HAB SPEC HAB SPEC QUALITY MANAGEMENT/ TRAINING DIRECTOR SHIFT TEAM LEADER SHIFT TEAM LEADER HAB SPEC HAB SPEC HAB SPEC HAB SPEC HAB SPEC HAB SPEC HAB SPEC All Qualified Professionals to meet the needs of the consumers, including but not limited to, Psychologists, Psychiatrists, Social Workers, Medical Professionals, Educational and/or Vocational Licensed persons, etc will be via contract. All services will be conducted in a manner that is fully integrated into ongoing treatment and driven by the consumer’s treatment plan. New Horizons, LLC Subject: Residential Treatment Level IV/Secure Policy No.: S-10 B Page 1 of 10 Effective Date: 05-30-17 Revised Date: 5-02-18 Program Description Residential Treatment Level IV is an intensive residential treatment facility that is a 24-hour residential facility which provides a structured living environment within a system of care approach for children or adolescents whose primary diagnosis is mental illness, severe emotional and behavioral disorders, or substance-related disorders; and may also have co-occurring disorders including developmental disabilities. The needs of the children/adolescents require more intensive treatment and supervision than would be available in a residential treatment facility offering only a staff secure setting. These consumers shall not meet the criteria for acute inpatient psychiatric services and require the following: • Removal from home to an intensive integrated treatment setting; and • Treatment in a locked setting. Services shall be designed to: • Assist in the development of symptom and behavior management skills; • Include intensive, frequent, and pre-planned crisis management; • Provide containment and safety from potentially harmful or destructive behaviors; • Promote involvement in regular productive activity, such as school or work; and • Support the consumer in gaining the skills needed for reintegration into community living. The intensive residential treatment facility shall coordinate with other individuals and agencies within the consumer’s system of care. For Medicaid, the Residential Treatment-Secure is a service targeted to children under age 21, which offers a physically secure, locked environment in a highly structured and supervised program setting only, excluding room and board. If a consumer has his 18th birthday while receiving treatment in the facility, he may remain for six months or until the end of the state fiscal year, whichever is longer. For NC Health Choice, the Residential Treatment-Secure is a service targeted to children under age 18, which offers a physically secure, locked environment in a highly structured and supervised program setting only, excluding room and board. This service is responsive to the need for intensive, active therapeutic intervention, which requires a secure treatment setting to be successfully implemented. This service provides the following activities under its core program: 1 New Horizons, LLC Subject: Residential Treatment Level IV/Secure • • • Policy No.: S-10 B Page 2 of 10 Effective Date: 05-30-17 Revised Date: 5-02-18 Medically supervised secure treatment interventions, which may include time-out room, passive restraints, etc. Structured programming/intervention to assist the consumer in acquiring control over acute behaviors, verbal aggression, depression, PTSD (post-traumatic stress disorder), etc. On-site consultation and supervision by psychologist or psychiatrists. Provider Requirements and Supervision: The minimal requirements are: • a high school diploma or GED, associate degree with one year of experience, or • a four-year degree in the human service field, or • a combination of experience, skills, and competencies that is equivalent, plus: • Skills and competencies of this service provider must be at a level that includes structured interventions in a contained setting to assist the consumer in acquiring control over acute behaviors. • Sex Offender Specific Service Provision: In addition to the above, when the consumer requires sex offender specific treatment, as outlined in their treatment plan, special training of the caregiver is required in all aspects of sex offender specific treatment. Implementation of therapeutic gains is to be the goal of the placement setting. AND • Supervision is provided by a Qualified Professional with sex offender specific treatment expertise is on-site per shift. • Must meet requirements established by state personnel system or equivalent for job classifications. Supervision provided by a qualified personnel as stated in 10 NCAC 27G rules regarding Professionals and Paraprofessionals. Staffing Requirements: Direct Care Staffing: Residential Treatment Level IV requires a minimum of three direct care staff per six consumers; four direct care per seven, eight, or nine consumers; and five direct care staff per ten, eleven, or twelve consumers, at all times. During consumer sleep hours, three direct care staff shall be present of which two shall be awake and the third may be asleep. In addition to the minimum number of direct care staff, more direct care staff may be required in the facility based on the consumer’s individual needs as specified in the treatment plan. 2 New Horizons, LLC Subject: Residential Treatment Level IV/Secure Policy No.: S-10 B Page 3 of 10 Effective Date: 05-30-17 Revised Date: 5-02-18 Qualified Professional: At least one full-time qualified professional, having at least two years of direct consumer care experience shall be employed to perform clinical and administrative responsibilities at a minimum of 40 hours each week; and 75% shall occur when consumers are awake and present in the facility. A Qualified Professional shall be available by telephone or page and shall be able to reach the facility within 30 minutes always. The Qualified Professional is responsible for a minimum of the following: • Management of the day to day operations of the facility; • Supervision of paraprofessionals regarding responsibilities related to the implementation of each consumer’s treatment plan; • Participation in the treatment planning meetings; and • Provision of basic case management functions. Licensed Professional: At least a full-time licensed professional, either fully licensed or provisional license issued by the governing board regulating a human service profession in NC. For substance related disorders this shall include a Licensed Clinical Addiction Specialist or a Certified Clinical Supervisor. The Licensed Professional is responsible for minimum the clinical and administrative responsibilities of the following: • Supervision of direct care staff; • Oversight of emergencies; • Provision of direct clinical psychoeducational services to the consumers or families; • Participation in treatment planning meetings; and • Coordination of each consumer’s treatment plan. Educational Services: Educational services within the facility shall be arranged and designed to maintain the educational and intellectual development of the consumer. Treatment staff shall coordinate with the local education agency to ensure that the consumer needs are met as identified in the education plan. An Educational Plan (IEP) shall be developed for each of the consumers coordinated by the contract Education Service staff person and the local education agency. This setting has a higher level of consultative and direct service from Licensed Qualified Professionals. Psychiatric consultation shall be available as needed for each consumer. Other licensed and/or certified professionals who may be involved with the service provision, depending on the consumer’s needs include but not limited to: Psychologists, Social Workers, Medical Professionals, Educational and/or Vocational Licensed persons, etc. All relevant licensed services, except for the full-time Licensed Professional (LPC, in the context of the 3 New Horizons, LLC Subject: Residential Treatment Level IV/Secure Policy No.: S-10 B Page 4 of 10 Effective Date: 05-30-17 Revised Date: 5-02-18 residential treatment with meeting the needs of the consumers will be via an agency contract position rather than job description. All services will be conducted in a manner that is fully integrated into ongoing treatment and driven by the consumer’s treatment plan. Service Type/Setting: Residential Treatment Level IV is a 24-hour service operating 24 hours per day, seven days per week, and each day of the year. It is provided in a facility program type setting. This service is billable to Medicaid. This service is licensed under 122-C. Program type (27G. 1800 Residential Treatment Secure). Each facility shall serve no more than 12 consumers. Each consumer shall be entitled to age-appropriate personal belongings unless such entitlement is counter-indicated in the treatment plan. Family members or other legally responsible persons shall be involved in development of plans to assure a smooth transition to a less restrictive setting. Program Requirements: Therapeutic Relationship/Cognitive/Behavioral Skill Acquisition: Residential Treatment Level IV service provides school, psychological and psychiatric consultation, nurse practitioner, vocational training, recreational activity, and other relevant services in the context of the residential treatment. The treatment needs of the consumers are usually so extreme that these activities can only be provided in a therapeutic setting. As a result, the number of on-site interventions from qualified professionals, including psychologists and physicians are notably higher than less restrictive residential settings. Through the intensive therapeutic focus, the consumers are taught and assisted with acquiring management skills relevant to their specific disability symptoms. All services are conducted in a manner that is fully integrated into ongoing treatment. Structure of Daily Living/ Program Type: The service is provided in a structured program setting and staff is present and available always with constant supervision, including staff awake during consumer sleep hours. A minimum of two direct care staff is required per six beneficiaries always. In addition, consultative and treatment services at a qualified professional level are provided no less than eight hours per child per week. This staff time may be contributed by various qualified professional individuals with examples of: a social worker conducting group treatment or activity; behavioral management consultation being provided by a psychologist; or, a psychiatrist providing evaluation and treatment services. These services must be provided at the residential facility. Group therapy or activity time may be included as the total time per beneficiary. For example: if there are six consumers in a group for 90 minutes, this may be counted as 90 minutes per consumer. However, periodic services may not be used to augment residential services. 4 New Horizons, LLC Subject: Residential Treatment Level IV/Secure Policy No.: S-10 B Page 5 of 10 Effective Date: 05-30-17 Revised Date: 5-02-18 This service includes all Family/Program Residential Treatment - High Level III elements along with activities relevant to Residential Treatment Level IV. An inclusive listing of all Level III and Level IV activities is provided below: 1. Medically supervised secure structured therapeutic treatment environment including intensive and frequent crisis management with or without physical restraints and containment in time-out room designed to maximize the opportunity to improve and/or maintain the consumer’s optimum level of functioning. Locked and secure to ensure safety for consumers who are involved in a wide range of dangerous behaviors which are manageable outside of the hospital setting. 2. Immediate staff support/supervision providing person directed and managed activities in all identified need areas, mentoring, modeling, positive reinforcement, redirection, deescalation, guidance, etc., supervised recreational activities when used as a strategy to meet clinical goals, supervised community integration activities; and direct assistance with adaptive skills training. 3. Continual and intensive programmatic structure with specific interventions designed to address and assist the consumer in acquiring control over acute behavioral or substance use disorder treatment needs through supervised psychoeducational activities including the development and maintenance of daily living, anger management, social, family living, communication, and stress management skills, etc. 4. Consultation from psychiatrist/psychologist monthly. And 5. This service is to support the consumer in gaining the skills necessary to step down to a lower level of care. Therapeutic Leave: Each consumer is entitled to take up to 45 days of therapeutic leave in any calendar year (no more than 15 days within one calendar quarter-3 months). Each of the below components are relevant to the therapeutic leave: 1. No more than five consecutive days may be taken without the approval of the consumer’s treatment team. 2. The leave must be for therapeutic purposes only and must be agreed by the consumer’s treatment team. The necessity and the expectations for the leave must be documented in the consumer’s treatment plan and the therapeutic justification for each instance of the leave entered into the consumer’s record which is maintained at the Residential Facility site. 3. Therapeutic leave shall be defined as the absence of a consumer from the residential facility overnight, with the expectation of return, to participate in a medically acceptable therapeutic facility as agreed upon by the treatment team and documented in the treatment plan. 4. New Horizon Group Home will reserve the consumer’s bed while on therapeutic leave. 5 New Horizons, LLC Subject: Residential Treatment Level IV/Secure Policy No.: S-10 B Page 6 of 10 Effective Date: 05-30-17 Revised Date: 5-02-18 5. New Horizon Group Home will keep a cumulative record of therapeutic leave days taken by each consumer for reference and audit purposes. Consumers are considered on therapeutic leave according to the facility’s midnight census. 6. The official record of therapeutic leave days take for each consumer shall be maintained by the State or it’s agent. 7. Therapeutic leave is not applicable regarding cases when the therapeutic leave is for receiving inpatient services or any other Medicaid or NC Health Choice covered service or in another facility. Therapeutic leave cannot be paid when Medicaid or NC Health Choice is paying for any other 24-hour service. 8. Transportation from a facility to the therapeutic leave site is not considered to be an emergency; therefore, ambulance service for this purpose is not reimbursable. Prior Approval Requirements: For both Medicaid, State Funded, and NC Health Choice, the MCO/LME authorizes the admissions and completes concurrent utilization reviews. The admissions documentation and utilization reviews must be documented in the service record. Medical Necessity: A primary care physician, psychiatrist, or a licensed psychologist must order service. All service orders must be made prior to or on the day service is initiated, on the standardized service order form. Entrance Criteria: The consumer is eligible for this service when: Consumer is medically stable but may need significant intervention to comply with medical treatment. AND The consumer’s identified need cannot be met with Residential Treatment Level III service. AND The consumer is experiencing any one of the following (may be related to the presence of sever affective, cognitive, or behavioral problems or intellectuals/developmental delays/disabilities): a. Severe difficulty maintaining in the naturally available family setting or lower level of treatment as evidenced by, but not limited to: 1. Frequent and severe conflict in the setting; OR 2. Frequently and severely limited acceptance of behavioral expectations and other structure; OR 6 New Horizons, LLC Subject: Residential Treatment Level IV/Secure b. c. d. e. f. g. Policy No.: S-10 B Page 7 of 10 Effective Date: 05-30-17 Revised Date: 5-02-18 3. Frequently and severely limited involvement in support or impaired ability to form trusting relationships, with caretakers; OR 4. A pervasive and severe inability to form trusting relationships with caretakers or family members; OR 5. An inability to consider the effect of inappropriate personal conduct on others. Frequent physical aggression including severe property damage or moderate to severe aggression toward self or others. Severe functional problems in school or vocational setting or other community setting as evidence by: 1. Failure in school or vocational setting because of frequent and severely disruptive behavioral problems in school or vocational setting; OR 2. Frequent and severely disruptive difficulty in maintaining appropriate conduct in community settings; OR 3. Severe and pervasive inability to accept age appropriate direction and supervision from caretakers or family members couple with involvement in potentially lifethreatening high-risk behaviors. Medication administration and monitoring has alleviated some symptoms, but other treatment interventions are needed to control severe symptoms. Experiences significant limitations in ability to independently access or participate in other human services and requires intensive, active support and supervision to stay involved in other services. Has significant deficits in ability to manage personal health, welfare, and safety without intense support and supervision. For consumers identified with or at risk for inappropriate sexual behavior; 1. The parent/caregiver is unable to provide the supervision of the sex offender required for community safety. 2. Moderate to high risk for re-offending. 3. Moderate to high risk for sexually victimizing others. 4. Deficits that put the community at risk for victimization unless specifically treated for sexual aggression problems. 5. A Sex Offender Specific Evaluation (SOSE) shall be provided by a trained professional and a level of risk shall be established (low, moderate, high) using the Risk Checklist for Sexual Offenders, the Juvenile Sexual Offender Decision Criteria, and a Checklist for Risk Assessment of Adolescent Sex Offenders. Continued Stay Criteria: The desired outcome or level of functioning has not been restored, improved, or sustained over the period outlined in the consumer’s service plan or the consumer continues to be at risk for 7 New Horizons, LLC Subject: Residential Treatment Level IV/Secure Policy No.: S-10 B Page 8 of 10 Effective Date: 05-30-17 Revised Date: 5-02-18 relapse based on history or the weak nature of the functional gains, or any one of the following apply: a. Consumer has achieved initial service plan goals and additional goals are indicated. b. Consumer is making satisfactory progress toward meeting goals. c. Consumer is making some progress, but the service plan (specific interventions) needs to be modified so that greater gains which are consistent with the consumer’s pre-morbid level of functioning, are possible or can be achieved. d. Consumer is not making progress; the service plan must be modified to identify more effective interventions. e. Consumer is regressing; the service plan must be modified to identify more effective interventions. AND The statewide vendor authorizes admission and conducts concurrent utilization reviews. Utilization review must be documented in the service record. Discharge Criteria: The consumer shall be discharged from this level of care if any one of the following is true: a. The level of functioning has improved with respect to the goals outlined in the service plan and the consumer can reasonably be expected to maintain these gains at a lower level of treatment. OR b. The consumer no longer benefits from service as evidenced by absence of progress toward service plan goals and more appropriate service(s) is available. OR c. Discharge or step-down services can be considered when in a less restrictive environment the safety of the consumer around sexual behavior and the safety of the community can reasonably be assured. Any denial, reduction, suspension, or termination of services requires notification to the consumer and legal guardian about their appeal rights. Emergency Discharge Criteria: A consumer shall not be discharged or transferred from the facility, except in case of emergency, without the advance written notification of the treatment team, including the legally responsible person. The facility shall meet with existing child and family teams or other involved persons including the parent(s) or legal guardian, area authority or county program representative(s) and other 8 New Horizons, LLC Subject: Residential Treatment Level IV/Secure Policy No.: S-10 B Page 9 of 10 Effective Date: 05-30-17 Revised Date: 5-02-18 representatives involved in the care and treatment of the child or adolescent, including local Department of Social Services, Local Education Agency and criminal justice agency, to make service planning decisions prior to the transfer or discharge of the child or adolescent from the facility. In case of an emergency, the facility shall notify the treatment team including the legally responsible person of the transfer or discharge of the child or adolescent as soon as the emergency is stabilized. In case of an emergency, notification may be by telephone. A service planning meeting as set forth in shall be held within five business days of an emergency transfer or discharge. Service Maintenance Criteria: If the consumer is functioning effectively at this level of treatment and discharge would otherwise be indicated, this level of service shall be maintained when it can be reasonable anticipated that regression is likely to occur if the service were to be withdrawn. This decision should be based on at least one of the following: a. There is history of regression in the absence of residential treatment or a lower level of residential treatment. b. There are current indications that the consumer requires this residential service to maintain level of functioning as evidenced by difficulties experienced on therapeutic visits or stays in a non-treatment residential setting or in a lower level of residential treatment. c. In the event there are epidemiologically sound expectations that symptoms will persist and that ongoing treatment interventions are needed to sustain functional gains the presence of a DSM-5, or any subsequent editions of this reference material, diagnosis would necessitate a disability management approach. Expected Outcomes: This service includes interventions that address the functional problems associated with complex and/or complicated conditions of the identified population. These interventions are strength based and focused on promoting symptom stability, increasing coping skills and achievement of the highest level of functioning in the community. Documentation Requirements: Documentation in the consumer’s medical record is required as defined in the Service Records Manual APSM 45-2. The minimum documentation standard is a full service note per shift on the standardized service note form. The documentation of interventions and activities is directly related to the consumer’s: a. Identified needs, b. Preferences or choices, 9 New Horizons, LLC Subject: Residential Treatment Level IV/Secure Policy No.: S-10 B Page 10 of 10 Effective Date: 05-30-17 Revised Date: 5-02-18 c. Specific goals, services, and interventions, and d. Frequency of the service which assists in restoring, improving, or maintaining their level of functioning. e. Documentation of critical events, significant events or changes in status during treatment shall be evidenced in the consumer’s medical record as appropriate. f. Sex Offender Specific Service Provision: Documentation includes the specific goals of sex offender treatment as supported and carried out through the therapeutic setting and interventions outlined in the service plan. Service Exclusions: Residential Treatment Level IV does not include and cannot be provided during the same authorization period as the following: • Activities provided by Medicaid or Health Choice funded residential programs: acute hospitalization programs: acute hospitalization, ICF-MR, rehabilitation facilities, and nursing facilities for medically fragile children, etc. • Child care facilities which cannot meet mental health licensure and standards. • Foster care • Run-away shelters • Respite providers • Summer recreation camps • Periodic services may not be used to augment residential services. 10 New Horizons, LLC Subject: Restrictive Interventions Policy No.: C-11 Page 1 of 6 Effective Date: 01/01/09 Revised Date: 2/5/13; 7/24/15; 2/28/18 Policy All treatment and habilitation are provided to consumers using the least restrictive, most appropriate, and effective positive treatment modalities possible. Restrictive interventions are not employed as a means of coercion, punishment, or retaliation by staff or for the convenience of staff or due to inadequacy of staffing. Restrictive interventions are not used in a manner that causes harm or abuse. Restrictive intervention is employed as the last resort and will only be employed if the consumer is in immediate danger of harming self or others. The only permitted restrictive intervention allowed by staff of New Horizons, LLC is relevant to the residential services. The following outlines the permitted restraints for each residential level: • Residential Level III: physical restraint will only be employed if the consumer is in immediate danger of harming self or others; • Residential Level IV: physical restraint will only be employed if the consumer is in immediate danger of harming self or others. Time-out and Isolation is not used as a behavior modification. Procedures 1. The Clinical Review Team reviews all Comprehensive Clinical Assessments of potential consumers being recommended for service. The review of the assessment includes appropriateness of the service as well as a review of the medical history to determine whether a possible emergency administered restraint can be completed without risk to the health and safety of the consumer. 2. All staff provide a positive environment that promotes adaptive behaviors. Positive alternatives and less restrictive interventions are considered and are used whenever possible prior to the use of more restrictive interventions. 3. The use of restrictive interventions is limited to: a. emergency situations, in order to terminate a behavior or action, in which a consumer is in imminent danger of abuse or injury to self or other persons or when substantial property damage is occurring that poses imminent danger of injury or harm to self or others. New Horizons, LLC Subject: Restrictive Interventions Policy No.: C-11 Page 1 of 6 Effective Date: 01/01/09 Revised Date: 2/5/13; 7/24/15; 2/28/18 4. All staff that provides direct care to consumers must successfully pass a DHHS approved alternative intervention curriculum prior to working alone with a consumer. 5. In the event a restrictive intervention is warranted to avoid injury, parameters have been established. The CEO or designee is responsible for reviewing the use of restrictive interventions and for ensuring all requirements are met and adhered. 6. Staff give consideration to the individual's physical and psychological wellbeing before, during and after utilization of a restrictive intervention, including: a. Review of the consumer’s health history or the comprehensive health assessment conducted upon admission to a service. The health history or comprehensive health assessment includes the identification of preexisting medical conditions or any disabilities and limitations that would place the consumer at greater risk during the use of restrictive interventions; b. Continuous assessment and monitoring of the physical and psychological well-being of the resident and the safe use of physical restraint throughout the duration of the restrictive intervention by a staff who is physically present and trained in the use of emergency safety interventions; c. Continuous monitoring by staff trained in the use of cardiopulmonary resuscitation of the individual’s physical and psychological well-being during the use of manual restraint; and d. Continued monitoring by staff trained in the use of cardiopulmonary resuscitation of the consumer’s physical and psychological well-being for a minimum of 30 minutes subsequent to the termination of a restrictive intervention. 7. Following the utilization of a restrictive intervention, the staff member who utilized the restrictive intervention conducts debriefing and planning with the individual and the legally responsible person, if applicable, to eliminate or reduce the probability of the future use of restrictive interventions. Debriefing and planning is conducted, as appropriate, to the level of cognitive functioning of the individual consumer. 8. It is the duty and responsibility of all staff to ensure the proper use and documentation of restrictive interventions. The staff member using the restrictive intervention has responsibility for its documentation and notification New Horizons, LLC Subject: Restrictive Interventions Policy No.: C-11 Page 1 of 6 Effective Date: 01/01/09 Revised Date: 2/5/13; 7/24/15; 2/28/18 of others that a restrictive intervention has been used. That staff member is also responsible for checking the consumer's physical and psychological wellbeing and assessing the possible consequences of the use of a restrictive intervention and, documentation if a consumer has a physical disability or has had surgery that would make affected nerves and bones sensitive to injury; and the identification and documentation of alternative emergency procedures, if needed. 9. The emergency use of restrictive interventions shall be limited, as follows: a. Documentation demonstrates that less restrictive intervention techniques were used prior to the use of restraint; b. staff approved to administer emergency interventions may employ such procedures for up to 15 minutes without further authorization; c. the continued use of such interventions is authorized only by the responsible professional or another qualified professional who is approved to use and to authorize the use of the restrictive intervention based on experience and training; d. the responsible professional meets with and conducts an assessment that includes the physical and psychological well-being of the consumer and writes a continuation authorization as soon as possible after the time of initial employment of the intervention. If the responsible professional or a qualified professional is not immediately available to conduct an assessment of the consumer, but concurs that the intervention is justified after discussion with the staff, continuation of the intervention may be verbally authorized until an on-site assessment of the consumer can be made; e. a verbal authorization does not exceed three hours after the time of initial employment of the intervention; f. each written order for physical restraint can only be completed by a designated, qualified and competent licensed physician or licensed independent practitioner. The physician or practitioner must complete a face-to-face evaluation of the person served within one hour of the order for physical restraint; and g. the order for restraint is time limited and does not exceed four hours for adult consumers and one hour for adolescents and/or children. The original order is only renewed in accordance with these limits or up to a total of 24 hours. 10. The following precautions and actions are employed whenever a consumer is in physical restraint: New Horizons, LLC Subject: Restrictive Interventions Policy No.: C-11 Page 1 of 6 Effective Date: 01/01/09 Revised Date: 2/5/13; 7/24/15; 2/28/18 a. when used for the purpose or with the intent of controlling unacceptable behavior: periodic observation of the consumer occurs at least every 15 minutes, or more often as necessary, to assure the safety of the consumer, attention is paid to the provision of regular meals, bathing and the use of the toilet; and such observation and attention are documented in the consumer record; and b. consumers may be subject to injury: staff remains present with the consumer continuously. 11. The use of a restrictive intervention is discontinued immediately at any indication of risk to the consumer's health or safety or immediately after the consumer gains behavioral control. If the consumer is unable to gain behavioral control within the time frame specified in the authorization of the intervention, a new authorization must be obtained. 12. The written approval of the CEO or designee is required when the original order for a restrictive intervention is renewed for up to a total of 24 hours in accordance with the limits specified above. 13. Standing orders or PRN orders are not used to authorize the use of physical restraint. 14. The use of a restrictive intervention is considered a restriction of the consumer's rights and complies with documentation requirements in these policies and procedures, which comply with GS 122C-62(e). 15. When any restrictive intervention is utilized for a consumer, notification of others occurs as follows: a. those to be notified as soon as possible but within 24 hours of the next working day, to include: the treatment or habilitation team, or its designee as determined by the team, after each use of the intervention; and the staff member who serves on the Human Rights Committee; and b. the legally responsible person of a minor is notified immediately unless she/he has requested not to be notified. 16. The agency conducts reviews and reports on any and all use of restrictive interventions, including: New Horizons, LLC Subject: Restrictive Interventions Policy No.: C-11 Page 1 of 6 Effective Date: 01/01/09 Revised Date: 2/5/13; 7/24/15; 2/28/18 a. a regular review by a designee appointed by the CEO who serves on the Human Rights Committee, and review by the Human Rights Committee, in compliance with confidentiality rules 10 NCAC 28A; b. an investigation of any unusual or possibly unwarranted patterns of utilization; and c. documentation of the following is maintained on a log: • name of the consumer; • name of the responsible professional; • date of each intervention; • time of each intervention; • type of intervention; • duration of each intervention; • reason for use of the intervention; • positive and less restrictive alternatives that were used or that were considered but not used and why those alternatives were not used; • debriefing and planning conducted with the consumer, legally responsible person, if applicable, and staff, to eliminate or reduce the probability of the future use of restrictive interventions; and • negative effects of the restrictive intervention, if any, on the physical and psychological well being of the consumer. 17. The CEO or designee ensures that data on the use of physical restraint is collected and analyzed. The data collected and analyzed reflects for each incident: a. the type of procedure used and the length of time employed; b. alternatives considered or employed; and c. the effectiveness of the procedure or alternative employed. 18. The data is analyzed on at least a quarterly basis to monitor effectiveness, determine trends and take corrective action where necessary. Data is made available to the Secretary of DHHS upon request and to the local LME/MCO’s. (Rules, policies and procedures do not prohibit the use of “voluntary restrictive interventions”, but is doubtful that a consumer will volunteer for physical restraint. If it did occur, the same policies and procedures would apply.) 19. Restrictive interventions are not permitted in some of the agency’s services. Staff always follows the consumer’s Crisis Plan. For those specified areas/services, in the event that a consumer’s behavior is dangerous to New Horizons, LLC Subject: Restrictive Interventions Policy No.: C-11 Page 1 of 6 Effective Date: 01/01/09 Revised Date: 2/5/13; 7/24/15; 2/28/18 themselves or others and cannot be redirected, staff use “natural consequences”, as appropriate, and call 911 for assistance if necessary. 20. Any violation by staff of consumer rights, including 10 NCAC 27D .0304, is grounds for dismissal of the staff member. a. the decision to continue the specific intervention is based on clear and recent behavioral evidence that the intervention is having a positive impact and continues to be needed. Planned Intervention Planned interventions are not employed by the agency staff. Documentation 1. Whenever an unplanned emergency restrictive intervention is utilized, documentation made in the consumer record includes, at a minimum: a. Notation of the consumer’s physical and psychological well-being; b. Notation of the frequency, intensity, and duration of the behavior which led to the intervention, and any precipitating circumstances contributing to the onset of the behavior; c. The rationale for the use of the intervention, the positive or less restrictive intervention considered and used and the inadequacy of less restrictive intervention techniques that were used; d. A description of the intervention and the date, time, and duration of its use; e. A description of accompanying positive methods of intervention; f. A description of the debriefing and planning with the consumer and the legally responsible person, if applicable, for the emergency use of restraint to eliminate or reduce the probability of the future use of interventions; g. A description of the debriefing and planning with the consumer and the legally responsible person, if applicable, for the planned use of restraint if determined to be clinically necessary; and h. Signature and title of the staff member who initiated, and of the staff member who further authorized the use of the intervention. Definition Restrictive Interventions: Defined as use of therapeutic holds/maneuvers exceeding 15 minutes of duration. (specific holds taught in the curriculum approved by DHHS) New Horizon Group Home, LLC Quarterly Health Safety Checklist Safety Checklist 2018 Ensure that sinks, toilets, doors, windows and chairs are in working order Ensure air vents are uncovered and that filters are not due for replacement. (Schedule replacement as necessary) Check locks and alarm system. Enable doors and windows and motions. Disable using your pin. Ensure the system reports when front door is open. Are functions in good working order? Ensure that there are no frayed electrical cords or overloaded outlets, and that outlets and light switches are working properly. Ensure that there are no pest problems or plan and schedule pest control. Locate flashlight and batteries in emergency kit. Are they stocked? Locate and test smoke detectors. Replace batteries at least 1xyear. Ensure that no hazardous chemical or bio-hazardous materials are on the premises. Ensure that all walkways and fire exits are fee of wires, unrolled carper, broken tile, and any other potential trip hazards. Locate and ensure that there is an Emergency Number list and a Bomb Threat Sheet by each phone Locate Evacuation Routes and Procedures (posted) and ensure they are intact. Replace, if necessary Ensure that first Aid Kits are in place and stocked according to Evacuation Route: Locate all fire extinguishers on evacuation plan (posted) and check each using 10point inspection: 1.There are no broken or missing safety seals; 2- There is no evidence of physical damage (cracking), corrosion, leakage or clogged nozzle; 3Pressure gauge readings are in the proper range or position (green area); 4Operating instructions are legible and facing outward; 5- Safety pin is in place; 6Fullness is ensured by shaking the extinguisher; 7- Turn the fire extinguisher upside down and rotate in a circle a few times to ensure powder does not settle at bottom; 8- Hydrostatic date is within 3 years; 9- Name and address of inspector are present and legible; 10- The fire extinguisher is returned to the proper location. Other: Ensure that the facility overall is representative of a safe facility, with no obvious potential hazards. Emergency information for each employee and consumer is in current Furnishings: check for evidence of needed repair/replacement; Linens: clean and evidence of extra supply in storage closet Emergency Supplies: evidence of supplies according to the agency’s EOP Page 1 of 1 New Horizons, LLC Subject: Search and Seizure Policy No.: C-9 Page 1 of 2 Effective Date: 01/01/09 Revised Date: 5-03-18 Policy New Horizons, LLC ensures that each consumer receiving services from New Horizons, LLC is free from unwarranted invasion of privacy. Procedures 1. Consumers and/or guardians are told at time of admission of their rights regarding search and seizure and specific articles or substances that are not allowed. The following items are not permitted on the premises of any office or person: fire arms (unless carried by law enforcement), fire works, stolen goods, illegal drugs, or alcohol. Notice of prohibition is documented in rules provided to consumers. 2. Employees do not search consumers receiving community periodic services, e.g. Intensive-In Home, or a person’s home or property. 3. All consumers are asked to voluntarily forfeit or dispose of any illegal or dangerous items. If there is reasonable cause to suspect danger, staff contact law enforcement. Situations justifying this may include but are not limited to the following: • drug abuse, • possession of dangerous articles (i.e. clubs, swords, fire arms, fire works, etc.), and • possession of stolen property that has been witnessed by an employee or reliable informant, or is clearly indicated by surrounding circumstances, such as a prior history of similar behavior, and opportunity or accessibility beyond that of other consumers exists. 4. If staff have information that a residential service recipient has dangerous or illegal property, and the person refuses to voluntarily forfeit the property, staff may search the person’s belongings. At no time will a strip search occur. If staff feels it is necessary to search a person’s body, there must be at least two staff involved with the search and one of the same sex as the person being searched. Any search must be conducted in a manner that is respectful to the person searched. Any confiscated substances are returned the rightful owner, given to the legal guardian, or give to the Director for action, e.g. to give to law enforcement. 5. All search and seizure activities by law enforcement or staff are documented on the Search and Seizure Report and IRIS Incident Reporting System, and include: New Horizons, LLC Subject: Search and Seizure a. b. c. d. e. Policy No.: C-9 Page 2 of 2 Effective Date: 01/01/09 Revised Date: 5-03-18 scope of search; reason for search; procedures followed in the search; a description of any property seized; and an account of the disposition of seized property. All reporting timelines relevant to Search and Seizures, reflected in the DMH Incident Reporting Manual, must be adhered. - . ?y is - - - North Carolina Interventions titty/NW. ncd'mh'. litm Participant 972119 certi?es tliat Monty Little . lids ?tf?l?zd' requirements for certi?cation and; su?fect to ammfmem?catwn, IS quali?ed'to use p?ysicaftec?m?qu WCI Intenentions Cm Training (Warts)! and'fB 91H: ind?md'ua?k cem?ed'in 13 optionafteclim?qms (see Eac?) Bryan Holliday ?y Mww,? my, mad/:9 4/14/2018 Instructor signatures Date Certi?cate is valid through 412019 Participant NCI Interventions Core+ Traini BLOCKS: _X_Kick block Method A _X_Kick block Method THERAPEUTIC HOLDS: _X_Overhead (A) _X_Overhead (B) _X_Hook (A) (B) _X_Straight (A) _X_Straight (B) _X_Uppercut _Kick (A) Therapeutic wrap RELEASES: _X_Two-handed hair pull front _X_Two-handed hair pull - back One-handed hair pull assist Two-handed hair pull assist _Optional bite release _Bite release (assist) _Back choke (bend) _Bear hug (bicep release) TRANSPORTS: _X_Limited control walk Modi?ed limited control walk (from standing position) Modified limited control walk (from ?oor) One person therapeutic walk Two person therapeutic walk Escape attempt Therapeutic walk to chair Therapeutic hold in chair with assistance CARRIES: __Two person therapeutic carry __Three person therapeutic carry (standing) __Three person therapeutic carry (from floor) _Four?Five person carry (optional) Participant NCI Interventions Core+ Training 1008 . . . Mk .5. .q . North Carolina Interventions gi?m/sng?gm I {i i net/WCI?Q?u??cjm ?tm Participant ?I??is certi?es t?at Jacqualine Cagle fins Wd' (if requirements for cem?catzbn and; su?ject to annuafrecertf?cation 1's qua??eifto use p?ysicaftec?nw WCI I interventions Con- Training (?irts amffB ?I??is certi?ed'in 13 ophbnaftec?niqu (see 6mg) cum'atfum qftlie NC {Division qf?tentaf?eaft?, (Develbpment (Disa?z?tiar and'Su?stance??use Services Bryan HOHiday ?y Wazgaawg as. (5:217 4/14/2018 Instruct?f signatures Date Certi?cate is valid through 412019 Participant Interventions Core+ Training 1008 BLOCKS: _Optional bite release Bite release (assist) _X_Kick block Method A Back choke (bend) Bear hug (bicep release) _X_Kick block Method TRANSPORTS: THERAPEUTIC HOLDS: _X_Limited control walk _X_Overhead (A) _Modi?ed limited control walk (from standing position) _X_Overhead (B) _Modified limited control walk (from floor) _X_Hook (A) _One person therapeutic walk (B) Two person therapeutic walk _X_Straight (A) Escape attempt _X_Straight (B) Therapeutic walk to chair _X_Uppercut Therapeutic hold in chair with assistance _Kick (A) _X_Therapeutic wrap CARRIES: RELEASES: Two person therapeutic carry Three person therapeutic carry (standing) _X_Two-handed hair pull - front Three person therapeutic carry (from floor) _X_Two-handed hair pull back Four-Five person carry (optional) One-handed hair pull assist Two-handed hair pull assist Participant NCI Interventions Core+ Training 1008 . . ?gemy is raspansi?t??rr ven?ing Instructor certyication. North Carolina Interventions go tom?i?f/iDQ/S?fwe?site: Participant Wits certi?es tliat Walter McKoy certi?cation and; .m?ject to annuafrecert?ication, is qual? ?at to use p?ysxbaftec?nme Interventions? Com ?Emitting (Parts )1 am?! disgnaterf 01!!th teclimques) ?11meme certi?ed'in 13 optional'tec?nigues (see ?at-E) cum'cufum qft?e WC minim qf?vtental?eaftli, (Deve?apment Oim?z?tiw and'SuEstance??use Swims Bryan Holliday ?y 3:5 {503 4/14/2018 Instructor signatures Date Certi?cate is valid through 4/2019 Participant NCI Interventions Core+ Training 1008 BLOCKS: _Optional bite release Bite release (assist) _X_Kick block Method A Back choke (bend) Bear hug (bicep release) _X_Kick block Method TRANSPORTS: THERAPEUTIC HOLDS: _X_Limited control walk _X_Overhead (A) Modified limited control walk (from standing position) _X_Overhead (B) Modified limited control walk (from ?oor) _X_Hook (A) One person therapeutic walk _X_Hook (B) Two person therapeutic walk _X_Straight (A) Escape attempt _X_Straight (B) Therapeutic walk to chair _X_Uppercut Therapeutic hold in chair with assistance _Kick (A) Therapeutic wrap CARRIES: RELEASES: Two person therapeutic carry _Three person therapeutic carry (standing) _X_Two-handed hair pull front Three person therapeutic carry (from ?oor) _X_Two-handed hair pull - back Four-Five person carry (optional) One-handed hair pull assist Two-handed hair pull assist Participant NCI Interventions Core+ Training 1008 7 . Agency is responsi??afor very?ring Instructor certi?cation a North Carolina Interventions we?site: Iitm Participant ?Hits certi?es t?at Sean Evans ?as?d??kd'a?'rcquimnentsfor ce?g?cation and: .m?ject to annual'mcertg?cation, is quaE?eJto use p?ysicaftec?m'que I nterventions Cm Training ((Parts? amffB designatetfoptiomftec?niques) Unis certi?ed'in 13 optionaftec?m'ques (see Eac?) cunicu?cm qft?e NC (Division qf 911:2an Heaft?, mew?rpmt misa?t?t?es anJSu?stance/??use Sendces Bryan Holliday ?y M16524 my: 6'55, 55c?? 4/14/2018 signatures Date Certificate is valid through 412019 Participant NCI interventions Core+ Training 1008 BLOCKS: _X_Kick block - Method A _X_Kick block - Method THERAPEUTIC HOLDS: _X_Overhead (A) _X_Overhead (B) _X_Hook (A) _X_Hook (B) _X_Straight (A) _X_Straight (B) _X_Uppercut _Kick (A) Therapeutic wrap RELEASES: _X_Two-handed hair pull front _X_Two-handed hair pull back One-handed hair pull assist Two-handed hair pull assist _Optional bite release release (assist) choke (bend) hug (bicep release) TRANSPORTS: _X_Limited control walk _Modified limited control walk (from standing position) limited control walk (from floor) person therapeutic walk Two person therapeutic walk _Escape attempt walk to chair _Therapeutic hold in chair with assistance CARRIES: person therapeutic carry _Three person therapeutic carry (standing) _Three person therapeutic carry (from ?oor) _Four-Five person carry (optional) Participant NCI Interventions Core+ Training 1003 mm got-mm?: and. Participant 1M Richard Clanton "it. w. .. q- .V *auu??wa BLOCKS: _X__Kick block Method A _X_Kick block Method THERAPEUTIC HOLDS: _X_0verhead (A) _X_0verhead (B) Hook (A) Hook (B) StraIght (A) _x_Straight (B) _X_Uppercut _Kick (A) Therapeutic wrap RELEASES: Two-handed hair pull - front _Two-handed hair pull back One- handed hair pull assist Two-handed hair pull assist _Optional bite release __Bite release (assist) _Back choke (bend) _Bear hug (bicep release) TRANSPORTS: Limited control walk Modified limited control walk (from standing position) Modified limited control walk (from ?oor) One person therapeutic walk Two person therapeutic walk Escape attempt Therapeutic walk to chair Therapeutic hold in chair with assistance CARRIES: Two person therapeutic carry Three person therapeutic carry (standing) Three person therapeutic carry (from floor) Four-Five person carry (optional) Participant NCI Interventions Core+ Training 1008 a - . )4 ?respmm'?le - ?mm, - . North Carolina Interventions Wm net/WCI?Q?u??c/imm 1 Participant certi?es t?at Melba Conley Ea: r1151r requirements for certi?cation and; su?ject to annuafrecertg?cauon, as quali?ed' to use pfqm'caftec?m'que Interventions Care Training (Q?arts? and'? designated'optionaftec?m'ques) infw?uafis cem?erfin 13 (see Eac?) cum'cu?m qft?e INC (Dwinbn quentaneal't?, (Devebpment @isa?i?ties and'SuEstance??use Services Bryan Holliday 4 A6554 Ami, as: 550;: 4/14/2018 Instruct?r signatures Date Certificate is valid through 412019 Participant NCI Interventions Core+ Training 1008 . . ?gemy is mousi?l? for ven?ring cert?catibn. North Carolina Interventions go mt/WCI?G?u??c/in?n?tm Participant certi?es t?at Melba Conley 541.: all requirements for certi?cation and; su?fect to annualrecerbi?cation, is qual?d' to use WCI Interventions Cane Training (Q?arts? ame ?signated'optibnaftec?m'ques) ?ITiis indi'w'd'uafis cem?ed'in 13 optionaftec?rdquzs (see Eac?) curricu?m qftlie INC mi?vision quentaf?eaft?, (Devetbpment ma?titiar and'Su?stance??use Services Bryan Holliday we was 62:? 65025 4/14/2013 Instructd'r signatures Date Certi?cate is valid through 412019 Participant NCI Interventions Core+ Training 1008 BLOCKS: _Optional bite release __Bite release (assist) _X_Kick block Method A __Back choke (bend) _Bear hug (bicep release) _X_Kick block - Method TRANSPORTS: THERAPEUTIC HOLDS: _X_Limited control walk _X_Overhead (A) Modi?ed limited control walk (from standing position) _X_Overhead (B) Modified limited control walk (from ?oor) _X_Hook (A) One person therapeutic walk (B) Two person therapeutic walk _X__Straight (A) Escape attempt _X_Straight (B) Therapeutic walk to chair _X_Uppercut Therapeutic hold in chair with assistance _Kick (A) _X_Therapeutic wrap CARRIES: RELEASES: Two person therapeutic carry Three person therapeutic carry (standing) Three person therapeutic carry (from ?oor) Four-Five person carry (optional) _X_Two-handed hair pull front _X_Two-handed hair pull back One-handed hair pull assist Two-handed hair pull assist Participant NCI Interventions Core+ Training 1008 North Carolina Interventions Agency is Wond?l? for vet-rm Instmaar cem' tion. 90 to we?site: ?ea ?tm Participant ?I'Eis cem?es t?at Cleveland Keaton 5a.: at? requirements for certi?cation am? subject to annuafmcertg?catzbn, is quali?ed" to use ply?mftec?nw CI I nterwnziam Care Tmim'ng (Q?arts? anar? ?13239me optionat' tedim?ques) ?Iliis infmd'uafis cem?eJin 13 optional" tec?m'ques (see Eac?) cum'aafum qft?e NC Division @isa?ditias and'SuEstance??use Samba: Bryan Holliday 52? (5075' 4/14/2018 Instructor signatures Date Certi?cate is valid through 4/2019 Participant NCI Interventions Core+ Training 1008 {it BLOCKS: _Optional bite release - Bite release (assist) _X_Kick block Method A Back choke (bend) Bear hug (bicep release) _X_Kick block Method TRANSPORTS: THEMPEUTIC HOLDS: _X_Limited control walk _X_Overhead (A) _Modified limited control walk (from standing position) _X_Overhead (B) Modified limited control walk (from ?oor) _X_Hook (A) One person therapeutic walk (B) Two person therapeutic walk _X_Straight (A) Escape attempt _X_Straight (B) Therapeutic walk to chair _X_Uppercut Therapeutic hold in chair with assistance _Kick (A) _X_Therapeutic wrap CARRIES: RELEASES: Two person therapeutic carry Three person therapeutic carry (standing) Three person therapeutic carry (from ?oor) Four-Five person carry (Optional) _X_Two-handed hair pull front _X_Two-handed hair pull - back One-handed hair pull assist Two-handed hair pull assist ll! Participant NCI Interventions Core+ Training 1008 I I i i I Maw?"mm . . ii- ?Client Daily Activity Schedule Monday-Thursday 7:05 am-8:00am 8:05 am-Bz40am 8:45 era-9:05 am 9:05 ant?9:30 am 9:30 am?i 1:00 am 11:05 am-12:00 pm 12:05 pm?12:35 pm 12:35 pin-12:55 'pm' 1:00 pm-2:00 pm 2:05 pm-2:45 pm 2:50 pm -3:25 pm 3:30 pro-4:35 pm 4:35 pro-5:00 pm 5:05 pm-5:55 pm 5:55 pm?6230 pm 6:30 pm:?:25 pm 7:30 pm?8:00 pm 8:00 put-8:15 pm 8:15 pm?8:45 pm 9:00 PM *9:30 and-5:00 pm Wake-up. Dres5, Wellness(moming exercise) Personal Hygiene. morning chores Breakfast Group'Discussion Education Educrational ExpioratoMcouid include educational ?lms tv programs. unc Arts and Crafts Education Drop Everything and Read Individual Choice/Free TIme Quiet TIme?nciudes individual snack) Group Discussion Study Hali(Client phone calls also take place during this time) Dinner IndoorlOutdoor Recreational Activities Self Re?ection Snack Bedtime Preparation Bedtime *Consumers are required to retire to their rooms at this time. They may engage in quiet activities in their room if they choose not to go to steep immediately?Ir Clients attend individuai, substance abuse, orspeciai diagnosis therapy Medication Management weekiy At least two group discussions per week are vocation based. etc.) 2 Friday 7: 05 am-8: 00am 8:05 ram?8:40am 8:45 am-9:05 am 3 9:05 am-9230 am 9:30 am-?i 1:00 am 11:05 am-12:00 pm 12:05 pm~12z35 pm 1 12:35 pin-12:55 pm 1:00 pm-2:00 pm 2:05 pm-2:45 pm ?2:50 pm -3:25 pm- i3:30 nth-4:35 pm =4:35 pro?5:00 pm 5:05 pm?5:55 pm 5:55 pm-6:30' pm 6:30 pm:T:25 pm 7:30 pin-3300 Pm 8:00 pm-8:15 pm 8:15 pm-8:45 pm 9:00 PM Wake-up, Dress, Weilness(morning exercise) Personal Hygiene. morning chores Breakfast Group Discussion Education Educational Exploratory(cou d inciude educational ?lms, tv programs, etc.) Lunch Arts and Crafts Education Drop Everything and Read individual ChoiceiFree Time(0verall Weekly Progress towards Butter?y Plan is discussed individually with the Executive Director during this time) Quiet Tlme?nciudes individual snack) House Meeting(Discuss possible program changes food preferences. etc.) Study Haii(Client phone calls also take place during this time) Dinner lndooriOutdoor Recreational Activities Seif Re?ection Snack Bedtime Preparation Bedtime Client Daily Activity Schedule Saturday 7:15 arm-8:00 am - 8:00 am?8:30 arn 8:35 am-9:05 am 9:05 am-?i 0:00 am 10:40 am?1:00 pm 10:05 am?10:35 am .. . 1 :05 pm-1 :35 pm 1:40 pm?2:35 pm 2:40 pm?3:25 pm 3:30 pm-4:30 pm 4:35 pm-5:55 pm 6:00 pin-6:35 pm 5:35 [am-7:05 pm 7:05 pm?9:10 pm 9:10 pm-9:30 pm Wake-up, Dress, Health 8: Wellness Personal Hygiene. Morning Chores Breakfast - Weekly Room Cleaning Group Discussion Structured Recreational Activities Lunch Drop Everything and Read Client Individual Choice/Hobbies Quiet TirneGncludes individual shack) - Recreational Activities Dinner indoor Activities - Group Movie Bedtime Preparation Based on the ieve! the ciient has achieved on the Butter?y Plan, and of facility activities and therapeutic leave occur on Saturday. Sunday . 7:15 ant-8:00 am 1 8:00 am?8:30 am 2 8:35 am?9:05 am Wake-up, Dress. Health Wellness Personal Hygiene, Morning Chores Breakfast Religion Expression/Free Time 9:05 arc-10:00 am Group Discussion 10:05 am?10:35 am 10:40 arm?1 :00 pm Recreational Activities 1:05 pm-1:35 pm Lunch 5 1:40 pm-2:35 pm . Drop Everything and Read . 3. 2:40 pm indoor Activities 1 3:30 pm-4:30 pm Quiet 'l?ime?ncludes individual snack) 34:35 pm?5:25 pm Recreational Activities i 5:30 pm-6:00 pm Dinner 6:05 pm-7:05 pm indoor Ac?vities i':05 pm-9:10 pm Group Movie 9:10 pm-9:30 pm Bedtime Preparation 5 *1 :00 pm-5:00 pm Client Visitation NEW HORIZON GROUP HOME Lumberbridge NC, 28357 April 25, 2018 The Curriculum Specialist Public Schools of Robeson County Dear Sir/ Madam, RE: Request of Approval of Homeschool Curriculum New Horizon Group Home Enclosed is the outline of the curriculum implemented by New Horizon Group Home. We provide services for school age students placed in the upper elementary level through the high school level in a residenn'al facility. Our curriculum is based on the skills and knowledge outlined in the North Carolina Public Schools Standard Course of Study for the core subjects of Reading /English/Language Arts: Zi': instructors and teachers and educational in working in the North Carolina Public Mathematics; Science. and Sociai Stu consultants are trained, certified and School system. The inswucn'onal me' zilies and resources are recommended and/or approved by the Deparmieni oil'iibli': instruction. We hope you find all the relevant indicators in this Working document to grant approval of its use with our students. We are confinuing to revise the content as updates and revisions are made to the state's Standard Course of Study. Thank you for your consideration. gig fill/71g! (41 Director New Horizon Group Home u; Wu :6 Robeson cow--j 2. North Carolina County of Robeson Contract: 0002 6 5 And New Horizon Group Home, LLC for educational ?7 ll services [Hold Harmless Agreement included This agreement dated the o7 :97 6/3) by and between LN l? ?1 . from this point named Educational Teacher and New Horizon Group Home, LLC, from this point named as AGENCY. Whereas the Educational Teacher and the AGENCY enter into an agreement whereby Educational Teacher shall provide Educational Teacher services for the AGENCY. The terms and conditions of the services to be provided are as follows: AGENCY AND EDUCATIONAL TEACHER mutually hereby indemnify and hold both parties harmless for any and all claims, demands, lawsuits, liabilities to include, but not limited to contract negligence, personal injury, property damage, criminal liability, etc. the same to include the payment of any and all attorney fees and costs. With regard to the services to be performed by the EDUCATIONAL TEACHER pursuant to the terms of this agreement, the EDUCATIONAL TEACH ER shall not be liable to the AGENCY, or to anyone who may claim any right due to any relationship with the Corporation/AGENCY, for any acts or omissions in the performance of services on the part of the EDUCATIONAL TEACHER or on the part of the agents or employees of the EDUCATIONAL TEACHER, except when said acts or omissions of the EDUCATIONAL TEACHER are due to willful misconduct or gross negligence. The AGENCY shall hold the EDUCATIONAL TEACHER free and harmless from any obligations, costs, claims, judgments, attorney's fees, and attachments arising from or growing out of the services rendered to the AGENCY pursuant to the terms of this agreement or in any way connected with the rendering of services, except when the same shall arise due to the willful misconduct or gross negligence of the EDUCATIONAL TEACHER and the EDUCATIONAL TEACHER is adjudged to be guilty of willful misconduct or gross negligence by a court of competent jurisdiction. Responsibilities: EDUCATIONAL TEACHER shall be to provide as requested by AGENCY the following services and contract deliverables: a. To provide the educational services within the facility to maintain the educational and intellectual deveIOpment of the consumers residing in the Level IV facility by coordinating with the local education agency to ensure that the consumer?s educational needs are met as identi?ed in the education plan. b. An Educational Plan (IEP) shall be developed for each of the consumers coordinated by the contract Education Service staff person and the local education agency. 3. Responsibilities of AGENCY shall be to provide: a. Work space that meets confidentiality of the consumers b. Electronic (computer) with Internet access, if needed c. Access to other of?ce equipment printer, copier, fax, etc. . . . . 4. Period of Performance: a. min date: Id' c. This agreement is effective on the above date entered Into and will terminate upon satisfactory completion of agreed upon services. AGENCV and EDUUTIONAL TEACHER may terminate this agreement without cause upon thirty (30) days notification to the other party at the addresses shown in this agreement. AGENCY may terminate this agreement immediately upon EDUCATIONAL refusal to, or inability to periorm under the agreement Or EDUCATIONAL breach of this agreement. Further, this agreement shall be terminated automatically in the event of EDUCATIONAL death. on termination of this agreement, obligation to pay EDUCATIONAL TEACHER, except for services already accrued or incurred, will forthwith cease and terminate. Upon completion or termination at performance period, all deliverables will be provided to AGENCV upon satisfactory payment of service 5. Place of Performance: a. Level IV Residential facllity site _Lumher Bridge 6. Payment: 3. is due at completion of each contract service month; end of the contracted performance period or upon termination of servlce. b. Payment for services at a rate of 3 per hour; 7, Confidentiality: a, The parties hereto acknowledge that during the course of EDUCATIONAL service to AGENCY pursuant to this agreement, it will become necessary or desirable for AGENCY to disclose to EDUCATIONAL TEACHER a substantial amount of AGENCV Proprietary information EDUCATIONAL TEACHER fully understands that the maintenance of such information in strict confidence and the confinement of its use to AGENCV is of vital importance to the AGENCY. EDUCATIONAL TEACHER agrees that the information and knowledge divulged to the EDUCATIONAL TEACHER by AGENCY or which EDUCATIONAL TEACHER acquires in connection with or as a result of EDUCATIONAL services hereunder Will be regarded by EDUCATIONAL TEACHER as confidential; b. EDUCATIONAL TEACHER recognizes that all records and copies of records touching operations, Investigations and business made or received by EDUCATIONAL TEACHER during the period of this agreement are and will be the exclusive property of AGENCV, and EDUCATIONAL TEACHER will keep the same at all times in EDUCATIONAL custody and subject to EDUCATIONAL control, and will surrender the same to AGENCY immediately upon the request of AGENCV, or upon completion to agreed upon services 8. Neither party to this agreement may assign, sell or transfer any part 01 this contract to any other firm or entity without first obtaining the written permission of the other party hereto. 9. This agreement has been negotiated, executed and delivered in the State of North Carolina. The parties hereto agree that all questions pertaining to the validity and interpretation of this agreement will be determined in accordance with the laws of the State of North Carolina. 10. Arbitration. Any controversy or claim arising out of or relating to this contract, or the breach thereof, shall be settled by arbitration in accordance of the rules of the American Arbitration Association, and judgment upon the award rendered by the arbitrator(s) shall be entered in any court having jurisdiction thereof. For that purpose, the parties hereto consent to the jurisdiction and venue of an appropriate court located in County, State of North Carolina. In the event that litigation results from or arises out of this Agreement or the performance thereof, the parties agree to reimburse the prevailing party's reasonable attorney's fees, courts costs, and all other expenses, whether or not taxable by the court as costs, in addition to any other relief to which the prevailing party may be entitled. in such event, no action shall be entertained by said court or any court of competent jurisdiction if ?led more than one year subsequent to the date the causels) of action actually accrued regardless of whether damages were otherwise as of said time calculable. This agreement and referenced attachments constitute the entire contract of the parties hereto and supersedes any lOl' agreement be en the pa s. gimme: ref/Z: 0? .07: Egg/Owner Date Barbara Brockington ?3 . /60 Printed Name Date 2.. 2. we Educational Teacher Date 94$le s1 - 30/ 8/ Witness Date men: 04/25/2013 PRFORM APPROVED Division of Health ServiceRegulation AND PLAN on DEFICIENCIES NAME or PROVIDEROR SUPPLIER NEW HORIZON GROUP HOME. LLC (Xi) or CORRECTION IDENTIFICATION swear AD LUMBER A BUILDING a (X2) MULTIPLE mess cn'v sure ZIPCDDE BRIDGE, Nc 23:57 as) one sunvgv COMPLEYED 04/1 3/2018 1x41 ID PREFIX me SUMMARY STATEMENT or DEFICIENCIES (EACH DEFICIENCY Musr BE PRECEDED av FULL ID PREFIX women's mm or CORRECTION (anon CORRECYIVEACYION SHOULD as ro THE APPROPRIATE DEFICIENCV) V000 INITIAL COMMENTS An annual and complaint survey was completed on April 13, 2018. The complaint was substantiated (Intake ID if NC00137426). Deficienmes were cited. This facllity is licensed for the following service category' 10A NCAC 276 1800 Intensive Residential Treatment lOr Children or Adolescents. Summary Suspension issue'u on 04/11/18. 276 0202 Personnel Requirements 10A NCAC 276 .0202 PERSONNEL REQUIREMENTS Continuing educallon shall be documented. (9) Employee iiaining programs shall be provided and, at a minimumshall consist of lhe following: (1) general organizallonal orientatlon: (2) training on client righls and confidentiality as delineated in 10A NCAC 27C, 27D, 27E, 27F and 10A NCAC 253i (3) lralning to meet the mtildd/sa needs olthe client as specified in the treatmentlhabilltation plan; and (4) tmlning in inrectiuus diseasesand bloodbome pathogens. Except as permitted under 103 NCAC 27G 5602(b) of this Subchapler, at least one stall membershall be available in the facility at all times when a client is present. That staff membershall be trained in basic first aid including seizure management, currently Irained to provide cardiopulmonary resuscitation and trained in lne Heimlich maneuver or other first aid such as those provided by Red Cross, V000 V108 Division or Health service Regulallon LAEORAYORY mnemon- PROVIPERISU ran rm; aZNIll (Xsi DAre 5-04-18 lieominiiziien snoei i or i ls