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Division of Health Service Regulation

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: ______________________ B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE (X3) DATE SURVEY COMPLETED

MHL041-877
NAME OF PROVIDER OR SUPPLIER

R 06/20/2013

PROGRESSIVE STEPS
(X4) ID PREFIX TAG

4103 LANDERWOOD COURT GREENSBORO, NC 27405

ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETE DATE

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

V 000 INITIAL COMMENTS

V 000

An Annual and Follow-Up Survey was completed on June 20, 2013. Deficiencies were cited. This facility is licensed for the following service category: 10A NCAC 27G .1300, Residential Treatment for Children or Adolescents.
V 366 27G .0603 Incident Response Requirments V 366

10A NCAC 27G .0603 INCIDENT RESPONSE REQUIREMENTS FOR CATEGORY A AND B PROVIDERS (a) Category A and B providers shall develop and implement written policies governing their response to level I, II or III incidents. The policies shall require the provider to respond by: (1) attending to the health and safety needs of individuals involved in the incident; (2) determining the cause of the incident; (3) developing and implementing corrective measures according to provider specified timeframes not to exceed 45 days; (4) developing and implementing measures to prevent similar incidents according to provider specified timeframes not to exceed 45 days; (5) assigning person(s) to be responsible for implementation of the corrections and preventive measures; (6) adhering to confidentiality requirements set forth in G.S. 75, Article 2A, 10A NCAC 26B, 42 CFR Parts 2 and 3 and 45 CFR Parts 160 and 164; and (7) maintaining documentation regarding Subparagraphs (a)(1) through (a)(6) of this Rule. (b) In addition to the requirements set forth in Paragraph (a) of this Rule, ICF/MR providers shall address incidents as required by the federal regulations in 42 CFR Part 483 Subpart I.
Division of Health Service Regulation
TITLE LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
(X6) DATE

STATE FORM

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Division of Health Service Regulation

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: ______________________ B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE (X3) DATE SURVEY COMPLETED

MHL041-877
NAME OF PROVIDER OR SUPPLIER

R 06/20/2013

PROGRESSIVE STEPS
(X4) ID PREFIX TAG

4103 LANDERWOOD COURT GREENSBORO, NC 27405

ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETE DATE

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

V 366 Continued From page 1

V 366

(c) In addition to the requirements set forth in Paragraph (a) of this Rule, Category A and B providers, excluding ICF/MR providers, shall develop and implement written policies governing their response to a level III incident that occurs while the provider is delivering a billable service or while the client is on the provider's premises. The policies shall require the provider to respond by: (1) immediately securing the client record by: (A) obtaining the client record; (B) making a photocopy; certifying the copy's completeness; and (C) (D) transferring the copy to an internal review team; (2) convening a meeting of an internal review team within 24 hours of the incident. The internal review team shall consist of individuals who were not involved in the incident and who were not responsible for the client's direct care or with direct professional oversight of the client's services at the time of the incident. The internal review team shall complete all of the activities as follows: (A) review the copy of the client record to determine the facts and causes of the incident and make recommendations for minimizing the occurrence of future incidents; (B) gather other information needed; (C) issue written preliminary findings of fact within five working days of the incident. The preliminary findings of fact shall be sent to the LME in whose catchment area the provider is located and to the LME where the client resides, if different; and (D) issue a final written report signed by the owner within three months of the incident. The final report shall be sent to the LME in whose
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Division of Health Service Regulation

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: ______________________ B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE (X3) DATE SURVEY COMPLETED

MHL041-877
NAME OF PROVIDER OR SUPPLIER

R 06/20/2013

PROGRESSIVE STEPS
(X4) ID PREFIX TAG

4103 LANDERWOOD COURT GREENSBORO, NC 27405

ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETE DATE

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

V 366 Continued From page 2

V 366

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 pertinent to the incident, and shall make recommendations for minimizing the occurrence of future incidents. If all documents needed for the report are not available within three months of the incident, the LME may give the provider an extension of up to three months to submit the final report; and (3) immediately notifying the following: (A) the LME responsible for the catchment area where the services are provided pursuant to Rule .0604; (B) the LME where the client resides, if different; (C) the provider agency with responsibility for maintaining and updating the client's treatment plan, if different from the reporting provider; (D) the Department; (E) the client's legal guardian, as applicable; and (F) any other authorities required by law.

This Rule is not met as evidenced by: Based on observation and interview, the facility staff failed to maintain documentation regarding their response to level I incidences. The findings are: Review on 6-19-13 of client #1 ' s facility record revealed he was: - 16 years old
Division of Health Service Regulation STATE FORM
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Division of Health Service Regulation

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: ______________________ B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE (X3) DATE SURVEY COMPLETED

MHL041-877
NAME OF PROVIDER OR SUPPLIER

R 06/20/2013

PROGRESSIVE STEPS
(X4) ID PREFIX TAG

4103 LANDERWOOD COURT GREENSBORO, NC 27405

ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETE DATE

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

V 366 Continued From page 3

V 366

- admitted to the facility 3-10-13 - diagnosed as having Oppositional-Defiant Disorder Review on 6-19-13 of client #2 ' s facility record revealed he was: - 14 years old - admitted to the facility 10-20-12 - diagnosed as having Attention Deficit-Hyperactivity Disorder, Oppositional-Defiant Disorder and Conduct Disorder Observation at 11:15 am on 6-20-13 of the Incident Report Log notebook revealed no documentation of any incidence in the previous 12 months. Interview on 6-20-13 with the Qualified Professional (QP) revealed there were no level I incident reports or level II incident reports for the last 12 months. Interview on 6-20-13 with client #1 revealed about 2 weeks after he was admitted to the facility (exact date not remembered) he had a pocket knife. He reported that he knew it was not allowed, and after several weeks of hiding it, he voluntarily gave it up. Client #1 indicated he only did this once, that it was not a usual occurrence, and that he didn ' t know of any other client that ever had a knife taken away from them. Interview on 6-20-13 with client #2 revealed he used to have a cellular telephone, he had gotten from a classmate at his school. Client #2 reported: - he had it for almost a month, back in the winter (exact dates unknown) - staff saw it in his room and confiscated it
Division of Health Service Regulation STATE FORM
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Division of Health Service Regulation

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: ______________________ B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE (X3) DATE SURVEY COMPLETED

MHL041-877
NAME OF PROVIDER OR SUPPLIER

R 06/20/2013

PROGRESSIVE STEPS
(X4) ID PREFIX TAG

4103 LANDERWOOD COURT GREENSBORO, NC 27405

ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETE DATE

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

V 366 Continued From page 4

V 366

- he knew he was not supposed to have it, and kept it hidden - it was not a usual occurrence for he or other clients to have cellular telephones - it was not a usual occurrence for he or other clients to have things confiscated Interview on 6-20-13 with the Assistant Director (AD) revealed that finding and confiscating items the clients are not supposed to have, " don ' t happen often ... " Further interview with the AD revealed, " I thought she (the QP) did one (completed an incident report), she should ' ve. " Additional interview with the AD revealed the Director/Licensee (DL), " has to approve if we write incident reports. " Further interview failed to reveal why direct care staff were not expected to, required to, or given the autonomy to write level I incident reports themselves, then submit them to her, the QP or the DL for proper documentation of unusual events occurring with clients in the facility. Additional interview with the QP on 6-20-13 failed to reveal why no Level I incident reports were written for the two events; staff confiscating client #1 ' s pocket knife and staff confiscating client #2 ' s cellular telephone, or; why direct care staff are not expected and required to write level I incident reports themselves, then submit them to her, the Assist Director or the Director/Licensee for proper documentation of unusual events occurring with clients in the facility. Interview with the DL on 6-20-13 revealed unusual events occurring with the clients in the facility will be written and documented as they are supposed to be.

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Division of Health Service Regulation

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: ______________________ B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE (X3) DATE SURVEY COMPLETED

MHL041-877
NAME OF PROVIDER OR SUPPLIER

R 06/20/2013

PROGRESSIVE STEPS
(X4) ID PREFIX TAG

4103 LANDERWOOD COURT GREENSBORO, NC 27405

ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETE DATE

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

V 736 Continued From page 5 V 736 27G .0303(c) Facility and Grounds Maintenance

V 736 V 736

10A NCAC 27G .0303 LOCATION AND EXTERIOR REQUIREMENTS (c) Each facility and its grounds shall be maintained in a safe, clean, attractive and orderly manner and shall be kept free from offensive odor. This Rule is not met as evidenced by: Based on observation and interview, the facility staff failed to maintain the facility in a safe, attractive and orderly manner. The findings are: Review on 6-19-13 of client #1 ' s facility record revealed he was: - 16 years old - admitted to the facility 3-10-13 - diagnosed as having Oppositional-Defiant Disorder Review on 6-19-13 of client #2 ' s facility record revealed he was: - 14 years old - admitted to the facility 10-20-12 - diagnosed as having Attention Deficit-Hyperactivity Disorder, Oppositional-Defiant Disorder and Conduct Disorder Review on 6-19-13 of client #3 ' s facility record revealed he was: - 15 years old - admitted to the facility 4-22-13 - diagnosed as having Attention Deficit-Hyperactivity Disorder, Oppositional-Defiant Disorder and Post Traumatic Stress Disorder.
Division of Health Service Regulation STATE FORM

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Division of Health Service Regulation

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: ______________________ B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE (X3) DATE SURVEY COMPLETED

MHL041-877
NAME OF PROVIDER OR SUPPLIER

R 06/20/2013

PROGRESSIVE STEPS
(X4) ID PREFIX TAG

4103 LANDERWOOD COURT GREENSBORO, NC 27405

ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETE DATE

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

V 736 Continued From page 6

V 736

Observation at 11:25 am on 6-20-13 in client #3 ' s bedroom revealed the following: - electric receptacle plate next to window is broken - drawer in the under-bed cabinet has a broken track slider - chest of drawers by the door has cosmetic damage on the right side near the back Observation at 11:50 am on 6-20-13 in client #1 ' s bedroom revealed the following: - cable television outlet box is broken - wall next to the doorway has several telephone numbers written in pencil Observation at 12:05 pm on 6-20-13 in client #2 ' s bedroom revealed the following: - left closet door is broken/dented/cracked - electric light switch plate is broken - bedroom door is broken/dented/cracked - toilet paper holder in the bathroom is broken Observation at 12:20 pm on 6-20-13 in the facility ' s hallway bathroom revealed the following: - hand towel bar broken/missing - electric switch for the fan is inoperative making the fan run constantly - commode water tank flapper/seal to bowl leaks causing tank to periodically refill - quarter-round shoe molding or caulk is missing where front of tub meets the floor - wallpaper is torn and peeling in 3 places near the bathroom door Observation at 12:40 pm on 6-20-13 in the great room (living room/den/dining room) revealed the following: - electric switch plate next to closet is broken
Division of Health Service Regulation STATE FORM
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Division of Health Service Regulation

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: ______________________ B. WING _____________________________ STREET ADDRESS, CITY, STATE, ZIP CODE (X3) DATE SURVEY COMPLETED

MHL041-877
NAME OF PROVIDER OR SUPPLIER

R 06/20/2013

PROGRESSIVE STEPS
(X4) ID PREFIX TAG

4103 LANDERWOOD COURT GREENSBORO, NC 27405

ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
(X5) COMPLETE DATE

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

V 736 Continued From page 7

V 736

- side chair next to the desk has a broken/missing arm - spackling/sheetrock repair on the ceiling needed painting Interview on 6-20-13 with the Qualified Professional (QP) revealed there is a maintenance request form, but that the repairs mentioned had been overlooked and not written on the form. The QP also reported there was an administrative person that came to the facility every two weeks to pick up time sheets, and he usually did a walk-thru to note any needed repairs or things to be fixed. Interview on 6-20-13 with the Assistant Director (AD) revealed, " we do ' em (repairs) all the time. Mr. [Director/Licensee] just came two months ago. " As for the current repairs needed, the AD stated, " The repairs, I ' ll get them worked on. "

Division of Health Service Regulation STATE FORM

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