Lanier M. Cansler, Secretary Phone: Fax:

Transcription

1 North Carolina Department of Health and Human Services Mental Health Licensure and Certification 109 West Main Street Clinton, North Carolina Phone Fax Beverly Eaves Perdue, Governor Stephanie Alexander, Chief Lanier M. Cansler, Secretary Phone: Fax: June 22, 2010 Ms. Carla J. Roberts, Director Yahweh Center Children s Village P.O. Box Wilmington, NC Re: Follow Up and Onsite Survey completed 06/09/10 Yahweh Center Children s Village PRTF, 5103 Lamb s Path Way, Castle Hayne, NC MHL # Address: croberts@yahwehcenter.org Dear Ms. Roberts: Thank you for the cooperation and courtesy extended during the follow up and onsite survey due to a media report completed June 9, As a result of the follow up survey, it was determined that the deficiency is now in compliance, which is reflected on the enclosed Revisit Report. Additional deficiencies were cited during the survey. Enclosed you will find all deficiencies cited listed on the Statement of Deficiencies Form. The purpose of the Statement of Deficiencies is to provide you with specific details of the practice that does not comply with state regulations. You must develop one Plan of Correction that addresses each deficiency listed on the State Form, and return it to our office within ten days of receipt of this letter. Below you will find details of the type of deficiencies found, the time frames for compliance plus what to include in the Plan of Correction. Type of Deficiencies Found Type B rule violations are cited for 10A NCAC 27G.0201Governing Body Policies Tag number 106 and 10A NCAC 27G.1902 Staff The other tag cited is a standard level deficiency. An Equal Opportunity / Affirmative Action Employer

2 Page 2 of 2 06/22/10 Yahweh Center Children s Village PRTF Yahweh Center Children s Village Time Frames for Compliance A completed Plan of Correction addressing all cited deficiencies must be returned to our office within ten days of receipt of this letter. Type B violations must be corrected within 45 days from the exit date of the survey, which is July 24, Pursuant to North Carolina General Statute 122C-24.1, failure to correct the enclosed deficiency by the 45 th day from the date of the survey may result in the assessment of an administrative penalty of $ (Two Hundred) against Yahweh Center Children s Village for each day the deficiency remains out of compliance. Standard level deficiency must be corrected within 60 days from the exit of the survey, which is August 8, What to include in the Plan of Correction Indicate what measures will be put in place to correct the deficient area of practice (i.e. changes in policy and procedure, staff training, changes in staffing patterns, etc.). Indicate what measures will be put in place to prevent the problem from occurring again. Indicate who will monitor the situation to ensure it will not occur again. Indicate how often the monitoring will take place. Sign and date the bottom of the first page of the State Form. Make a copy of the Statement of Deficiencies with the Plan of Correction to retain for your records. Send the original completed form to our office at the following address within 10 days of receipt of this letter. Mental Health Licensure and Certification Section NC 109 West Main Street Clinton, NC A follow up visit will be conducted to verify all violations have been corrected. If we can be of further assistance, please call Wendy Boone, Team Leader at ext Sincerely, Beverly Houston, RN Facility Survey Consultant I Mental Health Licensure Branch Enclosures Cc: File An Equal Opportunity / Affirmative Action Employer

3 YAHWEH CENTER CHILDREN'S VILLAGE PRTF B. WING MHL /09/ LAMB'S PATHWAY SUMMARY REGULATORY OR LSC ENTIFYING INFORMATION) V 000 INITIAL COMMENTS V 000 A follow up and onsite survey due to a media report was completed 06/09/10. Deficiencies were cited. V G.0201 (A) (8-18) (B) GOVERNING BODY POLICIES V A NCAC 27G.0201 GOVERNING BODY POLICIES (a) The governing body responsible for each facility or service shall develop and implement written policies for the following: (8) use of medications by clients in accordance with the rules in this Section; (9) reporting of any incident, unusual occurrence or medication error; (10) voluntary non-compensated work performed by a client; (11) client fee assessment and collection practices; (12) medical preparedness plan to be utilized in a medical emergency; (13) authorization for and follow up of lab tests; (14) transportation, including the accessibility of emergency information for a client; (15) services of volunteers, including supervision and requirements for maintaining client confidentiality; (16) areas in which staff, including nonprofessional staff, receive training and continuing education; (17) safety precautions and requirements for facility areas including special client activity areas; and (18) client grievance policy, including procedures for review and disposition of client grievances. (b) Minutes of the governing body shall be permanently maintained. LABORATORY DIRECTOR'S OR PROVER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) D5VT11 If continuation sheet 1 of 16

4 YAHWEH CENTER CHILDREN'S VILLAGE PRTF B. WING MHL /09/ LAMB'S PATHWAY SUMMARY REGULATORY OR LSC ENTIFYING INFORMATION) V 106 Continued From page 1 V 106 This Rule is not met as evidenced by: Based on observation, interviews, and record reviews, the facility failed to implement its transportation policy. The findings are: Review on 06/09/10 of "[The licensee] POLICY AND PROCEDURE Subject: Transporting Clients Effective Date: July 1, 2001" revealed, "Purpose: to establish policy that will promote the safe transportation of clients of [the licensee]... Procedure:...2. Each driver is responsible for ensuring that any vehicle used for transporting clients or staff is safe for operation. Before being driven, the vehicle is to be inspected by the driver doing a "walk around" of the vehicle to check for any visible unsafe conditions. Once a month the Assistant Director/designee will assign a staff person to complete a vehicle inspection using the "Monthly Vehicle Safety Inspection Report." This report is to be kept with the mileage log. 3) Each driver is responsible for notifying the Assistant Director, or designee, when maintenance and/or repairs of [the licensee] vehicles are needed. The Assistant Director, or designee, will be responsible for authorizing maintenance or repairs..." Observation on 06/09/10 at approximately 1:30 pm of the tires of the van identified as the one in use for client transport (white 2003 Ford van license tag #YNN6720) revealed that all four tires were very worn. The two rear tires were worn completely smooth in a 6-inch-wide central band, with barely visible tread remaining near the outer edges. The front tires were only slightly less worn. Continued observation revealed the license tag had expired 06/2009. D5VT11 If continuation sheet 2 of 16

5 YAHWEH CENTER CHILDREN'S VILLAGE PRTF B. WING MHL /09/ LAMB'S PATHWAY SUMMARY REGULATORY OR LSC ENTIFYING INFORMATION) V 106 Continued From page 2 V 106 Review on 06/09/10 of "MONTHLY VEHICLE SAFETY INSPECTION REPORTS" for the Ford van for February, March and April 2010 revealed the following comments in the "NEEDS REPAIR" column: --02/26/10: "...tires balding, needs to be replaced...brake light on...steering wheel shakes when braking. Steering stiff at times...oil change needed ASAP (as soon as possible)" --03/26/10: "...tires balding, rear in particular...inspection due...shakes steering wheel when braking...need oil change ASAP..." --04/13/10: "...tires needed-worn...shakes when braking, brake light on...in need of oil change ASAP..." Review on 06/09/10 of "Duplicate Vehicle Registration" from the North Carolina Division of Motor Vehicles revealed the Ford van's inspection would expire 06/30/10. Observation on 06/09/10 at 1:40 pm of the tires of the van identified as having not been in use for several months (white 2003 GMC (General Motors Corporation) van) revealed that all four tires were extremely worn. The two rear tires were worn completely smooth in the middle, with barely-visible tread remaining near the outer edges. The front tires were only slightly less worn. Review on 06/09/10 of "MONTHLY VEHICLE SAFETY INSPECTION REPORTS" for the GMC van for February, March, April, and May 2010 revealed the following comments in the "NEEDS REPAIR" column: --02/26/10: "...turn signal bulb out - left front turn-socket that holds the bulb needs to be replaced. All tires balding, need replacement D5VT11 If continuation sheet 3 of 16

6 YAHWEH CENTER CHILDREN'S VILLAGE PRTF B. WING MHL /09/ LAMB'S PATHWAY SUMMARY REGULATORY OR LSC ENTIFYING INFORMATION) V 106 Continued From page 3 V windshield wipers need fluid...fire extinguisher inspected Sept oil change needed..." --03/24/10: "...Front left turn signal needs part where bulb screws into replaced...rear tires balding-front are OK...needs to be inspected...registration/insurance information needs to be updated...needs oil change..." --04/13/10: "Left front turn signal needs part replaced where bulb screws into. Tires need to be replaced. All worn...needs to be inspected...needs to be re-registered...needs oil change ASAP..." --05/26/10: "...turn signal bulb broke due to female part being broken...inspection due April " During interview on 06/08/10 the admission coordinator stated her understanding was that the tag had been renewed last year but apparently had never been put on the van. Confidential interview with a staff member revealed the license tag had been expired for a "long time." Continued interview revealed the tires were very "slick" so all trips taken in the van with clients were short distances. Confidential interview with another staff member revealed they would not want to ride in the van used to transport clients if it was raining due to the tires being so "slick." During interviews with clients, 6 of 6 (#1, #2, #3, #4, #5, and #6) clients stated the clients were transported on the facility van to appointments and outings. Review on 06/09/10 of "Plan of Correction" dated 06/09/10 and signed by the Executive Director revealed, "Agency volunteer will be contacted on D5VT11 If continuation sheet 4 of 16

7 YAHWEH CENTER CHILDREN'S VILLAGE PRTF B. WING MHL /09/ LAMB'S PATHWAY SUMMARY REGULATORY OR LSC ENTIFYING INFORMATION) V 106 Continued From page 4 V /09/2010 in order to schedule appointment for tires to be replaced. Clients will not be transported in these vehicles prior to inspections. Following inspection, the vehicles will be registered with the state. Anticipated date of completion 06/10/10." This deficiency constitutes a Type B rule violation. An administrative penalty of $ per day will be imposed for failure to correct within 45 days. 27G.1902 Psych. Res. Tx. Facility - Staff 10A NCAC 27G.1902 STAFF (a) Each facility shall be under the direction a physician board-eligible or certified in child psychiatry or a general psychiatrist with experience in the treatment of children and adolescents with mental illness. (b) At all times, at least two direct care staff members shall be present with every six children or adolescents in each residential unit. (c) If the PRTF is hospital based, staff shall be specifically assigned to this facility, with responsibilities separate from those performed on an acute medical unit or other residential units. (d) A psychiatrist shall provide weekly consultation to review medications with each child or adolescent admitted to the facility. (e) The PRTF shall provide 24 hour on-site coverage by a registered nurse. This Rule is not met as evidenced by: Based on record review and interviews the facility D5VT11 If continuation sheet 5 of 16

8 YAHWEH CENTER CHILDREN'S VILLAGE PRTF B. WING MHL /09/ LAMB'S PATHWAY SUMMARY REGULATORY OR LSC ENTIFYING INFORMATION) Continued From page 5 failed to provide minimum staffing according to client's assessed needs and behaviors. The findings are: Review of three audited clients' (#2, #6, and #8) records revealed the following: 1. Review on 06/07/10 of client #2's record revealed a nine year old female admitted on 01/20/10 with diagnoses of Post Traumatic Stress Disorder, Reactive Attachment Disorder, Attention Deficit Hyperactivity Disorder, Neglect, Physical and Sexual Abuse of Child. Review on 06/07/10 of client's #2's admission assessment revealed the following conduct problems: Lying, Assault, Property Damage, Impulse Control, Oppositional/Defiant, Sexual Acting Out, Aggressive toward peers. Continued review revealed manic behaviors documented were Hyperactivity and Hypersexual. Review on 06/07/10 of client #2's record revealed a signed physician's order dated 02/18/10 which documented "Psychosexual assessment (assess potential perpetration) Close monitoring (no notes/bubble space/personal space) (arm's length away from other peers)." Review on 06/07/10 of client #2's Individual Crisis Management Plan revealed the following high risk behaviors: physical aggression; verbal aggression; property destruction; making false allegations against adults; self-injury (hitting herself, sticking herself w/ (with) pencils, banging into walls, picking at sores, pulling her hair); inappropriate sexual behaviors (exposing herself, insertion, inappropriately touching others, sexual talk). D5VT11 If continuation sheet 6 of 16

9 YAHWEH CENTER CHILDREN'S VILLAGE PRTF B. WING MHL /09/ LAMB'S PATHWAY SUMMARY REGULATORY OR LSC ENTIFYING INFORMATION) Continued From page 6 Review on 06/07/10 of a psychiatry progress note dated 04/19/10 revealed "Current Presentation: Upset this am because her level was frozen due to walking out of shower with only a towel covering her lower body--staff has repeatedly reviewed showing rules and expectations, so is likely acting out, manipulative and sexualized attention seeking behavior. She's working on how she behaves when she's frustrated or angry, rather than just withdraw or act out--today her strategy is to lie about showering incident and blame RN (registered nurse) for lying. Still has to be closely monitored due to sexualized behavior with history of acting out..." Review on 06/07/10 of a DHHS (Department of Health and Human Services) Incident and Death Report for client #2 dated 03/09/10 at 11:15 am revealed "Client became upset when staff explained to her that she would not be able to go outside because she had been touching herself inappropriately. Client began to tell staff that she was going to bit her lip until it bled. Client continued to tell staff that she was going to kill herself and that she was going to not eat and drink until she died. Staff informed the nurse who called on-call and client's therapist. The nurse assessed client and the assessment did not show her to be high risk. Staff monitored client closely to ensure her safety until she spoke with her therapist." 2. Review on 06/09/10 of client #6's record revealed a 12 year old male admitted on 03/14/10 with diagnoses of Tourettes Disorder, Mood Disorder NOS (not otherwise specified), Attention Deficit Hyperactivity Disorder combined type, Oppositional Defiant Disorder, and Asthma. Review on 06/09/10 of client #6's admission D5VT11 If continuation sheet 7 of 16

10 YAHWEH CENTER CHILDREN'S VILLAGE PRTF B. WING MHL /09/ LAMB'S PATHWAY SUMMARY REGULATORY OR LSC ENTIFYING INFORMATION) Continued From page 7 assessment dated 03/25/10 revealed "...He (client #6) was initially placed in the Residential level III cottage on 07/31/09 however required a higher level of care. He was referred by his case manager for the following presenting behaviors: anxiety, physical assault, unruly/unmanageable, verbal assault, property destruction, hyperactive, impulsive, lying, low self esteem, oppositional, self injuring behavior, difficulty with siblings, and stealing..." 3. Review on 06/09/10 of client #8's record revealed a 8 year old male admitted on 01/11/10 with diagnoses of Attention Deficit Hyperactivity Disorder, Disorder of written expression, rule out Dyslexia, and Post Traumatic Stress Disorder. Review on 06/09/10 of client #8's admission assessment dated 01/20/10 revealed the client's conduct problems were Lying, Assault, Fighting, Property Damage, Impulse control, Oppositional Defiant, Aggressive toward adults and peers. Review on 06/07/10 of the facility's incident reports for May and June 2010 revealed the following: - From 05/01/10 through 06/05/10 two clients with injuries while in reflection; - From 05/08/10 through 05/28/10 eight suicidal comments and four suicidal gestures; - From 05/04/10 through 05/11/10 client #1 had to be put in seclusion on three occasions, the first occasion was for 20 minutes, the second occasion was for 45 minutes, and the third occasion was for 21 minutes; - From 05/08/10 through 06/06/10 client #9 had to be put in seclusion on seven occasions as follows, 1st for 50 minutes, 2nd for 17 minutes, 3rd for 58 minutes, 4th for 47 minutes, 5th no time D5VT11 If continuation sheet 8 of 16

11 YAHWEH CENTER CHILDREN'S VILLAGE PRTF B. WING MHL /09/ LAMB'S PATHWAY SUMMARY REGULATORY OR LSC ENTIFYING INFORMATION) Continued From page 8 documented, 6th put in reflection by staff and injury occurred when staff accidentally hit client in eye resulting in a black eye, 7th for 33 minutes; - From 05/08/10 through 06/01/10 client #3 had to be put in seclusion on 2 occasions, 1st for 57 minutes and 2nd for 20 minutes; - From 05/10/10 through 05/27/10 client #5 had to be put in seclusion on 2 occasions, 1st for 9 minutes and 2nd for 23 minutes; - On 05/22/10 client #5 had to be put in a small child restraint for one minute and a team restraint for one minute due to self injurious behavior; - On 05/12/10 client #8 had to be but in seclusion for 17 minutes; - From 05/17/10 to 06/02/10 client #6 had to be put in seclusion on 2 occasions, 1st for 18 minutes and 2nd for 5 minutes; - On 06/02/10 client #6 had to be put in a small child restraint for 5 minutes. Review of the facility's personnel files revealed 2 staff had been terminated on 05/07/10 and 05/28/10 and 4 staff had been terminated on 06/01/10 and 06/04/10. Review on 06/08/10 for the facility's staff schedule revealed it was unable to be determined what staff had worked on some shifts due to no staff being assigned. Information was requested on 06/08/10 for documentation of shift coverage. No further information was provided by the end of the survey which showed the number of staff that worked each shift. Review on 06/09/10 of Yahweh Center "On-call week summary" the only documentation provided D5VT11 If continuation sheet 9 of 16

12 YAHWEH CENTER CHILDREN'S VILLAGE PRTF B. WING MHL /09/ LAMB'S PATHWAY SUMMARY REGULATORY OR LSC ENTIFYING INFORMATION) Continued From page 9 revealed the following (the information on the On-call week summary was for the current facility and a sister facility so it was unable to be determined which facility staff called out from since the facility was not indicated in some of the reports): "Week of 5/17 to 5/26/10" "Staffing Issues - Extra coverage needed in Peach cottage (current facility) 5/23 from 5-8 pm. [Two staff] called out from Peach cottage 5/20." Under "Client related issues" the following was documented: Lots of restraints and suicide watches in both cottages, often more than 1 child simultaneously... Placed several kids on phase 1 or frozen status for behaviors throughout the week." Written in hand writing across the bottom of the form was "[Executive Director] covered 05/ pm in Peach." Week of "May 26 - June 3rd" "Staffing Issues - [Staff] called me on Wednesday night to tell me that she didn't get [staffs] message about her needing to be at work, even if she found somewhere to sleep, or sat in a more comfortable chair. She told me that she had a doctor's note for her to be out of work until Monday May 31st and she said she could bring this in. She did not find someone to cover her shift for her. - The same night that this occurred (May 26) [1st staff nor 2nd staff] showed up for their shift. In the end it appears that they didn't know they were scheduled, because they were both leaning on the fact of what their rotation is. I asked both of them to please pay more close attention to the schedule in the future, because of the fact that we are still trying to hire an ORC (Overnight Residential Counselor) to fill the whole that we currently have in the schedule. [Staff] attempted D5VT11 If continuation sheet 10 of 16

13 YAHWEH CENTER CHILDREN'S VILLAGE PRTF B. WING MHL /09/ LAMB'S PATHWAY SUMMARY REGULATORY OR LSC ENTIFYING INFORMATION) Continued From page 10 to find someone to watch her kids, so she would still come in, but was unable to do so. - With both of these issues going on, this caused us to have the nurse in ratio in both cottages, and [staff] agreed to work the overnight shift, after working the evening shift. - [Staff] appeared to be very tired on several occasions this week. I know that him working the doubles is getting to him, and he admitted and other staff noted that he didn't seem to be able to be as therapeutic as he normally is, because he is worn out. He and I worked out a plan to give some of his shifts to others for the benefit of the kids, the program, and of course [himself]. He is looking at getting [another staff] to cover his morning shifts on Thursday and Friday. He worked the double on Monday May 31st, and we are working on getting someone to cover one of his shifts on Wednesday. - [Staff] arrived 10 minutes late on two days this week Wednesday and Friday, and then arrived an hour late for his shift on Sunday Morning. He thought he was suppose to arrive at 8am, but the schedule showed 7am, He didn't look at schedule, he said he just went of [Administration Staff] word about his schedule in regards to TCI (?). - [Staff] called out and did not find coverage for Tuesday night." Under "Client related issues" -...[Client #9] was secluded twice, and made suicidal comments on both occasions, which ended up being more for intention than because he really wanted to do this." "Week of June 2 thru June 9, Monday 6/7/10: Prior to first shift, [Cottage Operations Coordinator (COC)] called to report that he was not coming in to work first shift. [COC] stated he was not coming in to work today because he had already resigned and was not D5VT11 If continuation sheet 11 of 16

14 YAHWEH CENTER CHILDREN'S VILLAGE PRTF B. WING MHL /09/ LAMB'S PATHWAY SUMMARY REGULATORY OR LSC ENTIFYING INFORMATION) Continued From page 11 going to honor the plan he had made with [Executive Director] and [Human Resources] to work out a 30 day notice so he could receive payment for his PDO (paid day off). [COC] reported to me that after seeing the news on Friday night and talking with his family, he was going to forgo his commitment to work out a 30 day notice - he stated he could not come in and work at the Yahweh Center any longer... - Later in the morning, I received a call from [staff] RC (Residential Counselor) who informed me she had to leave first shift in Peach PRTF at 12:30 to go to a doctor's appointment because of her high blood pressure. Due to the schedule confusion, I referred her to [Human Resources] who has the responsibility for the schedule since I was unable to access a correct schedule. In my follow up to this issue, I was told that [another RC] was coming in early for second shift to cover for [staff] so she could go to her doctor's appointment." During interview on 06/07/10 client #7 stated there's normally 4 or 5 staff here during the day including the teacher and teacher's assistant. "Usually three on the weekend. [Client #9, #1, #3, #5, and #6] are having to go to seclusion." During interview on 06/07/10 client #4 stated "I can't remember" (how many staff work). "There's nine kids... Usually at night usually have two staff with one nurse at night." During interview on 06/07/10 client #8 stated "...In the morning when we are waking up there's 2 or 3 staff, 2 on floor and nurse. There's enough staff here all the time." During interview on 06/07/10 client #1 stated "Always three staff. Three staff at night includes D5VT11 If continuation sheet 12 of 16

15 YAHWEH CENTER CHILDREN'S VILLAGE PRTF B. WING MHL /09/ LAMB'S PATHWAY SUMMARY REGULATORY OR LSC ENTIFYING INFORMATION) Continued From page 12 nurse." During interview on 06/07/10 client #5 stated "...Usually 3 or 4 staff here. Two at night on the floor and the nurse is here. There's plenty of staff. Outside if three kids go outside at least two staff." During interview on 06/07/10 client #6 stated "Four or Five staff mostly four. Sometimes three mostly four. At night mostly two and nurse." During interview on 06/07/10 client #2 stated "Don't know how many staff are here..." During interview on 06/07/10 client #3 stated "...At night 2 staff and nurse." During interview on 06/07/10 the Teacher's Assistant stated there are always four staff when he worked on Mondays through Friday during the day. Continued interview revealed only two staff had worked at night plus the nurse in the last three months. "We are not getting paid on time. Six weeks behind. Supposed to get paid last Friday but we are supposed to be getting paid tomorrow. Some people don't have the motivation to work without getting paid on time... " During confidential interview a staff member stated "We only have three floor staff now it used to be four. We're not getting paid on time... They are six weeks behind. Lately there's been two some mornings and three some mornings plus the nurse. The nurse comes out and helps if needed. Staff probably called in because not getting paid." The staff member named four staff had left recently because of not getting paid and some have given notice. D5VT11 If continuation sheet 13 of 16

16 YAHWEH CENTER CHILDREN'S VILLAGE PRTF B. WING MHL /09/ LAMB'S PATHWAY SUMMARY REGULATORY OR LSC ENTIFYING INFORMATION) Continued From page 13 During a confidential interview another staff member stated on first shift four staff worked plus the teacher and assistant. Continued interview revealed the staffing ratio was the same on 2nd except for the school staff. The staff stated "[Client #2] needs two staff with her. Staff sit outside her door." The staff member stated there used to be four staff at night but recently staff members were calling in at the last minute and there had been only two staff on the floor and one nurse. The staff member stated their paycheck was eight weeks behind and "I have had checks bounce and have had to hold checks... People started leaving three weeks ago..." During confidential interview a third staff member stated "On days there's usually 3 staff. On 11p (pm) to 7a (am) there's 2 or 3 not including the nurse. People are calling in lately. Staff are normally replaced. The ratio is supposed to be 3:1. [Client #2] is on one to one." The staff named three staff members who had been calling in. "There have been several people who have quit." The nurses are not included in ratio but recently the nurses are because staff is calling in but the nurse goes on the floor only when she is needed. During interview on 06/08/10 the Executive Director stated they were working with minimal staffing right now due to employees leaving without notice and they were hiring and training staff as fast as they could. Based on interview with staff and clients there were only two to three staff on the floor with nine clients, one of which (client #2) was on close observation per physician's order which left one to two staff for eight other clients outside of the required ratio of two to six. D5VT11 If continuation sheet 14 of 16

17 YAHWEH CENTER CHILDREN'S VILLAGE PRTF B. WING MHL /09/ LAMB'S PATHWAY SUMMARY REGULATORY OR LSC ENTIFYING INFORMATION) Continued From page 14 Review on 06/09/10 of the "Plan of Correction" dated 06/09/10 and signed by the Executive Director revealed, "We currently have three residential counselors in training who will be deployed immediately following their training period. In addition, the director and clinical manager will be available for back-up. There is also an on-call person available at any time as a first responder." This deficiency constitutes a Type B rule violation. An administrative penalty of $ per day will be imposed for failure to correct within 45 days. V G.0304(b)(3) Maintenance of Elec., Mech., & Water Systems V A NCAC 27G.0304 FACILITY DESIGN AND EQUIPMENT (b) Safety: Each facility shall be designed, constructed and equipped in a manner that ensures the physical safety of clients, staff and visitors. (3) Electrical, mechanical and water systems shall be maintained in operating condition. This Rule is not met as evidenced by: Based on record review and interviews the facility failed to ensure mechanical systems were maintained in working order. The findings are: During interviews on 06/08/10, 8 of 9 clients (#1, #2, #3, #4, #5, #6, #7, and #8) stated the air conditioner had not been working for approximately a month in May of In continued interviews the clients stated it had been very hot in their sleeping area which made it hard D5VT11 If continuation sheet 15 of 16

18 YAHWEH CENTER CHILDREN'S VILLAGE PRTF B. WING MHL /09/ LAMB'S PATHWAY SUMMARY REGULATORY OR LSC ENTIFYING INFORMATION) V 750 Continued From page 15 V 750 for them to sleep. The clients also stated the staff had to bring fans in the hallway and they had to pull their mattress close to the door. During confidential interviews on 06/08/10, 2 of 2 staff members stated the air conditioner had not been working in May Both staff members stated the work was being done by a volunteer so he had worked around his normal schedule to get the air conditioner repaired. The Admission Coordinator provided a receipt for the air conditioner repair on 06/08/10. Review of the air conditioner repair receipt on 06/08/10 revealed a thermostat for the air conditioner had been ordered 05/04/10 and delivered on 06/01/10. D5VT11 If continuation sheet 16 of 16

19 North Carolina Department of Health and Human Services Mental Health Licensure and Certification 109 West Main Street Clinton, North Carolina Phone Fax Beverly Eaves Perdue, Governor Stephanie Alexander, Chief Lanier M. Cansler, Secretary Phone: Fax: June 22, 2010 Ms. Carla Roberts, Director Yahweh Center, Inc. P.O. Box Wilmington, NC Re: Onsite Survey completed 06/09/10 Yahweh Center PPD-PRTF MHL # Address: croberts@yahwehcenter.org Dear Ms. Roberts: Thank you for the cooperation and courtesy extended during the onsite survey due to a media report completed June 9, Enclosed you will find all deficiencies cited listed on the Statement of Deficiencies Form. The purpose of the Statement of Deficiencies is to provide you with specific details of the practice that does not comply with state regulations. You must develop one Plan of Correction that addresses each deficiency listed on the State Form, and return it to our office within ten days of receipt of this letter. Below you will find details of the type of deficiencies found, the time frames for compliance plus what to include in the Plan of Correction. Type of Deficiencies Found Type B rule violations are cited for 10A NCAC 27G.0201Governing Body Policies Tag V106 and 10A NCAC 27G.1902 Staff Tag V315 The other tag cited is a standard level deficiency. Time Frames for Compliance A completed Plan of Correction addressing all cited deficiencies must be returned to our office within ten days of receipt of this letter. Type B violations must be corrected within 45 days from the exit date of the survey, which is July 24, Pursuant to North Carolina General Statute 122C-24.1, failure to correct the enclosed deficiency by the 45 th day from the date of the survey may result in the assessment of an administrative penalty of $ (Two Hundred) against Yahweh Center, Inc. for each day the deficiency remains out of compliance. Standard level deficiency must be corrected within 60 days from the exit of the survey, which is August 8, An Equal Opportunity / Affirmative Action Employer

20 Page 2 of 2 06/22/10 Yahweh Center PPD-PRTF Yahweh Center, Inc. What to include in the Plan of Correction Indicate what measures will be put in place to correct the deficient area of practice (i.e. changes in policy and procedure, staff training, changes in staffing patterns, etc.). Indicate what measures will be put in place to prevent the problem from occurring again. Indicate who will monitor the situation to ensure it will not occur again. Indicate how often the monitoring will take place. Sign and date the bottom of the first page of the State Form. Make a copy of the Statement of Deficiencies with the Plan of Correction to retain for your records. Send the original completed form to our office at the following address within 10 days of receipt of this letter. Mental Health Licensure and Certification Section NC 109 West Main Street Clinton, NC A follow up visit will be conducted to verify all violations have been corrected. If we can be of further assistance, please call Wendy Boone, Team Leader at ext Sincerely, Beverly Houston, RN Facility Survey Consultant I Mental Health Licensure Branch Enclosures Cc: File An Equal Opportunity / Affirmative Action Employer

21 YAHWEH CENTER - PPD - PRTF B. WING MHL /09/ LAMB'S PATH WAY SUMMARY REGULATORY OR LSC ENTIFYING INFORMATION) V 000 INITIAL COMMENTS V 000 An onsite survey due to a media report was completed on 06/09/10. Deficiencies were cited. V G.0201 (A) (8-18) (B) GOVERNING BODY POLICIES V A NCAC 27G.0201 GOVERNING BODY POLICIES (a) The governing body responsible for each facility or service shall develop and implement written policies for the following: (8) use of medications by clients in accordance with the rules in this Section; (9) reporting of any incident, unusual occurrence or medication error; (10) voluntary non-compensated work performed by a client; (11) client fee assessment and collection practices; (12) medical preparedness plan to be utilized in a medical emergency; (13) authorization for and follow up of lab tests; (14) transportation, including the accessibility of emergency information for a client; (15) services of volunteers, including supervision and requirements for maintaining client confidentiality; (16) areas in which staff, including nonprofessional staff, receive training and continuing education; (17) safety precautions and requirements for facility areas including special client activity areas; and (18) client grievance policy, including procedures for review and disposition of client grievances. (b) Minutes of the governing body shall be permanently maintained. LABORATORY DIRECTOR'S OR PROVER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) Q45F11 If continuation sheet 1 of 18

22 YAHWEH CENTER - PPD - PRTF B. WING MHL /09/ LAMB'S PATH WAY SUMMARY REGULATORY OR LSC ENTIFYING INFORMATION) V 106 Continued From page 1 V 106 This Rule is not met as evidenced by: Based on observation, interviews, and record reviews, the facility failed to implement its transportation policy. The findings are: Review on 06/09/10 of "[The licensee] POLICY AND PROCEDURE Subject: Transporting Clients Effective Date: July 1, 2001" revealed, "Purpose: to establish policy that will promote the safe transportation of clients of [the licensee]... Procedure:...2. Each driver is responsible for ensuring that any vehicle used for transporting clients or staff is safe for operation. Before being driven, the vehicle is to be inspected by the driver doing a 'walk around' of the vehicle to check for any visible unsafe conditions. Once a month the Assistant Director/designee will assign a staff person to complete a vehicle inspection using the 'Monthly Vehicle Safety Inspection Report.' This report is to be kept with the mileage log. 3) Each driver is responsible for notifying the Assistant Director, or designee, when maintenance and/or repairs of [the licensee] vehicles are needed. The Assistant Director, or designee, will be responsible for authorizing maintenance or repairs..." Observation on 06/09/10 at approximately 1:30 pm of the tires of the van identified as the one in use for client transport (white 2003 Ford van license tag #YNN6720) revealed that all four tires were very worn. The two rear tires were worn completely smooth in a 6-inch-wide central band, with barely visible tread remaining near the outer edges. The front tires were only slightly less worn. Continued observation revealed the license tag had expired 06/2009. Q45F11 If continuation sheet 2 of 18

23 YAHWEH CENTER - PPD - PRTF B. WING MHL /09/ LAMB'S PATH WAY SUMMARY REGULATORY OR LSC ENTIFYING INFORMATION) V 106 Continued From page 2 V 106 Review on 06/09/10 of "MONTHLY VEHICLE SAFETY INSPECTION REPORTS" for the Ford van for February, March and April 2010 revealed the following comments in the "NEEDS REPAIR" column: --02/26/10: "...tires balding, needs to be replaced...brake light on...steering wheel shakes when braking. Steering stiff at times...oil change needed ASAP (as soon as possible)" --03/26/10: "...tires balding, rear in particular...inspection due...shakes steering wheel when braking...need oil change ASAP..." --04/13/10: "...tires needed-worn...shakes when braking, brake light on...in need of oil change ASAP..." Review on 06/09/10 of "Duplicate Vehicle Registration" from the North Carolina Division of Motor Vehicles revealed the Ford van's inspection would expire 06/30/10. Observation on 06/09/10 at 1:40 pm of the tires of the van identified as having not been in use for several months (white 2003 GMC (General Motors Corporation) van) revealed that all four tires were extremely worn. The two rear tires were worn completely smooth in the middle, with barely-visible tread remaining near the outer edges. The front tires were only slightly less worn. Review on 06/09/10 of "MONTHLY VEHICLE SAFETY INSPECTION REPORTS " for the GMC van for February, March, April, and May 2010 revealed the following comments in the "NEEDS REPAIR" column: --02/26/10: "...turn signal bulb out - left front turn-socket that holds the bulb needs to be replaced. All tires balding, need replacement...windshield wipers need fluid...fire extinguisher Q45F11 If continuation sheet 3 of 18

24 YAHWEH CENTER - PPD - PRTF B. WING MHL /09/ LAMB'S PATH WAY SUMMARY REGULATORY OR LSC ENTIFYING INFORMATION) V 106 Continued From page 3 V 106 inspected Sept oil change needed..." --03/24/10: "...Front left turn signal needs part where bulb screws into replaced...rear tires balding-front are OK...needs to be inspected...registration/insurance information needs to be updated...needs oil change..." --04/13/10: "Left front turn signal needs part replaced where bulb screws into. Tires need to be replaced. All worn...needs to be inspected...needs to be re-registered...needs oil change ASAP..." --05/26/10: "...turn signal bulb broke due to female part being broken...inspection due April " During interview on 06/08/10 the admission coordinator stated her understanding was that the tag had been renewed last year but apparently had never been put on the van. Confidential interview with a staff member revealed the license tag had been expired for a "long time." Continued interview revealed the tires were very "slick" so all trips taken in the van with clients were short distances. Confidential interview with another staff member revealed they would not want to ride in the van used to transport clients if it was raining due to the tires being so "slick." During interviews with clients, 6 of 6 (#1, #2, #3, #4, #5, and #6) clients stated the clients were transported on the facility van to appointments and outings. Review on 06/09/10 of "Plan of Correction" dated 06/09/10 and signed by the Executive Director revealed, "Agency volunteer will be contacted on 06/09/2010 in order to schedule Q45F11 If continuation sheet 4 of 18

25 YAHWEH CENTER - PPD - PRTF B. WING MHL /09/ LAMB'S PATH WAY SUMMARY REGULATORY OR LSC ENTIFYING INFORMATION) V 106 Continued From page 4 V 106 appointment for tires to be replaced. Clients will not be transported in these vehicles prior to inspections. Following inspection, the vehicles will be registered with the state. Anticipated date of completion 06/10/10." This deficiency constitutes a Type B rule violation. An administrative penalty of $ per day will be imposed for failure to correct within 45 days. 27G.1902 Psych. Res. Tx. Facility - Staff 10A NCAC 27G.1902 STAFF (a) Each facility shall be under the direction a physician board-eligible or certified in child psychiatry or a general psychiatrist with experience in the treatment of children and adolescents with mental illness. (b) At all times, at least two direct care staff members shall be present with every six children or adolescents in each residential unit. (c) If the PRTF is hospital based, staff shall be specifically assigned to this facility, with responsibilities separate from those performed on an acute medical unit or other residential units. (d) A psychiatrist shall provide weekly consultation to review medications with each child or adolescent admitted to the facility. (e) The PRTF shall provide 24 hour on-site coverage by a registered nurse. This Rule is not met as evidenced by: Based on record review and interviews the facility failed to provide minimum staffing according to Q45F11 If continuation sheet 5 of 18

26 YAHWEH CENTER - PPD - PRTF B. WING MHL /09/ LAMB'S PATH WAY SUMMARY REGULATORY OR LSC ENTIFYING INFORMATION) Continued From page 5 client's assessed needs and behaviors. The findings are: Observation on 06/07/10 at approximately 3:30 pm revealed two staff members on the floor and one nurse in the nursing station. Review on 06/08/10 of the facility records revealed the facility opened 05/10/10 and the following clients had been admitted since that date. 1. Review on 06/09/10 of client #1's record revealed a 12 year old female admitted 05/10/10 with diagnoses of Bipolar Disorder, Oppositional Defiant Disorder, and Attention Deficit Hyperactive Disorder. Review on 06/09/10 of client #1's admission assessment dated 05/14/10 revealed under "Present Problems/needs" the following problems were identified: Thinks about self harm as evidenced by suicidal thoughts, is physically aggressive toward others, aggression is impulsive, is emotionally explosive, is oppositional toward authority. Continued review revealed abandonment issues, anxiety, unruly/unmanageable, parent neglect issues, socially immature, suicidal, running away, victim of neglect and victim of emotional abuse... Client has made threats to kill her mother and chased her mother around with a knife... She verbalizes she hates her parents and wants to kill them......is physically assaultive toward mother on a day to day basis. [Client #1] can not be alone with Mom. 2. Review on 06/09/10 of client #2's record revealed a 11 year old male admitted on 05/10/10 with diagnoses of Post Traumatic Stress Disorder Q45F11 If continuation sheet 6 of 18

27 YAHWEH CENTER - PPD - PRTF B. WING MHL /09/ LAMB'S PATH WAY SUMMARY REGULATORY OR LSC ENTIFYING INFORMATION) Continued From page 6 NOS (not otherwise specified), History of neglect and abuse. Review on 06/09/10 of client #2's record revealed an admission assessment dated 05/14/10 and listed presenting behaviors as "Abandonment issues, anxiety, lack of empathy, unruly, unmanageable, property destruction, fire setting, hyperactive, impulsive, lying, low self esteem, loss/grief problems, oppositional, self injurious behavior, victim of physical abuse, victim of sexual abuse." Conduct behaviors listed were "lying, stealing, assault, fighting, property damage, fire setting, Impulse Control, family desertion, Oppositional Defiant Disorder, sexual ac ting out, aggressive toward adults and peers." 3. Review on 06/09/10 of client #3's record revealed a 10 year old male admitted on 05/10/10 with diagnoses of Intermittent Explosive Disorder, Mood Disorder, Oppositional Defiant Disorder, Nocturnal Enuresis, and Urinary Urgency. Review on 06/09/10 of client #3's admission assessment dated 05/14/10 revealed conduct problems as "Lying, Assault, Fighting, Property Damage, Impulse Control, Oppositional Defiant/Aggressive toward adults, and aggressive towards peers. Continued review revealed client #3's problems include conflicts with peers, siblings, parents, history of child abuse and neglect." 4. Review on 06/08/10 of client #4's record revealed a 10 year old male admitted on 05/11/10 with diagnoses of Psychotic Disorder, Oppositional Defiant Disorder, Bipolar, Anemia, Tachycardia, and Exposure to Neglect leading to termination of parental rights. Q45F11 If continuation sheet 7 of 18

28 YAHWEH CENTER - PPD - PRTF B. WING MHL /09/ LAMB'S PATH WAY SUMMARY REGULATORY OR LSC ENTIFYING INFORMATION) Continued From page 7 Review on 06/08/10 of client #4's admission assessment revealed conduct disorders as "lying, assault, property damage, fire setting, impulse control, oppositional/defiant, aggressive toward adults and peers." Continued review revealed under client history "He threatens to kill others. Most threats are made towards his adoptive mom. He attempted to poison his mother by putting his medication into her food. He also tried to drown another child while swimming when he was 3 years old. He has been aggressive towards family pets, trying to drown a puppy and throw a kitten in front of a moving car. 5. Review on 06/08/10 of client #5's record revealed a 11 year old male admitted on 05/12/10 with diagnoses of Cyclothymia and Oppositional Defiant Disorder. Review on 06/08/10 of client #5's admission assessment dated 05/19/10 revealed conduct problems as "lying, assault, fighting, property damage, impulse control, oppositional/defiant, aggressive toward staff and peers." Continued review revealed a history of trying to hang himself with numerous objects (belt, shirt, etc.). Review on 06/08/10 of client #5's "Individual Crisis Management Plan" revealed "History of Safety Concerns- Warnings: anxiety, unruly/unmanageable, physical assault, verbal assault, property destruction, depression, lying, low self-esteem, impulsive, oppositional, socially immature, suicidal, self injuring behavior, victim of neglect, victim of emotional abuse, victim of physical abuse." Under "Current Issues- Potential Triggers: limit setting; peers; authority figures; suicidal gestures/ideations/attempts; low frustration level; not feeling well; people taking his things; smokers or those he thinks smokes." Q45F11 If continuation sheet 8 of 18

29 YAHWEH CENTER - PPD - PRTF B. WING MHL /09/ LAMB'S PATH WAY SUMMARY REGULATORY OR LSC ENTIFYING INFORMATION) Continued From page 8 6. Review on 06/09/10 of client #6's record revealed a 10 year old male admitted on 05/12/10 with diagnoses of Anxiety Disorder, Oppositional Defiant Disorder, and Attention Deficit Hyperactivity Disorder. Review on 06/09/10 of client #6's admission assessment dated 05/19/10 revealed present problems as verbal assault, depression, hyperactivity, lying, low self esteem, loss/grief problems, oppositional, self injury, suicidal, and running away. History of jumping from moving cars, demonstrates self injurious behaviors including stabbing himself with a pencil, picking at skin, biting self, banging his head with whatever is on hand, including a 5 pound weight that resulted in the need for a butterfly stitch. Has stated he's going to set the school on fire and then shoot everyone with a gun when they run out. Also threatens to kill his family while they sleep. Has stated "wants to kill self." Review on 06/07/10 of the facility's incident reports for May and June 2010 revealed the following: - From 05/11/10 through 05/20/10 client #4 made two comments with suicidal gestures and had to be secluded two times. - From 05/16/10 through 06/03/10 client #5 made one suicidal comment and four suicidal gestures and had to be secluded 13 times. Client #5 was also on suicide precaution and had a one on one staff person for 10 days during this period of time. - From 05/11/10 through 05/30/10 client #3 had to be put in seclusion on five occasions - On 05/25/10 client #6 had to be put in a small child restraint. - On 05/27/10 client #2 had to be put in seclusion. Q45F11 If continuation sheet 9 of 18

30 YAHWEH CENTER - PPD - PRTF B. WING MHL /09/ LAMB'S PATH WAY SUMMARY REGULATORY OR LSC ENTIFYING INFORMATION) Continued From page 9 Review on 06/08/10 of client #4's record revealed he had also been on suicide watch and every five minute checks on 05/20-21/10 at the same time as client #5 was on suicide watch and every five minute checks. Review on 06/08/10 of a note written on the back of a suicidal assessment for client #5 dated 05/17/10 revealed "Only two on overnight shifts... 1 kid [client #5] on suicide watch every 5 mins (minutes). 5 kids had 15 mins checks by [nurse]. I was able to sweep 1/2 of the hallway. Wash and folded 3 loads of cloths and towels. Clean boys bathroom sinks/toilet/tub. Clean kitchen (wiped down). Straigh hall closet. The remaining of time was spent watching [client #5]..." Review on 06/08/10 of the facility's personnel files revealed 2 staff had been terminated on 05/07/10 and 05/28/10 and 4 staff had been terminated on 06/01/10 and 06/04/10. Review on 06/08/10 for the facility's staff schedule revealed it was unable to be determined what staff had worked on some shifts due to no staff being assigned. Continued review revealed " anyone interested " was typed on multiple night shifts. Information was requested on 06/08/10 for documentation of shift coverage. Review on 06/09/10 of Yahweh Center "On-call week summary" the only documentation provided revealed the following (the information on the On-call week summary was for the current facility and a sister facility so it was unable to be determined which facility staff called out since facility was not indicated): "Week of 5/17 to 5/26/10" Q45F11 If continuation sheet 10 of 18