New Hanover Treatment Center - 2017 DHHS Inspection (Redacted)

PRINTED: 10/16/2017
FORM APPROVED
Division of Health Service Regulation
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING: ______________________
R
MHL065-117 B. WING _____________________________
09/29/2017
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
1611 CASTLE HAYNE ROAD, UNIT D
NEW HANOVER TREATMENT CENTER
WILMINGTON, NC 28404
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)
V 000 INITIAL COMMENTS V 000
An annual, complaint and follow up survey was

completed on September 29, 2017. The
complaint was unsubstantiated (#NC00130497).
Deficiencies were cited.
This facility is licensed for the following service

category: 10A NCAC 27G .3600 Outpatient
Opioid Treatment. The census at the time of the
survey was 360.
V 105 27G .0201 (A) (1-7) Governing Body Policies V 105
10A 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:
(1) delegation of management authority for the
operation of the facility and services;
(2) criteria for admission;
(3) criteria for discharge;
(4) admission assessments, including:
(A) who will perform the assessment; and
(B) time frames for completing assessment.
(5) client record management, including:
(A) persons authorized to document;
(B) transporting records;
(C) safeguard of records against loss, tampering,
defacement or use by unauthorized persons;
(D) assurance of record accessibility to
authorized users at all times; and
(E) assurance of confidentiality of records.
(6) screenings, which shall include:
(A) an assessment of the individual's presenting
problem or need;
(B) an assessment of whether or not the facility
can provide services to address the individual's
needs; and
(C) the disposition, including referrals and
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
STATE FORM 6899

4BC611 If continuation sheet 1 of 50
PRINTED: 10/16/2017
FORM APPROVED
A. BUILDING: ______________________
R
MHL065-117 B. WING _____________________________
09/29/2017
DEFICIENCY)
V 105 Continued From page 1 V 105
recommendations;
(7) quality assurance and quality improvement
activities, including:
(A) composition and activities of a quality
assurance and quality improvement committee;
(B) written quality assurance and quality
improvement plan;
(C) methods for monitoring and evaluating the
quality and appropriateness of client care,
including delineation of client outcomes and
utilization of services;
(D) professional or clinical supervision, including
a requirement that staff who are not qualified
professionals and provide direct client services
shall be supervised by a qualified professional in
that area of service;
(E) strategies for improving client care;
(F) review of staff qualifications and a
determination made to grant
treatment/habilitation privileges:
(G) review of all fatalities of active clients who
were being served in area-operated or contracted
residential programs at the time of death;
(H) adoption of standards that assure operational
and programmatic performance meeting
applicable standards of practice. For this
purpose, "applicable standards of practice"
means a level of competence established with
reference to the prevailing and accepted
methods, and the degree of knowledge, skill and
care exercised by other practitioners in the field;
This Rule is not met as evidenced by:

Based on record review and interviews the facility
failed to develop and implement written policies
STATE FORM 6899
PRINTED: 10/16/2017
FORM APPROVED
A. BUILDING: ______________________
R
MHL065-117 B. WING _____________________________
09/29/2017
DEFICIENCY)
for the adoption of standards that assure

operational and programmatic performance
meeting applicable standards of practice for
patients with continuous positive drug
screens effecting of Deceased Clients (DC
#1). The findings are:
Review on 9/28/17 of the facility's policy on

Treatment Retention of Patients with Continuous
Positive Drug Screens revealed:
-"[The Licensee] recognizes that some patients
may continue to use illicit drugs during treatment
and, that such use may be detected through urine
drug screens. In such cases, it is the policy of [the
Licensee] to use clinically-appropriate intervention
in an attempt to motivate the patient to
discontinue drug use ...Identify the chemical
being used, the route of administration, and the
frequency of use ...Place patient on 90 day
probation ...document in the patient's chart, if
appropriate, the patient's written rational for
continuing treat, increase counseling contact,
create a referral to an outside agency to an
outside agency ...such as Alcoholics Anonymous
...consider effecting a counselor change, transfer
to inpatient, intensive outpatient, or another
outpatient treatment center, increase frequency of
urine drug screens. Consider Involuntary
Medically Supervised Withdrawal. This is not to
be based solely on the results of a urine drug
screen, but with input from the counselors,
nurses, Program Director (PD) and Medical
Director (MD). Seek supervision from the PD, MD
and peers to facilitate learning and identify
potential strategies. Once the PD and MD's
determination are issued, treatment shall either
proceed toward discharge or continuation of
treatment per team direction."
Review on 9/28/17 of the facility's policy on

STATE FORM 6899
PRINTED: 10/16/2017
FORM APPROVED
A. BUILDING: ______________________
R
MHL065-117 B. WING _____________________________
09/29/2017
DEFICIENCY)
DC #1.
-The MD would have to make the decision for
and a treatment team meeting would have
to have been held.
-A ) was
not discussed with DC #1.
-DC #1's case was never brought before the
treatment team. The Medical Director was never
consulted regarding drug
screens. There was never a discussion
regarding a higher level of care.
This deficiency is cross referenced into: 10A

NCAC 27G .3601 SCOPE (V233) for a Type A1
rule violation and must be corrected within 23
days.
V 109 27G .0203 Privileging/Training Professionals V 109
10A NCAC 27G .0203 COMPETENCIES OF

QUALIFIED PROFESSIONALS AND
ASSOCIATE PROFESSIONALS
(a) There shall be no privileging requirements for
qualified professionals or associate professionals.
(b) Qualified professionals and associate
professionals shall demonstrate knowledge, skills
and abilities required by the population served.
(c) At such time as a competency-based
employment system is established by rulemaking,
then qualified professionals and associate
professionals shall demonstrate competence.
(d) Competence shall be demonstrated by
exhibiting core skills including:
(1) technical knowledge;
(2) cultural awareness;
(3) analytical skills;
(4) decision-making;
(5) interpersonal skills;
(6) communication skills; and
STATE FORM 6899
PRINTED: 10/16/2017
FORM APPROVED
A. BUILDING: ______________________
R
MHL065-117 B. WING _____________________________
09/29/2017
DEFICIENCY)
should have met with the treatment team, but I

did not ..."
-After the first or second screen, "I
should have done an intervention ..."
-"I encouraged (DC #1) not to , how it
was detrimental and referred to a Medical
Doctor ...I did the best I could ...I could have done
better ..."
-After learning the effects of mixed with
"I learned of the risks and I told
not to ..."
-DC #1's case was not reviewed for
-Was unable to recall if Coordination of Care was

done for DC #1.
-When asked why the counseling requirement
had not been met she indicated that "may have
been because wouldn't come by, would say
coming back, but wouldn't come back".
-DC #1 informed that was experiencing
( days before death)
but failed to inform the nurses and the
Medical Director.
-"My office is right next to the nurse, I hear
tell them every day the stuff that is wrong with
...I can hear talking to them about the
problems having ..."
- stated that had talked to the Program
Director about DC #1's case. " ...we had a
conversation about how much was
and that needed medical attention ..."
-Was aware DC #1 complained of .
-Did not consult with the Medical Director
regarding DC #1's complaints of .
- indicated that observed and touched the
in and advised to "take care
of that immediately, see the doctor". replied
to
Interview on 9/29/17 with the RN #1 revealed:

STATE FORM 6899
PRINTED: 10/16/2017
FORM APPROVED
A. BUILDING: ______________________
R
MHL065-117 B. WING _____________________________
09/29/2017
DEFICIENCY)
intervention.
-"They were really lacking there in that sense.
Counselors just had training on how to improve
with documentation ..."
-" ...For to be saying
not qualified (to make a
diagnosis). should have brought to
doctor, then a treatment team meeting with the
patient to try to figure out what to do. When not
telling anyone, how is anyone else going to know
...?"
-The PD stated the Medical Director (MD) was
not involved in DC #1's treatment after testing
for
-The MD should have been involved by the
second test. DC #1 tested for
months in a row.
-No one had mentioned DC #1's in the
or .
-"I wasn't very cognizant of that
until we reviewed
record after death ...some things we're limited
in what we do and what we treat, if someone is
telling you and you're a counselor and that's out
of your knowledge base, you need to immediately
get the nurse or doctor, could even call 911, must
document follow through. Those things did not
occur in that case ..."
-No were used when DC #1 tested
for
-" ...After the first should have been
right then, If it came back
counselor would say we need to meet with doctor
...The reality was as soon as first drug screen
for action should have been
taken and it wasn't ..."
- DC #1's case was not staffed by CSAC #1 for
or for a treatment team meeting.
-Stated the nurses should be looking at drug
screen and the counselors should be checking
STATE FORM 6899
PRINTED: 10/16/2017
FORM APPROVED
A. BUILDING: ______________________
R
MHL065-117 B. WING _____________________________
09/29/2017
DEFICIENCY)
and doctor should be checking when they look at

a patient.
-"After the second (screen), the
counselor should have called a treatment team
meeting and met with the doctor ...
-DC #1 should have been assessed by the MD
and but was not.
-" ... was just meeting with counselor and
saying whatever and was just writing it
down."
-"If doctor had said to 'this is not realistic that
is causing you to have this
...and now you're having
medical issues, then we can say 'let's talk about
the importance of and the dangers of
continuing to while on ...
-" ...We should have tried to gotten
gotten the care needed ..."
- "Professionally speaking, (CSAC #1)
struggles with documentation and following
through.
Kind of thought ...In a sense, this is redundant to
this, what they're supposed to do with the
drug screen ...The MD gets very frustrated with
these issues. is a good doctor and wants to
do the right thing, tries hard to be cautious and
safe with patients' care ..."
-The only way the PD would know about
screens was if someone brought it to
attention or audited chart.
-"When died and got chart to audit, is when
I realized the whole gamut. I had last audited
chart in (2017) ...the treatment plan, drug
screen notes, I had noticed back in
(2017) that wasn't seeing as required,
wasn't addressing the I put that in the
93b, it's a score for corporate compliance. That's
when I first saw chart ..."
- CSAC #1 did receive disciplinary action.
-When noticed the CSAC #1 was having
STATE FORM 6899
PRINTED: 10/16/2017
FORM APPROVED
A. BUILDING: ______________________
R
MHL065-117 B. WING _____________________________
09/29/2017
DEFICIENCY)
-In 2017, (the RN #1) noted, in

(of DC #1) ...I never saw anything about that
until after had died. Nurses said after died
they'd been telling repeatedly to go to
hospital or see a doctor about but never
said a word to me..."
-When asked about the MD stated
clients should be prior to dosing
every time.
-"If testing ), they're impaired,
shouldn't be dosed. There should have been an
intervention. . There weren't any
used on [DC #1]. should have been brought
to attention a long time ago, and there should
have been an intervention ..."
-"The nursing staff, if they have concerns about a
patient, they should say something ...it this
particular case, when I reviewed the drug
screens, I was disturbed by what was in the
counselor's notes and nothing was done"
-The documentation is not as good as it should
be and the facility staff were dealing with high risk
individuals.
-Stated treatment team meetings occurred one a
week and sometime they met daily depending on
the clients.
-When asked about the PD, the MD stated " ...My
role here is to be the medical person, and I
should be the medical person and those things
shouldn't be talked over. kind of tells you
what you want to hear and then does something
else entirely ..."
-Stated the CSAC #1 should have put DC #1 on
, increased number of
increased , and convened a
treatment team staffing.
-The CSAC #1 was to implement, monitor and
follow up with DC #1.

STATE FORM 6899
PRINTED: 10/16/2017
FORM APPROVED
A. BUILDING: ______________________
R
MHL065-117 B. WING _____________________________
09/29/2017
DEFICIENCY)

days.
V 112 27G .0205 (C-D) V 112

Assessment/Treatment/Habilitation Plan
10A NCAC 27G .0205 ASSESSMENT AND

TREATMENT/HABILITATION OR SERVICE
PLAN
(c) The plan shall be developed based on the
assessment, and in partnership with the client or
legally responsible person or both, within 30 days
of admission for clients who are expected to
receive services beyond 30 days.
(d) The plan shall include:
(1) client outcome(s) that are anticipated to be
achieved by provision of the service and a
projected date of achievement;
(2) strategies;
(3) staff responsible;
(4) a schedule for review of the plan at least
annually in consultation with the client or legally
responsible person or both;
(5) basis for evaluation or assessment of
outcome achievement; and
(6) written consent or agreement by the client or
responsible party, or a written statement by the
provider stating why such consent could not be
obtained.

Based on record reviews and interviews, the
STATE FORM 6899
PRINTED: 10/16/2017
FORM APPROVED
A. BUILDING: ______________________
R
MHL065-117 B. WING _____________________________
09/29/2017
DEFICIENCY)
something to that fact. And to just accept that,

and then month after month see results
for and not say anything, that's
disturbing...This particular case (involving DC #1),
when I reviewed the drug screens, I was
disturbed by what was in the counselor's notes
and nothing was done."
Interview on 9/29/17 with the PD revealed:

-CSAC #1 was responsible for writing the
treatment plans for DC #1
-First learned of DC #1's chronic and
testing after death.
-No one brought it to attention.
-The only way the PD would know about
screens was if someone brought it to
attention or audited chart.
-"When died and got chart to audit, is when
I realized the whole gamut. I had last audited
chart in (2017) ...the treatment plan, drug
screen notes, I had noticed back in
(2017) that wasn't seeing as required,
wasn't addressing the I put that in the
93b, it's a score for corporate compliance. That's
when I first saw chart ..."

days.
V 131 G.S. 131E-256 (D2) HCPR - Prior Employment V 131

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

REGISTRY
(d2) Before hiring health care personnel into a
health care facility or service, every employer at a
health care facility shall access the Health Care
STATE FORM 6899
PRINTED: 10/16/2017
FORM APPROVED
A. BUILDING: ______________________
R
MHL065-117 B. WING _____________________________
09/29/2017
DEFICIENCY)
Personnel Registry and shall note each incident

of access in the appropriate business files.

facility failed to access the Health Care Personnel
Registry (HCPR) prior to hire for of audited
staff (Cashier). The findings are:
Review on 9/27/17 of the facility's cashier's

record revealed:
-A hire date of 9/18/17
-A job description of Cashier
-A HCPR check completed on 9/24/17
Interview on 9/29/17 with the Program Director

revealed:
-Was aware the HCPR were to be completed
prior to hire for facility staff
-"Those checks are done when a staff was
interviewed."
-Stated the facility was cited last year during their
annual survey for not conducting the HCPR
-"I started doing it for all I interviewed ...I noticed
while doing personnel files, sometimes it (the
HCPR) was there and sometimes it wasn't ..."
-Inquired as to what the requirements were for
NCI from the State
-"I just didn't think when I interviewed [the
cashier]..."
V 233 27G .3601 Outpt. Opiod Tx. - Scope V 233
10A NCAC 27G .3601 SCOPE

STATE FORM 6899
PRINTED: 10/16/2017
FORM APPROVED
A. BUILDING: ______________________
R
MHL065-117 B. WING _____________________________
09/29/2017
DEFICIENCY)
(a) An outpatient opioid treatment facility

provides periodic services designed to offer the
individual an opportunity to effect constructive
changes in his lifestyle by using methadone or
other medications approved for use in opioid
treatment in conjunction with the provision of
rehabilitation and medical services.
(b) Methadone and other medications approved
for use in opioid treatment are also tools in the
detoxification and rehabilitation process of an
opioid dependent individual.
(c) For the purpose of detoxification, methadone
and other medications approved for use in opioid
treatment shall be administered in decreasing
doses for a period not to exceed 180 days.
(d) For individuals with a history of being
physiologically addicted to an opioid drug for at
least one year before admission to the service,
methadone and other medications approved for
use in opioid treatment may also be used in
maintenance treatment. In these cases,
methadone and other medications approved for
use in opioid treatment may be administered or
dispensed in excess of 180 days and shall be
administered in stable and clinically established
dosage levels.

Based on interviews and record review the facility
failed to provide services designed to affect
constructive changes in the client's lifestyle by
using methadone in conjunction with the provision
of rehabilitation and medical services affecting
of deceased clients (DC #1), of former
clients (FC #2), and of current clients (#1,
#3, #4, #9, #10, #12). The findings are:

STATE FORM 6899
PRINTED: 10/16/2017
FORM APPROVED
A. BUILDING: ______________________
R
MHL065-117 B. WING _____________________________
09/29/2017
DEFICIENCY)
Cross Reference: 10A NCAC 27G .0201

Governing Body Policies (V105). Based on
record review and interviews the facility failed to
develop and implement written policies for the
adoption of standards that assure operational and
programmatic performance meeting applicable
standards of practice for patients with continuous
drug screens effecting of
Deceased Clients (DC #1).

Competencies of Qualified Professionals and
Associate Professionals (V109). Based on
record reviews and interviews, of Qualified
Professionals (the Certified Substance Abuse
Counselor #1 (CSAC #1), the Registered Nurse
#1 (RN #1) the Program Director (PD) failed to
demonstrate knowledge, skills and abilities
required by the population served.
Cross Reference: 10 A NCAC 27G .0205

Assessment and Treatment/Habilitation or
Service Plan (V112). Based on record reviews
and interviews, the facility failed to develop and
implement strategies to address continued
drugs screens for affecting
of deceased clients (DC #1).

Operations (V238). Based on record review and
interviews the facility failed to ensure that of
deceased clients (DC #1), of former clients
(FC #2) and of current clients (#3) received
the required counseling sessions each month and
failed to ensure that of current clients (#1,
#3, #4, #9, #10, #12) and of deceased clients
(DC #3) were not dually enrolled in other opioid
treatment programs within a 75 mile radius.
Review on 9/26/17 of Deceased Client #1 (DC

STATE FORM 6899
PRINTED: 10/16/2017
FORM APPROVED
A. BUILDING: ______________________
R
MHL065-117 B. WING _____________________________
09/29/2017
DEFICIENCY)
would have been nice to make the effort.

should have been told need to go to if
refused, we should say you are too high risk to be
in this program here ..."
-The MD further stated, "...If not going to do
what needs to be done and continuing to put
at risk, and me continuing to give
is not the answer. We're not helping
-When asked about the MD stated

clients should be prior to
every time.
-"If testing ), they're impaired,
shouldn't be There should have been an
intervention. . There weren't any
used on [DC #1]. should have been brought
to attention a long time ago, and there should
have been an intervention ..."
Review on 9/29/17 of the facility's Plan of

Protection, dated 9/29/17, and written by the
Regional Director revealed:
What immediate action will the facility take to
ensure the safety of the consumers in your care?
-"For the next 30 days, a member of the
CMG/New Season's corporate staff will be onsite
Monday through Friday at New Hanover
Treatment Center to ensure quality patient care
and adherence to policies and procedures and
state and federal regulations. Director of Clinical
and Quality Compliance will train all staff by
October 6, 2017 on CMG/New Season's policies
and procedures related to patient discharge
including voluntary and involuntary discharges,
medically supervised withdrawal, and treatment
retention of patients with continuous positive drug
screens. Regional Director will conduct a chart
audit by October 6, 2017 of all patients who are
on medically supervised withdrawal or have
continuous positive drug screens to ensure
STATE FORM 6899
PRINTED: 10/16/2017
FORM APPROVED
A. BUILDING: ______________________
R
MHL065-117 B. WING _____________________________
09/29/2017
DEFICIENCY)
compliance with CMG/New Season's policies."

-"All counselors will complete a NAADAC (The
Association for Addiction Professionals) approved
Counselor Essentials Course by October 22,
2017. All counselors must pass with at least an
85% or higher. Nursing Supervisor will complete
of the CMG nursing onboarding matrix by
October 22, 2017. Program Director will be
placed on a Performance Improvement Plan
focusing on leadership, supervision, clinical
oversight, and quality management. This
Performance Improvement Plan will be monitored
by Regional Director and Zone Director."
-"The Director of Clinical and Quality Compliance
will train all staff by October 6, 2017 on CMG/New
Season's policies and procedures related to the
treatment planning process to include the
importance of including medical diagnosis in the
treatment plan, as well as the documentation and
follow through of appropriate staff interventions.
Each counselor will review their caseloads to
ensure any patient with a dual diagnosis will have
a medical goal included on their treatment plan.
All treatment plans will have this goal added by
October 22, 2017."
-"In addition to the immediate trainings outlined in
the subsequent Plans of Protection, counselors
and Program Director will complete the
Documenting the Treatment Planning Process,
Implementing SAMHSA (Substance Abuse and
Mental Health Services Administration)
Evidenced Based Practices, and Treatment Team
training modules by October 22nd. Additionally,
the Director of Clinical and Quality Compliance
will complete a coordination of care training with
New Hanover staff by October 6th, 2017."
-"All patient charts will be audited for compliance
regarding state regulations for dual enrollment
prevention and monthly counseling sessions by
October 13, 2017. The Regional Director will
STATE FORM 6899
PRINTED: 10/16/2017
FORM APPROVED
A. BUILDING: ______________________
R
MHL065-117 B. WING _____________________________
09/29/2017
DEFICIENCY)
conduct a staff training by October 6, 2017

reviewing state regulations pertaining to non-dual
enrollment and required counseling sessions."
Describe your plans to make sure the above
happens.
-"An all staff training has been scheduled for
October 5th, 2017 with the Director of Clinical and
Quality Compliance to review New Season's
policies and procedures related to patient
discharge and treatment retention. Regional
Director will continue to review all patient charts
who are on a medically supervised withdrawal or
have continued positive drug screens monthly to
ensure compliance with all policies related to
patient discharge. Program Director is out on
medical leave and scheduled to return on
November 1st. Upon return, Program Director
will complete required trainings within 3 weeks.
Regional Director will serve as the acting
Program Director in absence."
-"Regional Director will take over monitoring
Nurse Supervisor's training and completion of the
CMG nursing onboard matrix to ensure
competency of nursing protocols. Program
Director's Performance Improvement plan will be
monitored by the Regional Director and Zone
Director for compliance over the next 30 days. At
that time, Program Director's performance will be
re-evaluated for any necessary additional
measures needed to ensure quality patient care
and compliance with state and federal
regulations. All counselors will be assigned the
Counselor Essentials Course by October 6, 2017.
The Regional Director will monitor counselor
progress and ensure completion of the Counselor
Essentials Course by October 22, 2017. Program
Director is out on medical leave and scheduled to
return on November 1st. Upon return, Program
Director will complete required trainings within 3
weeks. Regional Director will serve as the acting
STATE FORM 6899
PRINTED: 10/16/2017
FORM APPROVED
A. BUILDING: ______________________
R
MHL065-117 B. WING _____________________________
09/29/2017
DEFICIENCY)

-"An all staff training has been schedules for
October 5, 2017 with the Director of Clinical and
policies and procedures related to the treatment
planning process. The Regional Director will
conduct a quality assurance check for each
counselor's caseload to ensure treatment plans
include a medical goal for applicable patients by
October 22, 2017. Patients with dual diagnosis
will be audited on a quarterly basis to ensure
continued compliance. Program Director is out
on medical leave and scheduled to return on
November 1st. Upon return, Program Director
will complete required trainings within 3 weeks.
Regional Director will serve as the acting
-" An all staff training has been schedules for
October 5, 2017 with the Director of Clinical and
policies and procedures related to coordination of
care. Regional Director will conduct ongoing
monthly audits to ensure compliance with
treatment plans and monthly requirements.
Program Director is out on medical leave and
scheduled to return on November 1st. Upon
return, Program Director will complete required
trainings within 3 weeks. Regional Director will
serve as the acting Program Director in
absence."
-"Regional Director will conduct an audit to
ensure compliance regarding state regulations for
dual enrollment prevention and monthly
counseling sessions by October 13, 2017.
Moving forward, New Hanover Metro Treatment
Center will ensure that clients meet the monthly
requirements as outlines in state regulations and
ensure patients are not dually enrolled on date of
intake with all opioid treatment programs within at
least a 75-mile radius of New Hanover Metro
STATE FORM 6899
PRINTED: 10/16/2017
FORM APPROVED
A. BUILDING: ______________________
R
MHL065-117 B. WING _____________________________
09/29/2017
DEFICIENCY)
Treatment Center. Regional Director will conduct

a staff training by October 6, 2017 reviewing the
state regulations pertaining to non-dual
enrollment and required monthly counseling
sessions. Program Director is out on medical
leave and scheduled to return on November 1st.
Upon return, Program Director will complete
required trainings within 3 weeks. Regional
Director will serve as the acting Program Director
in absence."
DC #1 started to test for use in

2017. The facility failed to implement
policies to address the continuous
drug screens. The Medical Director was never
consulted and the treatment team was never
convened to address chronic of
The Medical Director, being unaware of the
drug screens, had no opportunity to
assess DC #1 for the use of the
implementation of or a referral to
a higher level of care. The frequency of
drug screens were never increased,
were not conducted prior to
and were not
added during course of treatment. CSAC #1
failed to identify strategies to address
continued of failed to make needed
referrals on behalf and did not meet with DC
#1 for the minimum counseling sessions required
every month. In 2017 when DC #1 was
observed to have in and then
just prior to death CSAC
#1 and RN #1 again failed to involve the Medical
Director. The PD had identified deficiencies in
CSAC #1's job performance as early as January
2017 but did not provide the oversight needed to
ensure that DC #1's medical and therapeutic
needs were met. DC #1's consistent
and the deterioration of physical condition
STATE FORM 6899
PRINTED: 10/16/2017
FORM APPROVED
A. BUILDING: ______________________
R
MHL065-117 B. WING _____________________________
09/29/2017
DEFICIENCY)
went unaddressed for 8 months. Ultimately in

2017, DC #1 expired of hypovolemic
shock, upper gastrointestinal bleeding and liver
disease with alcohol abuse as a contributing
factor. This deficiency constitutes a Type A1 rule
violation for serious harm and neglect and must
be corrected within 23 days. An administrative
penalty of $12,000.00 is imposed. If the violation
is not corrected within 23 days, an additional
administrative penalty of $500.00 per day will be
imposed for each day the facility is out of
compliance beyond the 23rd day.
V 238 27G .3604 (E-K) Outpt. Opiod - Operations V 238
10A NCAC 27G .3604 OUTPATIENT OPIOD

TREATMENT. OPERATIONS.
(e) The State Authority shall base program
approval on the following criteria:
(1) compliance with all state and federal
law and regulations;
(2) compliance with all applicable
standards of practice;
(3) program structure for successful
service delivery; and
(4) impact on the delivery of opioid
treatment services in the applicable population.
(f) Take-Home Eligibility. Any client in
comprehensive maintenance treatment who
requests unsupervised or take-home use of
methadone or other medications approved for
treatment of opioid addiction must meet the
specified requirements for time in continuous
treatment. The client must also meet all the
requirements for continuous program compliance
and must demonstrate such compliance during
the specified time periods immediately preceding
any level increase. In addition, during the first
year of continuous treatment a patient must
STATE FORM 6899
PRINTED: 10/16/2017
FORM APPROVED
A. BUILDING: ______________________
R
MHL065-117 B. WING _____________________________
09/29/2017
DEFICIENCY)
attend a minimum of two counseling sessions per

month. After the first year and in all subsequent
years of continuous treatment a patient must
attend a minimum of one counseling session per
month.
(1) Levels of Eligibility are subject to the
following conditions:
(A) Level 1. During the first 90 days of
continuous treatment, the take-home supply is
limited to a single dose each week and the client
shall ingest all other doses under supervision at
the clinic;
(B) Level 2. After a minimum of 90 days of
continuous program compliance, a client may be
granted for a maximum of three take-home doses
and shall ingest all other doses under supervision
at the clinic each week;
(C) Level 3. After 180 days of continuous
treatment and a minimum of 90 days of
continuous program compliance at level 2, a
client may be granted for a maximum of four
take-home doses and shall ingest all other doses
under supervision at the clinic each week;
(D) Level 4. After 270 days of continuous
client may be granted for a maximum of five
take-home doses and shall ingest all other doses
under supervision at the clinic each week;
(E) Level 5. After 364 days of continuous
granted for a maximum of six take-home doses
and shall ingest at least one dose under
supervision at the clinic each week;
(F) Level 6. After two years of continuous
treatment and a minimum of one year of
client may be granted for a maximum of 13

STATE FORM 6899
PRINTED: 10/16/2017
FORM APPROVED
A. BUILDING: ______________________
R
MHL065-117 B. WING _____________________________
09/29/2017
DEFICIENCY)
take-home doses and shall ingest at least one

dose under supervision at the clinic every 14
days; and
(G) Level 7. After four years of continuous
treatment and a minimum of three years of
granted for a maximum of 30 take-home doses
and shall ingest at least one dose under
supervision at the clinic every month.
(2) Criteria for Reducing, Losing and
Reinstatement of Take-Home Eligibility:
(A) A client's take-home eligibility is reduced
or suspended for evidence of recent drug abuse.
A client who tests positive on two drug screens
within a 90-day period shall have an immediate
reduction of eligibility by one level of eligibility;
(B) A client who tests positive on three drug
screens within the same 90-day period shall have
all take-home eligibility suspended; and
(C) The reinstatement of take-home
eligibility shall be determined by each Outpatient
Opioid Treatment Program.
(3) Exceptions to Take-Home Eligibility:
(A) A client in the first two years of
continuous treatment who is unable to conform to
the applicable mandatory schedule because of
exceptional circumstances such as illness,
personal or family crisis, travel or other hardship
may be permitted a temporarily reduced schedule
by the State authority, provided she or he is also
found to be responsible in handling opioid drugs.
Except in instances involving a client with a
verifiable physical disability, there is a maximum
of 13 take-home doses allowable in any two-week
period during the first two years of continuous
treatment.
(B) A client who is unable to conform to the
applicable mandatory schedule because of a
verifiable physical disability may be permitted

STATE FORM 6899
PRINTED: 10/16/2017
FORM APPROVED
A. BUILDING: ______________________
R
MHL065-117 B. WING _____________________________
09/29/2017
DEFICIENCY)
additional take-home eligibility by the State

authority. Clients who are granted additional
take-home eligibility due to a verifiable physical
disability may be granted up to a maximum
30-day supply of take-home medication and shall
make monthly clinic visits.
(4) Take-Home Dosages For Holidays:
Take-home dosages of methadone or other
medications approved for the treatment of opioid
addiction shall be authorized by the facility
physician on an individual client basis according
to the following:
(A) An additional one-day supply of
methadone or other medications approved for the
treatment of opioid addiction may be dispensed
to each eligible client (regardless of time in
treatment) for each state holiday.
(B) No more than a three-day supply of
methadone or other medications approved for the
treatment of opioid addiction may be dispensed
to any eligible client because of holidays. This
restriction shall not apply to clients who are
receiving take-home medications at Level 4 or
above.
(g) Withdrawal From Medications For Use In
Opioid Treatment. The risks and benefits of
withdrawal from methadone or other medications
approved for use in opioid treatment shall be
discussed with each client at the initiation of
treatment and annually thereafter.
(h) Random Testing. Random testing for alcohol
and other drugs shall be conducted on each
active opioid treatment client with a minimum of
one random drug test each month of continuous
treatment. Additionally, in two out of each
three-month period of a client's continuous
treatment episode, at least one random drug test
will be observed by program staff. Drug testing is
to include at least the following: opioids,

STATE FORM 6899
PRINTED: 10/16/2017
FORM APPROVED
A. BUILDING: ______________________
R
MHL065-117 B. WING _____________________________
09/29/2017
DEFICIENCY)
methadone, cocaine, barbiturates,

amphetamines, THC, benzodiazepines and
alcohol. Alcohol testing results can be gathered
by either urinalysis, breathalyzer or other
alternate scientifically valid method.
(i) Client Discharge Restrictions. No client shall
be discharged from the facility while physically
dependent upon methadone or other medications
approved for use in opioid treatment unless the
client is provided the opportunity to detoxify from
the drug.
(j) Dual Enrollment Prevention. All licensed
outpatient opioid addiction treatment facilities
which dispense Methadone,
Levo-Alpha-Acetyl-Methadol (LAAM) or any other
pharmacological agent approved by the Food and
Drug Administration for the treatment of opioid
addiction subsequent to November 1, 1998, are
required to participate in a computerized Central
Registry or ensure that clients are not dually
enrolled by means of direct contact or a list
exchange with all opioid treatment programs
within at least a 75-mile radius of the admitting
program. Programs are also required to
participate in a computerized Capacity
Management and Waiting List Management
System as established by the North Carolina
State Authority for Opioid Treatment.
(k) Diversion Control Plan. Outpatient Addiction
Opioid Treatment Programs in North Carolina are
required to establish and maintain a diversion
control plan as part of program operations and
shall document the plan in their policies and
procedures. A diversion control plan shall include
the following elements:
(1) dual enrollment prevention measures
that consist of client consents, and either
program contacts, participation in the central
registry or list exchanges;

STATE FORM 6899
PRINTED: 10/16/2017
FORM APPROVED
A. BUILDING: ______________________
R
MHL065-117 B. WING _____________________________
09/29/2017
DEFICIENCY)
10A NCAC 27E .0107 TRAINING ON

ALTERNATIVES TO RESTRICTIVE
INTERVENTIONS
(a) Facilities shall implement policies and
practices that emphasize the use of alternatives
to restrictive interventions.
(b) Prior to providing services to people with
disabilities, staff including service providers,
employees, students or volunteers, shall
demonstrate competence by successfully
completing training in communication skills and
other strategies for creating an environment in
which the likelihood of imminent danger of abuse
or injury to a person with disabilities or others or
property damage is prevented.
(c) Provider agencies shall establish training
based on state competencies, monitor for internal
compliance and demonstrate they acted on data
gathered.
(d) The training shall be competency-based,
include measurable learning objectives,
measurable testing (written and by observation of
behavior) on those objectives and measurable
methods to determine passing or failing the
course.
(e) Formal refresher training must be completed
by each service provider periodically (minimum
annually).
(f) Content of the training that the service
provider wishes to employ must be approved by
the Division of MH/DD/SAS pursuant to
Paragraph (g) of this Rule.
(g) Staff shall demonstrate competence in the
following core areas:
(1) knowledge and understanding of the
people being served;
(2) recognizing and interpreting human
behavior;

STATE FORM 6899
PRINTED: 10/16/2017
FORM APPROVED
A. BUILDING: ______________________
R
MHL065-117 B. WING _____________________________
09/29/2017
DEFICIENCY)
(3) recognizing the effect of internal and

external stressors that may affect people with
disabilities;
(4) strategies for building positive
relationships with persons with disabilities;
(5) recognizing cultural, environmental and
organizational factors that may affect people with
disabilities;
(6) recognizing the importance of and
assisting in the person's involvement in making
decisions about their life;
(7) skills in assessing individual risk for
escalating behavior;
(8) communication strategies for defusing
and de-escalating potentially dangerous behavior;
and
(9) positive behavioral supports (providing
means for people with disabilities to choose
activities which directly oppose or replace
behaviors which are unsafe).
(h) Service providers shall maintain
documentation of initial and refresher training for
at least three years.
(1) Documentation shall include:
(A) who participated in the training and the
outcomes (pass/fail);
(B) when and where they attended; and
(C) instructor's name;
(2) The Division of MH/DD/SAS may
review/request this documentation at any time.
(i) Instructor Qualifications 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 for restrictive interventions.
(2) Trainers shall demonstrate competence
by scoring a passing grade on testing in an
instructor training program.

STATE FORM 6899
PRINTED: 10/16/2017
FORM APPROVED
A. BUILDING: ______________________
R
MHL065-117 B. WING _____________________________
09/29/2017
DEFICIENCY)
(3) The training shall be

competency-based, include measurable learning
objectives, measurable testing (written and by
observation of behavior) on those objectives and
measurable methods to determine passing or
failing the course.
(4) The content of the instructor training the
service provider plans to employ shall be
approved by the Division of MH/DD/SAS pursuant
to Subparagraph (i)(5) of this Rule.
(5) Acceptable instructor training programs
shall include but are not limited to presentation of:
(A) understanding the adult learner;
(B) methods for teaching content of the
course;
(C) methods for evaluating trainee
performance; and
(D) documentation procedures.
(6) Trainers shall have coached experience
teaching a training program aimed at preventing,
reducing and eliminating the need for restrictive
interventions at least one time, with positive
review by the coach.
(7) Trainers shall teach a training program
aimed at preventing, reducing and eliminating the
need for restrictive interventions at least once
annually.
(8) Trainers shall complete a refresher
instructor training at least every two years.
(j) Service providers shall maintain
documentation of initial and refresher instructor
training for at least three years.
(1) Documentation shall include:
(A) who participated in the training and the
outcomes (pass/fail);
(B) when and where attended; and
(C) instructor's name.
(2) The Division of MH/DD/SAS may
request and review this documentation any time.

STATE FORM 6899
PRINTED: 10/16/2017
FORM APPROVED
A. BUILDING: ______________________
R
MHL065-117 B. WING _____________________________
09/29/2017
DEFICIENCY)
(k) Qualifications of Coaches:

(1) Coaches shall meet all preparation
requirements as a trainer.
(2) Coaches shall teach at least three times
the course which is being coached.
(3) Coaches shall demonstrate
competence by completion of coaching or
train-the-trainer instruction.
(l) Documentation shall be the same preparation
as for trainers.

facility failed to have initial training in alternatives
to restrictive interventions for of audited staff
(Cashier). The findings are:
Review on 9/27/17 of the facility's cashier's

record revealed:
-A hire date of 9/18/17
-A job description of Cashier
-No documentation of training in North Carolina
Intervention Part A

revealed:
-Was not aware all facility staff were required to
have training in North Carolina Intervention (NCI)
Part A.
-"Now I know. I've scheduled for to go for
NCI, next week... Everyone that works here (or
volunteers) will have NCI ..."
This deficiency constitutes a re-cited deficiency

and must be corrected within 30 days.
STATE FORM 6899
PRINTED: 10/16/2017
FORM APPROVED
A. BUILDING: ______________________
R
MHL065-117 B. WING _____________________________
09/29/2017
DEFICIENCY)
V 736 27G .0303(c) Facility and Grounds Maintenance 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.

Based on observations and interviews, the facility
staff failed to maintain the facility grounds in a
safe, clean and attractive manner. The findings
are:
Observation on 9/27/17 of the facility's

emergency evacuation plan for the facility
revealed:
-The facility was a one story building
-There were three hallways, A, B and C
-The emergency evacuation plan was hung on
the way in hallway A
Observations on 9/27/17, at approximately

12:21pm, of the facility revealed:
-An odor of mold/mildew as you walked into the
facility
-The lobby area had: numerous scuff marks on
the baseboards, numerous stains on the wall,
dead insects inside the lights covers and worn
and frayed carpet
-On hallway A, there were numerous stains on the
carpet, the carpet was worn flat in the middle with
corners taped, tattered and wrinkled.
-The carpet under an office was worn
-Paint was chipped on hallway A
-The air conditioning vents had dirty filters.
-The vents were caked in dust as well as the air
STATE FORM 6899
PRINTED: 10/16/2017
FORM APPROVED
A. BUILDING: ______________________
R
MHL065-117 B. WING _____________________________
09/29/2017
DEFICIENCY)
conditioning slats
-The ceilings had water stains
-On hallway B, near the dosing window, there
were black strips of tape holding the frayed carpet
down
-Numerous ends of the carpet were untapped
and loose in areas.
-The tile in the dosing room area had worn and
stained tiles
-The two dosing window ledges had worn and
missing paint
-On hallway C, the clients' bathroom had debris in
the light fixture cover
-The sink was dirty
-A three foot by two foot area on the floor was
brown and appeared to have rust on it
-The toilet was clogged with toilet tissue
-The drawer under the sink was off the track on
the right side
-There were numerous stains on the carpet
throughout the hallway
-Black tape held down places on the carpet that
were frayed
-The clients' group room had a strong odor of
mold/mildew
-There were several large black stains on the
carpet
-Numerous small holes on the walls
-The conference room table had white stains
covering it
-There were spider webs on the window blinds
-Pooled and dried coffee stains on the coffee
stand

(PD) revealed:
-Was aware of the facility's appearance
-Part of the facility was much older than the new
wing
-When asked to discuss the conditions of the
STATE FORM 6899
PRINTED: 10/16/2017
FORM APPROVED
A. BUILDING: ______________________
R
MHL065-117 B. WING _____________________________
09/29/2017
DEFICIENCY)
facility, the PD stated "Corporate looked at

everything, it's looking at moving the building."
-The facility had a cleaning crew that came out
Mondays, Wednesdays and Fridays every week
for a general cleaning.
-This included a general cleaning to counseling
offices.
-"They take out trash, clean the offices, mop,
clean the bathrooms. On Tuesdays and
Thursdays, we just do it ourselves."
-Clients had pushed chairs up against wall while
sitting in the conference room attending groups
which resulted in holes in the walls.
-The building needed to be relocated.
-"The building is so old and the layout, the cost
with what would take to improve it...It would
better if they could get the place next door,
smaller and better fit, better layout and not so old.
There is not much they could do to fix this (the
facility) ..."

STATE FORM 6899

New Hanover Treatment Center - 2017 DHHS Inspection (Redacted)

Caricato da

Informazioni sul documento

Titolo originale

Copyright

Formati disponibili

Condividi questo documento

Condividi o incorpora il documento

Opzioni di condivisione

Hai trovato utile questo documento?

Questo contenuto è inappropriato?

Copyright:

Formati disponibili

New Hanover Treatment Center - 2017 DHHS Inspection (Redacted)

Caricato da

Copyright:

Formati disponibili

PRINTED: 10/16/2017

V 000 INITIAL COMMENTS V 000

An annual, complaint and follow up survey was

This facility is licensed for the following service

V 105 27G .0201 (A) (1-7) Governing Body Policies V 105

10A NCAC 27G .0201 GOVERNING BODY

STATE FORM 6899

V 105 Continued From page 1 V 105

This Rule is not met as evidenced by:

V 105 Continued From page 2 V 105

for the adoption of standards that assure

Review on 9/28/17 of the facility's policy on

Review on 9/28/17 of the facility's policy on

V 105 Continued From page 5 V 105

This deficiency is cross referenced into: 10A

V 109 27G .0203 Privileging/Training Professionals V 109

10A NCAC 27G .0203 COMPETENCIES OF

V 109 Continued From page 12 V 109

should have met with the treatment team, but I

-Was unable to recall if Coordination of Care was

Interview on 9/29/17 with the RN #1 revealed:

V 109 Continued From page 15 V 109

V 109 Continued From page 16 V 109

and doctor should be checking when they look at

V 109 Continued From page 18 V 109

-In 2017, (the RN #1) noted, in

This deficiency is cross referenced into: 10A

V 109 Continued From page 19 V 109

NCAC 27G .3601 SCOPE (V233) for a Type A1

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

10A NCAC 27G .0205 ASSESSMENT AND

This Rule is not met as evidenced by:

V 112 Continued From page 24 V 112

something to that fact. And to just accept that,

Interview on 9/29/17 with the PD revealed:

This deficiency is cross referenced into: 10A

V 131 G.S. 131E-256 (D2) HCPR - Prior Employment V 131

G.S. §131E-256 HEALTH CARE PERSONNEL

V 131 Continued From page 25 V 131

Personnel Registry and shall note each incident

This Rule is not met as evidenced by:

Review on 9/27/17 of the facility's cashier's

Interview on 9/29/17 with the Program Director

V 233 27G .3601 Outpt. Opiod Tx. - Scope V 233

10A NCAC 27G .3601 SCOPE

V 233 Continued From page 26 V 233

(a) An outpatient opioid treatment facility

This Rule is not met as evidenced by:

Division of Health Service Regulation

V 233 Continued From page 27 V 233

Cross Reference: 10A NCAC 27G .0201

Cross Reference: 10A NCAC 27G .0203

Cross Reference: 10 A NCAC 27G .0205

Cross Reference: 10A NCAC 27G .3604

Review on 9/26/17 of Deceased Client #1 (DC

V 233 Continued From page 30 V 233

would have been nice to make the effort.

-When asked about the MD stated

Review on 9/29/17 of the facility's Plan of

V 233 Continued From page 31 V 233

compliance with CMG/New Season's policies."

V 233 Continued From page 32 V 233

conduct a staff training by October 6, 2017