statement of deficiencies (x2) multiple ...each corrective action should be cross-referenced to the...
TRANSCRIPT
![Page 1: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/1.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 000 INITIAL COMMENTS V 000
An annual and complaint survey was completed
on July 25, 2013. Deficiencies were cited. These
complaints were substantiated (Intake #
NC00088081, Intake NC #00089869, Intake
#NC00088889, Intake #NC00089858, and Intake
# NC00089855). These complaints were
unsubstantiated (Intake #NC00089196, Intake
#NC00089808, Intake #NC00089870, Intake
#NC90288 and Intake #NC90330). Deficiencies
were cited.
This facility is licensed for the following service
category: 10A NCAC 27G .3600 Outpatient
Opioid Treatment
V 105 27G .0201 (A) (1-7) Governing Body Policies
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
V 105
Division of Health Service Regulation
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
If continuation sheet 1 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 105Continued From page 1 V 105
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
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;
Division of Health Service Regulation
If continuation sheet 2 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 105Continued From page 2 V 105
This Rule is not met as evidenced by:
Based on record reviews and interviews, the
facility failed to implement its discharge policy.
The findings are:
Review on 4/18/13 of the facility ' s policy and
procedure manual regarding the discharge
criteria of clients revealed:
- " Discharge Summary: When a patient leaves
services, a written discharge summary is
prepared to ensure that the person served has
documented treatment episodes and results of
treatment. 1. The discharge summary will include:
a. Date of admission, b. Description of services
provided, c. Presenting condition: Description of
the extent to which goals and objectives included
in the Treatment Plan were achieved, d.
Description of the reasons for discharge, e. The
status of the person served at last contact, f.
Counselor ' s recommendations for services or
other supports, g. date of discharge from the
program. 2. The Primary Counselor and Medical
Director will sign all Discharge Summaries within
30 days of discharge. 3. The final signed copy will
be placed in the patient ' s chart. "
Review on 5/12/13 of Deceased Client #2 (DC
#2) ' s record revealed:
- An admission date of 8/2/12
- A diagnosis of Opioid Dependence
- A date of death of 3/18/13
- He was 29 years of age
-A facility discharge summary list dated 5/13/13
with a discharge date of 3/26/13 with the reason
for discharge entered by the Program Director #1
(PD#1) as " left against staff advice - missed 7
consecutive days after being contacted. "
- No documentation of a discharge summary
Division of Health Service Regulation
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 105Continued From page 3 V 105
Review on 5/13/13 of Deceased Client #3 (DC
#3) ' s record revealed:
-An admission date of 12/28/12
-Diagnoses of Generalized Anxiety Disorder,
Panic Disorder, Post Traumatic Stress Disorder,
Mood Disorder, Depressive Disorder and Opioid
Disorder
-A date of death of 3/1/13
-He was 20 years of age
-A facility discharge summary list dated 5/13/13
with a discharge date of 3/08/13 with the reason
for discharge entered by the PD#1 as " left
against staff advice - missed 7 consecutive days
after being contacted. "
-No documentation of a discharge summary
Review on 5/13/13 of Deceased Client #4 (DC
#4)' s record revealed:
-An admission date of 3/15/13
- A diagnosis of Opioid Dependence
-A date of death of 3/18/13
-He was 35 years of age
- A facility discharge summary list dated 5/13/13
with a discharge date of 3/26/13 with the reason
for discharge entered by the PD #1 as " left
against staff advice - missed 7 consecutive days
after being contacted. "
-No documentation of a discharge summary
Review on 5/13/13 of Deceased Client #5 (DC
#5)' s record revealed:
-An admission date of 3/15/13
-A diagnosis of Opioid Dependence
-A date of death of 3/18/13
-She was 32 years of age
-A facility discharge summary list dated 5/13/13
with a discharge date of 3/26/13 with the reason
for discharge entered by the PD #1 as " left
against staff advice - missed 7 consecutive days
Division of Health Service Regulation
If continuation sheet 4 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 105Continued From page 4 V 105
after being contacted. "
-No documentation of a discharge summary
Review on 4/12/13 of Former Client #1 (FC #1)' s
record revealed:
-An admission date of 8/19/11
-A diagnosis of Opioid Dependence
A discharge date of 1/9/13
-No documentation of a discharge summary
Interview on 5/13/13 with Counselor #16
revealed:
- " Discharge summaries have to be approved.
Counselors do it after approval. 7 day no show. "
Interview on 5/16/13 with the Clinical Director
(CD) revealed:
- " Counselors do discharge summary. Methasoft
system (facility ' s computer program), name
pops up on each form. Whoever discharges
client their name appears on discharge summary.
"
-When asked if there was a reason why PD #1 ' s
name would be on discharges she replied: "
Would be no other reason why. Everybody
discharges their own people. "
- " Counselors are responsible for discharges. "
Interview on 5/16/13 with The Program Director
#1 (PD #1) revealed:
-Regarding who does Discharge Summaries: " If
patient misses 7 days and counselor has it noted
counselor will send me and [Assistant Program
Director #1 (APD #1)] and [CD] an email stating
they need to discharge. We make sure counselor
has made contact. And it ' s documented on the
no show list, make sure they are not hospitalized
or incarcerated (if so keep open for 30 days). On
8th day (of no show) they are discharged.
Counselor does that (the discharge summary) all
Division of Health Service Regulation
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 105Continued From page 5 V 105
done in Methasoft (facility ' s computer program).
(Counselor) finds patient in computer goes to
discharge and brings up service (which has
patient identifier on it). There ' s a drop down box
with all the reasons patient has been discharged.
They print that out and put it in the (client ' s) file.
"
-No reason was provided as to why the
Counselors did not complete their own discharge
summaries and why PD #1 entered the reasons
for discharge for each client.
Interview on 5/16/13 with the Medical Director
revealed:
-Regarding Discharges: " My role is anyone they
are considering discharge they run it by me and
we discuss it. We taper them down and then
refer them to a higher level of care if they need it.
"
-No reason was provided as to why the
Counselors did not complete their own discharge
summaries and why PD #1 entered the reasons
for discharge for each client.
V 109 27G .0203 Privileging/Training Professionals
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
V 109
Division of Health Service Regulation
If continuation sheet 6 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 109Continued From page 6 V 109
exhibiting core skills including:
(1) technical knowledge;
(2) cultural awareness;
(3) analytical skills;
(4) decision-making;
(5) interpersonal skills;
(6) communication skills; and
(7) clinical skills.
(e) Qualified professionals as specified in 10A
NCAC 27G .0104 (18)(a) are deemed to have
met the requirements of the competency-based
employment system in the State Plan for
MH/DD/SAS.
(f) The governing body for each facility shall
develop and implement policies and procedures
for the initiation of an individualized supervision
plan upon hiring each associate professional.
(g) The associate professional shall be
supervised by a qualified professional with the
population served for the period of time as
specified in Rule .0104 of this Subchapter.
This Rule is not met as evidenced by:
Based on record reviews and interviews 2 of 9
Qualified Professionals (QPs) failed to
demonstrate knowledge, skills and abilities
required by the population served (the Program
Director #1 (PD #1) and Assistant Program
Director #1 (APD #1). The findings are:
Review on 4/10/13 of the PD #1 ' s record
revealed:
- A hire date of 11/1/10
- A job description of Program Director
Review on 6/14/13 of an email from the Vice
Division of Health Service Regulation
If continuation sheet 7 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 109Continued From page 7 V 109
President of Operations revealed:
- PD #1 was terminated on 5/24/13
Review on 4/10/13 of the APD #1 ' s record
revealed:
- A hire date of 7/21/10
- A job description of the Assistant Program
Director
Review on 7/25/13 of the Plan of Protection dated
7/25/13 written by the Director of Nursing,
(Registered Nurse #1/Director of Nursing)
Assistant Program Director, (Assistant Program
Director #2) Program Director (Program Director
#2) and Vice President of Operations revealed:
- APD #1 was transferred to another role within
the agency outside of Greensboro on 6/3/13
Interview on 4/11/13 with Counselor #15
revealed:
- " After you all (State surveyors) left the first time,
[the PD #1] had a staff meeting and passed
around the rules and regulations and a book on
IRIS (Incident Response Improvement System) .
He told us the rules and regulations about
reporting deaths had changed. So, I asked him,
these rules have changed after April (2013) and
he said ' these laws change all the time ' ...he
said there was a loop hole where he wouldn ' t
have to report the deaths ...it was one of those
shady things that went on around here. If you
asked him any questions, he would not answer it.
He would talk around it. The day the State came
out (on 4/8/13), they (the PD #1, the APD #1 and
the Clinical Director (CD)) came around and told
us, ' there ' s only one death that has occurred. "
[Counselor #3] was asked by [the APD #1] to
change the clients ' records (deceased clients)
saying we had tried to contact the clients, but they
were already dead. They wanted us to make it
Division of Health Service Regulation
If continuation sheet 8 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 109Continued From page 8 V 109
look like we did not know they had died. We saw
one client ' s death (Deceased Client #2 (DC #2))
on the news ... "
Further interview on 5/21/13 with Counselor #15
revealed:
- " It is my understanding that deaths must be
reported immediately. [The PD #1] is responsible
for that. "
- " I have some text messages (dated 5/8/13)
between me and [the APD #1] about them lying
about the deaths of clients. "
Review on 5/21/13 of texts, dated 5/8/13,
between Counselor #15 and the APD #1
regarding the patients deaths revealed:
- Counselor #15 was concerned because " I
knew [the PD #1] was lying to us (about not
having to report deaths), which he was ...if he had
done what he was legally obligated to do, this
wouldn ' t be an issue ...he ' s not protecting us by
lying ... [the PD #1 ' s] choices have affected us
all ...you really thought it was a good idea (to lie to
the State)? All of our careers are on the line ...I
answered [the State Opioid Treatment Authority '
s Coordinator (SOTA)] truthfully when she
interviewed me ...I know right from wrong ...lying
is wrong ...you can ' t sit there and say what was
going on here was ethical ...I answered truthfully
bc (because) it was the right thing to do ...YOU
put your career and license on the line when you
lied when you and [the PD #1] were asked about
this (client deaths) in the beginning ... "
- The APD #1 ' s responses to Counselor #15 ' s
concerns: " ...you should have clue me on the
fact that you put my job and my license on the
line ...supervisors lie all the time to protect their
employees ...that was a shitty selfish move on
your part (to tell the State about deaths not being
reported) ...I don ' t know what you ' ll try to use
Division of Health Service Regulation
If continuation sheet 9 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 109Continued From page 9 V 109
against me if this goes to court ...[the PD #1] has
never lied to me ...you may have gotten us shut
down and I may not have a job ...if you have a
problem with your place of employment you quit
...you threw us (the facility) under the bus ... "
Interview on 5/15/13 with Counselor #3 revealed:
- " I learned of [DC #2] ' s death the day that it
happened (3/18/13), on the news. I was his
counselor. The next morning, I got to work and
pulled his chart. I took his chart to [APD #1] ' s
office and [the PD #1] was in there. They said '
yeah, we know it was him (DC #2) ...I was told to
make sure the file was in order and I took the file
into [the PD #1] ' s office and never saw it again
...then I was instructed to go back into the notes
(by the PD #1) to change what I had put in there. I
was documenting the client was deceased every
day for 7 days. I had to change the
documentation to show that he was absent for 7
consecutive days so he could be shown as
discharged and a death report would not have to
be reported ...I was told to change it
(documentation) by [the APD #1] also ...it was
unethical and wrong ...they did this intentionally
...all the staff here knew there was more than one
deceased client ... After you (the State) left the
first time, we had several staff meetings to go
over the criteria for reporting deaths and it had
changed ...we knew it was a lie ...He (the PD #1)
told us the death reporting (requirements)
changed daily ... "
Interview on 5/17/13 with Counselor #16
revealed:
- " I was at home the night it (DC #2 ' s death)
was aired on [a local television station]. I knew it
was [Counselor #3 ' s] client ...we were highly
instructed by all 3 (the PD #1, the APD #1 and
the CD) not to have a clue about any other deaths
Division of Health Service Regulation
If continuation sheet 10 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 109Continued From page 10 V 109
except [Deceased Client #1] ' s ...[The CD] went
to each counselor ' s office, whether it was
through [the PD #1] ' s advice or on her own
doing, to tell us we were to tell the State there
was only one death ...we (the counselors) were
all wondering why the deaths were not reported
...we were concerned with the legality of it (not
reporting the deaths) ...[the PD #1] was in
[Counselor #3 ' s] office as she was documenting
in [DC #2] ' s that he was deceased. [The APD
#1] instructed her to change her documentation to
make it look like he was still alive and that he was
absent from the program ...if anytime [the PD #1 '
s] mouth is moving, he is lying ... "
Interview on 5/15/13 with the Senior Counselor #1
revealed:
- " I was on vacation and recently returned. I just
recently learned (about the deaths) due to other
counselors talking. I understand people have died
and things weren ' t done right (unreported
deaths). Some of it (not reporting the deaths) is
disturbing. They are just trying to cover
themselves when the State comes in. It should
have been a process. There is chaos here.
Reporting them (the deaths) would be the ethical
thing to do. "
Interview on 5/16/13 with the CD revealed:
- " Deaths are reported to [the PD #1], [the APD
#1] and now me. [The PD #1] does them (the
IRIS report). I don ' t know the requirements to
report a death. I have not had anyone
(counselors) report deaths on their caseloads.
The deaths have been mentioned in staff
meetings and we do talk about it. I am not sure
who would make a note (document) about the
debriefing with the counselors ... "
Interview on 5/17/13 with the APD #1 revealed:
Division of Health Service Regulation
If continuation sheet 11 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 109Continued From page 11 V 109
- " [The PD #1] filled out the report in IRIS (for
patient deaths). We were under the impression
we had to confirm a death through family
members, hospitals and the death report (from
the Medical Examiner) before we reported it. Now
we have to report it if we have a suspicion it
occurred. We don ' t have a lot of deaths. I have
not had any deaths. I don ' t think I have ever
done a death report. My guess is that the
counselors do the death reports. Sometimes [the
PD #1] will do it (IRIS reports) because he has
the death report or death certificate. All the death
reports go to [the PD #1] and he does IRIS then. "
- When asked about the recent deaths of clients,
the APD #1 stated, " Gosh, I don ' t know exactly
(when the clients died). Probably some time,
gosh, I hate to say, February or January (2013)? I
don ' t remember the patients ' names. A couple
of clients dosed a few times. The counselor could
not reach or get in touch with their emergency
contact. A few days later we found an obituary. It
was not a confirmed death. We did not find out
about the deaths until after discharge. We would
use an obituary as unconfirmed, unless we had
contact with the family ...with [DC #2]; I know his
counselor was [Counselor #3]. She wrote
deceased in her notes. I told her to put patient
discharged. She was told to put that she tried to
have contact. We had not confirmed his death.
The protocol was to call the client or the family.
We could not get a hold of them. We don ' t
typically use a news article (to confirm a death)
...People can have the same first and last name.
We would call their emergency contact. We just
happened to check and see if we could find the
deaths. It was something we just stumbled upon
(clients ' deaths). It could have been in March
(when we learned of the death). I know it was in
the first quarter of the year ... [DC #1] is the one I
am talking about ...with [DC #2], we could never
Division of Health Service Regulation
If continuation sheet 12 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 109Continued From page 12 V 109
confirm it. A couple of employees saw a news
article about his death. The counselor (Counselor
#3) would not verify it (his death) with the family.
It was not my patient. I heard it through the
grapevine. They told me and then I assume they
called [the PD #1] as well. We really like to have it
(a death) confirmed with family. I know IRIS asks
for a cause of death. We cannot list it without an
autopsy. I don ' t report deaths, so no, I ' ve never
been told not to report them. "
- Regarding DC #3 ' s death: " I don ' t remember
if we talked about it in a staff meeting. I spoke
with his mother weeks after his death. She
wanted a refund ($200.00) on his account. I know
Corporate cut her a check. His (DC #3 ' s) mom
called to speak with someone in charge. The call
was transferred to me. It was one of those
random things ... "
Interview on 5/16/13 with the PD #1 revealed:
- " If a counselor is out for any reason and there
is a death (of a patient), I have to investigate the
death. If it is by another patient ' s report or we
hear that a patient has died, it is not a confirmed
death. After the last visit by [the SOTA
Coordinator], I was told to contact the patient ' s
emergency contact, contact the local police
department and complete an IRIS report. I was
cited for this because I did not know I had to
report deaths to the State Opioid Treatment
Authority ...If it is a confirmed death, I call the
police, the Office of the Chief Medical Examiner
(OCME) and try to get the death certificates ...I
was not aware unconfirmed deaths had to be
reported ...it is my responsibility to report (the
deaths). If I contact family (of a deceased patient)
and they confirm the death, that is confirmation of
a death. If I have an obituary, that would be
confirmed (death). That is while they are an
active patient ...if 3 or 4 weeks later and the
Division of Health Service Regulation
If continuation sheet 13 of 1396899STATE FORM DOBD11
![Page 14: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/14.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 109Continued From page 13 V 109
patient is discharged and died, I was under the
assumption our responsibility ends at the date of
discharge ...I only reported one death ...I am
aware of the 4 other deaths ...those 4 clients
were discharged and we went through the
process of trying to contact the patient, contacting
local police and just got confirmation (Medical
Examiner ' s Report) on 2 of the patients ...[DC
#2] and what ' s the other name (of the deceased
client)?...ummm, oh crap. I just got the report this
week ...since they were discharged, I won ' t
report those (discharged patients deaths) ...With
[DC #2], I don ' t know the exact date of his
death. It was a patient I think that came in and
reported it. I tried to contact his emergency
contact and tried the Sheriff ' s Department. I
could not get in touch with them. I am not sure if
the counselor (Counselor #3) did ...I have to
contact the family if they are an active patient ...if
a counselor tells me they thought a patient died,
then I start the process (of trying to confirm the
death). I was made aware of [DC #2] ' s death
after his discharge. I was not made aware of all 4
deaths until after their discharge. I don ' t know
why [Counselor #3] did not tell me about [DC #2] '
s death ...with [DC #4] and [DC #5] ' s deaths, I
learned after their discharge. I cannot remember
when [Counselor #6] started. I did not want her in
the position, on her first day, to be involved in that
(contacting family or emergency contact on a
patient that had died) ... "
- " I made the contacts daily, numerous contacts,
daily (to try to get in touch with the deceased
clients). I do that as part of my job. I feel
responsible to do that. We (me and the
counselors) work together, unless the counselor
contacts a family member. I am not aware if any
of the counselors contacted the deceased clients
' family members. None of the family members
(of the deceased clients) have contacted me. The
Division of Health Service Regulation
If continuation sheet 14 of 1396899STATE FORM DOBD11
![Page 15: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/15.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 109Continued From page 14 V 109
counselor for the clients (deceased) should have
contacted me ...I would complete an IRIS report
on active clients that have died ...I don ' t know if
a patient is discharged, do I report to IRIS if they
are discharged and died afterwards? [The SOTA
Coordinator] did not interview me (when she was
out in April 2013). That would be a question I ' d
like answered ...I have not covered up a death. I
will be glad to do that (report submitted in IRIS).
When is a patient not a patient? I can ' t find an
answer to that. So, do I go ahead and complete
IRIS (on the deaths)? Am I liable for these (the
deaths)? Is it IRIS ' fault? I did not know I had to
file them (the deaths). If a patient dies 6 months
later, do we still do an IRIS report? To be honest
with you, I don ' t know (if the IRIS reporting
criteria has changed) ...I have only done one
(death report in IRIS). We haven ' t had that many
deaths until now. I did not know they (the deaths)
had to be reported. I apologize for that. "
Interview on 5/16/13 with the Medical Director
(MD) revealed:
- " Regarding patients ' deaths, there really is not
a protocol. My understanding is when there ' s
actual verification, [the CD] does a report. In
general practice, I sign off on it. That is pretty
much the extent of it. I just get a phone call from
Nursing or [the PD #1]. Sometimes they call with
a suspicion of a death. Death certificates are the
legal way we find out about deaths. We don ' t
check obituaries. If we saw an obituary, we can ' t
discuss it with just anyone. I was made aware of
the deaths, three of which were confirmed (DC
#1, DC #2 and DC #4). I guess that was about
three weeks ago. There have only been 4 deaths
since I have been here. "
Interview on 5/17/13 with the Corporate Director
of Clinical Practices revealed:
Division of Health Service Regulation
If continuation sheet 15 of 1396899STATE FORM DOBD11
![Page 16: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/16.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 109Continued From page 15 V 109
- " [The PD #1] has been suspended last night
(5/16/13) as the Program Director. We are
becoming aware of incidents that needed to be
reported immediately. I am sure it will result in
termination ...I arrived at the facility on Tuesday,
(5/14/13). I had not had a lot of contact with [the
PD #1]. [The PD #1] said the State investigators
were here. He was very specific it was a
complaint (the State investigators were looking
into). What he said was that a patient had died
after discharge. How can we (Corporate Office)
know? He said why report it if they are not a client
anymore. In the course of my record audits, I
noticed he did not do something correctly. I found
I was not able to account for 12 charts. The
counselors said 4 of them (charts) were with the
State (surveyors) because they died. I spoke with
[the Chief Executive Officer/Program Sponsor
(CEO/PS)] and he said he had a conversation
with [the PD #1] over the phone. There were
patients that were discharged and had died. He
[CEO/PS] pressed [the PD #1]. When did they
(the 4 clients) die? Near their discharge date?
[The Program Director from Atlanta] and I sat at a
table and took the 4 deceased clients ' name and
went on the Internet to see the obituaries. I
looked their names up on Methasoft (the facility '
s computer program). I looked at the dates of
death versus the dates of discharge. Oh hell,
every one of these patients was discharged after
they died. That was not communicated to us by
[the PD #1]. I was not aware of [DC #1] ' s death
either. I spoke with [the CEO/PS] again. There is
no way 4 patients die and you don ' t report it. It is
appalling. It just can ' t happen. He (the PD #1)
was called and told he was suspended. There is
no way for it not to be communicated. You ' ve
got to know. It is doing your job. It all ends the
same way, termination. We are looking at
processes that need to change. About 3 weeks
Division of Health Service Regulation
If continuation sheet 16 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 109Continued From page 16 V 109
ago, I sent out a binder/template for critical
incident reports, very easy to track. I included the
manual which tells you how to report and to who.
We sent it out. In this situation, it clearly did not
get done. The first thing that had to happen was
[the PD #1] being suspended. Documentation
being deleted or added is beyond troubling. Why
not report a death? A death is a death. Trying to
hide it (deaths), I just don ' t understand it. "
This deficiency is cross referenced into 10A
NCAC 27D .0304 Protection from Harm, Abuse,
Neglect or Exploitation (V512) for a Type A1 rule
violation and must be corrected within 23 days.
V 110 27G .0204 Training/Supervision
Paraprofessionals
10A NCAC 27G .0204 COMPETENCIES AND
SUPERVISION OF PARAPROFESSIONALS
(a) There shall be no privileging requirements for
paraprofessionals.
(b) Paraprofessionals shall be supervised by an
associate professional or by a qualified
professional as specified in Rule .0104 of this
Subchapter.
(c) Paraprofessionals shall demonstrate
knowledge, skills and abilities required by the
population served.
(d) At such time as a competency-based
employment system is established by rulemaking,
then qualified professionals and associate
professionals shall demonstrate competence.
(e) Competence shall be demonstrated by
exhibiting core skills including:
(1) technical knowledge;
(2) cultural awareness;
(3) analytical skills;
(4) decision-making;
V 110
Division of Health Service Regulation
If continuation sheet 17 of 1396899STATE FORM DOBD11
![Page 18: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/18.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 110Continued From page 17 V 110
(5) interpersonal skills;
(6) communication skills; and
(7) clinical skills.
(f) The governing body for each facility shall
develop and implement policies and procedures
for the initiation of the individualized supervision
plan upon hiring each paraprofessional.
This Rule is not met as evidenced by:
Based on record reviews and interviews, the
facility failed to develop and initiate individualized
supervision plans for 5 of 13 audited
paraprofessional staff (Clinical Director (CD),
Counselors #3, #4, #6, and #16) and the CD
failed to demonstrate the knowledge, skills and
abilities required by the population served
affecting 1 of 13 audited paraprofessional staff
(the Clinical Director (CD)). The findings are:
Finding #1
Review on 5/13/13 of the facility ' s policy on
supervision of Paraprofessionals revealed:
- " All clinical staff members must receive
individual supervision. The goal of clinical
supervision is to ensure that client-centered
clinical care if provided to all purposes served
that works toward the goals identified in the client
' s individual treatment plan ... "
Review on 5/13/13 of the Program Director #1 ' s
(PD #1 ' s) Supervisory Notes Binder revealed:
- No documentation of supervision with audited
staff.
Review on 5/16/13 of Counselor #3 ' s record
Division of Health Service Regulation
If continuation sheet 18 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 110Continued From page 18 V 110
revealed:
- A hire date of 6/27/12
- A job description of Substance Abuse Counselor
- Intern (SAC - I)
Review on 5/14/13 of Counselor #4 ' s record
revealed:
- A hire date of 3/29/11
- A job description of Substance Abuse Counselor
- Registered (SAC-R)
Review on 5/14/13 of Counselor #6 ' s record
revealed:
- A hire date of 3/18/13
- A job description of Substance Abuse
Counselor-Registered (SAC-R)
Review on 4/10/13 of Counselor #16 ' s record
revealed:
- A hire date of 11/21/11
- A job description of Substance Abuse Counselor
-Registered (SAC-R)
Review on 4/10/13 of the CD ' s record revealed:
- A hire date of 2/15/11
- A job description of Clinical Director
Interview on 7/23/13 with the Vice President of
Operations revealed:
- Couselor #16 was terminated on 7/9/13
- The CD was terminated on 7/11/13
Interview on 5/16/13 with Counselor #1 revealed:
- " [The PD #1] is old school. I have had no
recent supervision, just a meeting (staff). You just
have to go and grab him (for supervision). I have
never done 1:1 supervision with [the PD #1] ... "
Interview on 5/14/13 with Counselor #3 revealed:
- Regarding supervision, " It is supposed to be
Division of Health Service Regulation
If continuation sheet 19 of 1396899STATE FORM DOBD11
![Page 20: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/20.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 110Continued From page 19 V 110
[the PD #1] ...staff meetings are to be considered
supervision ... "
Interview on 5/16/13 with Counselor #4 revealed:
- " ...I go in and demand my supervision ...I
demand my supervision ...I am fairly new to this
field ... "
Interview on 5/14/13 with Counselor #6 revealed:
- Regarding supervision: " ...supervision with [the
PD #1] .... When I was hired, I was told he did
supervision differently ...group counseling ...can
have 1:1 if we have questions ...it was quite
different (supervision) where I worked previously
...it (supervision) was a little off to me ... "
Interview on 5/14/13 with Counselor #16
revealed:
- Regarding supervision, " I plead the fifth on that
one. Anything I say about supervision would be
detrimental to my own program ... "
Interview on 5/16/13 with the CD revealed:
-No information regarding the supervision
provided to her by the PD #1.
Interview on 4/10/13 with the Assistant Program
Director #1 (APD #1) revealed:
- Regarding supervision, " ...it is through [the PD
#1] ...we don ' t have a scheduled time but spend
at least an hour a day with [the PD #1] or if
something comes up ... "
Interview on 5/16/13 with the PD #1 revealed:
- " Supervision for a registered person is 4 hours
per week. We do this (supervision) individually,
group and patients ' staffing. I do group
differently ...if one of the counselors has a
question; I turn it back on them. We don ' t have a
set time for one hour per week for supervision.
Division of Health Service Regulation
If continuation sheet 20 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 110Continued From page 20 V 110
Most of the counselors don ' t learn that way
(meeting one hour per week for supervision). I
keep my supervisory notes in a binder. We have
many staff meetings (used for supervision). "
Finding #2
Review on 4/10/13 of the CD ' s record revealed:
- A job description of Clinical Director
- A client case load of 48
Interview on 5/16/13 with the CD revealed:
Deaths are reported to [the PD #1], [the APD #1]
and now me. [The PD #1] does them (the IRIS)
report). I don ' t know the requirements to report a
death. I have not had anyone (counselors) report
deaths on their caseloads. The deaths have been
mentioned in staff meetings and we do talk about
it. I am not sure who would make a note
(document) about the debriefing with the
counselors ... "
- Regarding DC #2: " I don ' t know when he
passed. I don ' t know why his name is on there
(deceased clients list). I don ' t know. Why would
they put a note in there if the person is
deceased? I don ' t know. I haven ' t messed with
that (case notes). I see what you are seeing (list
of deceased clients), but I don ' t know about that.
I would not go around telling people (counselors)
to do that (only talk about 1 death). I would not go
around telling people not to say that. These
deaths (5) were discussed in a staff meeting. I
am assuming the right things were done (deaths
being reported). I was a counselor then. I was not
the Clinical Director when the clients died. I would
think that the right procedures were followed
(regarding deaths being reported). "
Interview on 5/15/13 with Counselor #3 revealed:
- "[The CD] was telling us to tell the State there
was only one client death."
Division of Health Service Regulation
If continuation sheet 21 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 110Continued From page 21 V 110
Interview on 4/11/13 with Counselor #15
revealed:
- " The day the State came out (on 4/8/13), they
(the PD #1, the APD #1 and the CD) came
around and told us, ' there ' s only one death that
has occurred at the facility, I was surprised to
hear that ...she knew everything [the PD #1] was
doing ...she blessed me out for telling the truth
(revealing other clients had died)... "
Interview on 5/17/13 with Counselor #16
revealed:
-The [CD] went to each counselor ' s office,
whether it was through [the PD #1] ' s advice or
on her own doing, to tell us we were to tell the
State there was only one death ...we (the
counselors) were all wondering why the deaths
were not reported ...we were concerned with the
legality of it (not reporting the deaths) ..."
V 116 27G .0209 (A) Medication Requirements
10A NCAC 27G .0209 MEDICATION
REQUIREMENTS
(a) Medication dispensing:
(1) Medications shall be dispensed only on the
written order of a physician or other practitioner
licensed to prescribe.
(2) Dispensing shall be restricted to registered
pharmacists, physicians, or other health care
practitioners authorized by law and registered
with the North Carolina Board of Pharmacy. If a
permit to operate a pharmacy is Not required, a
nurse or other designated person may assist a
physician or other health care practitioner with
dispensing so long as the final label, Container,
and its contents are physically checked and
approved by the authorized person prior to
V 116
Division of Health Service Regulation
If continuation sheet 22 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 116Continued From page 22 V 116
dispensing.
(3) Methadone For take-home purposes may be
supplied to a client of a methadone treatment
service in a properly labeled container by a
registered nurse employed by the service,
pursuant to the requirements of 10 NCAC 45G
.0306 SUPPLYING OF METHADONE IN
TREATMENT PROGRAMS BY RN. Supplying of
methadone is not considered dispensing.
(4) Other than for emergency use, facilities shall
not possess a stock of prescription legend drugs
for the purpose of dispensing without hiring a
pharmacist and obtaining a permit from the NC
Board of Pharmacy. Physicians may keep a small
locked supply of prescription drug samples.
Samples shall be dispensed, packaged, and
labeled in accordance with state law and this
Rule.
This Rule is not met as evidenced by:
Based on observation, record reviews and
interviews, the facility failed to ensure prescription
drugs were dispensed with the final label,
container and its contents being physically
checked and approved by the authorized person
prior to dispensing affecting 4 of 10 clients dosed
(Former Client #1 (FC #1), Client #s 16, 17 and
18). The findings are:
Review on 4/11/13 and 4/12/13 of Former Client
#1 (FC #1) ' s record revealed:
- An admission date of 8/19/11
- A diagnosis of Opioid Dependence
- A discharge date of 1/9/13
- No physician ' s order noting FC #1 ' s
Methadone disks could be dispensed in any other
manner than in an approved container.
Division of Health Service Regulation
If continuation sheet 23 of 1396899STATE FORM DOBD11
![Page 24: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/24.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 116Continued From page 23 V 116
Review on 5/17/13 of client #16 ' s record
revealed:
- An admission date of 6/15/10
- A diagnosis of Opioid Dependence
- No physician ' s order noting client #16 ' s
Methadone disks could be dispensed in any other
manner than in an approved container.
Review on 5/17/13 of client #17 ' s record
revealed:
- An admission date of 3/17/10
- A diagnosis of Opioid Dependence, Anxiety and
Hepatitis C
- No physician ' s order noting client #17 ' s
Methadone disks could be dispensed in any other
manner than in an approved container.
Review on 5/17/13 of client #18 ' s record
revealed:
- An admission date of 1/24/12
- A diagnosis of Opioid Dependence
- No physician ' s order noting client #18 ' s
Methadone disks could be dispensed in any other
manner than in an approved container.
Interview on 4/11/13 with client #16 revealed:
- " ...It is just that certain nurse (Registered
Nurse #2 (RN #2)) that leaves them (pills) there
(in the bowl) ...it was a Styrofoam bowl ... "
Interview on 5/17/13 with client #17 revealed:
- " I remember seeing [RN #2] pour the bottle (of
Methadone 40mg disks) into a bowl ...I have not
seen that in awhile ...It would not surprise me if
someone tried to grab those pills ...I know she did
shut the window (dosing) when she was finished,
but I don ' t think she ever locked it (dosing
window) ... "
Division of Health Service Regulation
If continuation sheet 24 of 1396899STATE FORM DOBD11
![Page 25: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/25.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 116Continued From page 24 V 116
Interview 5/17/13 with client #18 revealed:
- He had seen the Methadone 40mg disks in the
bowl during his dosing on 1/5/13
- He could not remember if they were within arm '
s reach, but stated " they (the Methadone 40mg
disks) were visible to anyone that dosed that day
... "
Attempted interview on 5/17/13 with FC #1 was
unsuccessful.
-Further attempted interviews on 4/12/13 and
4/16/13, with FC #1, were unsuccessful due to
her statement " I don ' t want to answer any
questions ...I have something to do. "
Observation on 4/12/13, at approximately 6:52
am, of the bowl used by RN #2 to dispense
Methadone 40mg disks revealed:
- The bowl was made of heavy duty paper
- The bowl had no final medication label
Review on 5/16/13 of the facility ' s dosing roster
from 1/5/13 by RN #2 revealed:
- Ten clients had dosed at the handicapped
accessible (dosing) window on 1/5/13
Interview on 4/12/13 with RN #2 revealed:
- She poured 100 40mg Methadone disks into a
bowl on 1/5/13.
- She poured the disks into the bowl due to " that
is the way I was trained. "
- There was no label on the bowl
- No one had authorized her to dispense the
Methadone disks into the bowl.
Further interview on 5/15/13 with the RN #2
revealed:
- " I poured the whole bottle into the bowl. That '
s how I was trained ...all in one place (putting the
disks in the bowl). Now we hand count them.
Division of Health Service Regulation
If continuation sheet 25 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 116Continued From page 25 V 116
Some disks/bottles had too little or too much
methadone in them. I now put the bottle under the
counter. "
Interview on 4/11/13 with the Registered Nurse
#1/Director of Nursing (RN #1/DON) revealed:
- " ...I administer my pills (Methadone 40mg
disks) from the bottle. All of us do except [RN #2]
...when I administer the disks (pills), I keep them
under the counter (at the dosing window). "
Interview on 4/11/13 with the Licensed Practical
Nurse #1/Lead Dosing Nurse (LPN #1/LDN)
revealed:
- " ...We (nurses) all use the bottles for our
dosing and [RN #2] still uses the bowls. I don ' t
know why she (RN #2) can ' t keep her
medications (Methadone 40mg disks) in a bottle
like everyone else. "
Interview on 4/10/13 with the Assistant Program
Director #1 revealed:
- " ...I know she (RN #2) uses a bowl to keep her
pill count ... "
Interview on 4/16/13 with the Medical Director
revealed:
- " That (RN #2) dispensing Methadone from a
bowl would not be an authorized or proper
method to dispense Methadone ... "
Interview on 4/17/13 with the Program Director #1
revealed:
- He was not sure why RN #2 poured the
Methadone disks into a bowl, " that is something
you will have to ask her. "
V 117 27G .0209 (B) Medication Requirements V 117
Division of Health Service Regulation
If continuation sheet 26 of 1396899STATE FORM DOBD11
![Page 27: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/27.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 117Continued From page 26 V 117
10A NCAC 27G .0209 MEDICATION
REQUIREMENTS
(b) Medication packaging and labeling:
(1) Non-prescription drug containers not
dispensed by a pharmacist shall retain the
manufacturer's label with expiration dates clearly
visible;
(2) Prescription medications, whether purchased
or obtained as samples, shall be dispensed in
tamper-resistant packaging that will minimize the
risk of accidental ingestion by children. Such
packaging includes plastic or glass bottles/vials
with tamper-resistant caps, or in the case of
unit-of-use packaged drugs, a zip-lock plastic bag
may be adequate;
(3) The packaging label of each prescription
drug dispensed must include the following:
(A) the client's name;
(B) the prescriber's name;
(C) the current dispensing date;
(D) clear directions for self-administration;
(E) the name, strength, quantity, and expiration
date of the prescribed drug; and
(F) the name, address, and phone number of the
pharmacy or dispensing location (e.g., mh/dd/sa
center), and the name of the dispensing
practitioner.
This Rule is not met as evidenced by:
Based on observations, record reviews and
interviews, the facility failed to ensure all
prescription medications were administered in
tamper-resistant packaging and labeled with clear
directions, expiration date of the drug and the
name and address of the dispensing location
Division of Health Service Regulation
If continuation sheet 27 of 1396899STATE FORM DOBD11
![Page 28: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/28.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 117Continued From page 27 V 117
affecting 1 of 10 clients dosed (Former Client #1
(FC #1)). The findings are:
Observation on 4/12/13, at approximately
6:52am, of the bowl used by Registered Nurse #2
(RN #2) to dispense Methadone 40mg disks on
1/5/13 revealed:
- The bowl was made of heavy duty paper
- The bowl was not in a tamper-resistant package
- There was no expiration date of the drug
- There was no name and address of the
dispensing location
Review on 5/16/13 of the facility ' s dosing roster
from 1/5/13 by RN #2 revealed:
- Ten clients had dosed at the handicapped
accessible window on 1/5/13
Review on 4/11/13 and 4/12/13 of FC #1 ' s
record revealed:
- An admission date of 8/19/11
- A diagnosis of Opioid Dependence
- A discharge date of 1/9/13
Review on 5/17/13 of client #16 ' s record
revealed:
- An admission date of 6/15/10
- A diagnosis of Opioid Dependence
Review on 5/17/13 of client #17 ' s record
revealed:
- An admission date of 3/17/10
- A diagnosis of Opioid Dependence, Anxiety and
Hepatitis C
Review on 5/17/13 of client #18 ' s record
revealed:
- An admission date of 1/24/12
- A diagnosis of Opioid Dependence
Division of Health Service Regulation
If continuation sheet 28 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 117Continued From page 28 V 117
Interview on 4/12/13 with RN #2 revealed:
- " ...I keep my bowl of pills (Methadone 40mg
disks) to my right side on the counter ... "
-When asked why the bowl, filled with pills was on
the counter, RN #2 stated, " The bowl was on the
counter because I was getting ready to count
them ... "
- She stated the bowl was not in a
tamper-resistant package
- She stated there was no expiration date of the
drug
- She stated there was no name and address of
the dispensing location
Interview on 4/11/13 with the Registered Nurse
#1/Director of Nursing (RN #1/DON) revealed:
- " ...She (RN #2) kept hers (Methadone 40mg
disks) in a bowl off to the side. "
- The RN#1/DON stated the bowl was not in a
tamper-resistant package
- The RN #1/DON stated there was no expiration
date of the drug
- The RN#1/DON stated there was no name and
address of the dispensing location
Interview on 4/11/13 with the Licensed Practical
Nurse #1/Lead Dosing Nurse (LPN #1/LDN))
revealed:
- The LPN #1/LDN stated the bowl used by RN#1
was not in a tamper-resistant package
- The LPN #1/LDN stated there was no expiration
date of the drug
- The LPN #1/LDN stated there was no name and
address of the dispensing location
Interview on 4/16/13 with the Medical Director
revealed:
- " That (RN #2 dispensing Methadone from a
bowl) would not be an authorized or proper
method to dispense Methadone ... "
Division of Health Service Regulation
If continuation sheet 29 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 117Continued From page 29 V 117
Interview on 4/17/13 with the Program Director #1
revealed:
- He was not sure why RN #2 poured the
Methadone disks into a bowl, " that is something
you will have to ask her. "
- He did not think the bowl was a tamper-resistant
package because there was no locking top to the
bowl
- He was not sure what was required to be
labeled on a prescription medication bottle
V 118 27G .0209 (C) Medication Requirements
10A NCAC 27G .0209 MEDICATION
REQUIREMENTS
(c) Medication administration:
(1) Prescription or non-prescription drugs shall
only be administered to a client on the written
order of a person authorized by law to prescribe
drugs.
(2) Medications shall be self-administered by
clients only when authorized in writing by the
client's physician.
(3) Medications, including injections, shall be
administered only by licensed persons, or by
unlicensed persons trained by a registered nurse,
pharmacist or other legally qualified person and
privileged to prepare and administer medications.
(4) A Medication Administration Record (MAR) of
all drugs administered to each client must be kept
current. Medications administered shall be
recorded immediately after administration. The
MAR is to include the following:
(A) client's name;
(B) name, strength, and quantity of the drug;
(C) instructions for administering the drug;
(D) date and time the drug is administered; and
(E) name or initials of person administering the
V 118
Division of Health Service Regulation
If continuation sheet 30 of 1396899STATE FORM DOBD11
![Page 31: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/31.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 118Continued From page 30 V 118
drug.
(5) Client requests for medication changes or
checks shall be recorded and kept with the MAR
file followed up by appointment or consultation
with a physician.
This Rule is not met as evidenced by:
Based on record reviews and interviews the
facility failed to administer medication on the
written order of a physician affecting 1 of 7
Deceased Clients (Deceased Client #3) (DC #3)).
The findings are:
Review on 5/13/13 of DC #3 ' s record revealed:
-An admission date of 12/28/12
-A discharge date of 3/8/2013
-Client died on 3/1/13
-He was 21 years old
-Diagnoses of Generalized Anxiety, Panic
Disorder, Post Traumatic Stress Disorder, Mood
Disorder and Depressive Disorder
-Screening Assessment dated 12/28/12 which
reflected: history of IV (Intravenous) with opiates,
history of arrest, history of rehabilitation and
history of domestic violence.
-Treatment plan dated 12/18/12 which reflected
goals of: stabilize treatment in an outpatient
treatment program setting, Continue abstinence
of illicit substance use, Reduce burden of client
attendance
-Signed doctors order written 2/11/13 for 100 mg
Methadone
-No documentation of a signed physician ' s order
for 110 mg Methadone
-No SOWS (Subjective Opiate Withdrawal Scale)
or OOWS (Objective Opiate Withdrawal Scale) to
support the increased dose up to 110 mg
Division of Health Service Regulation
If continuation sheet 31 of 1396899STATE FORM DOBD11
![Page 32: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/32.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 118Continued From page 31 V 118
Methadone
Review on 5/13/13 of the facility ' s policy and
procedures for Dispensing Methadone revealed:
- " ...9. If the doctor has approved a change in
the patient ' s dosage level over the phone, two
important rules must be followed:
a. The order over the phone must be received
by the nurse;
b. An order must be written up by the nurse
and signed by the doctor within 72 hours (in NC
(North Carolina) only). "
Review on 5/13/13 of the facility ' s dosing report
record from 2/19-2/28/13 revealed:
-DC #3 received 110 mg Methadone on 2/19/13
-DC #3 received 110 mg Methadone on 2/20/13
-DC #3 received 110 mg Methadone on 2/21/13
-DC #3 received 110 mg Methadone on 2/22/13
-DC #3 received 110 mg Methadone on 2/23/13
-DC #3 received 110 mg Methadone on 2/24/13
-DC #3 received 110 mg Methadone on 2/25/13
-DC #3 received 110 mg Methadone on 2/26/13
-DC #3 received 110 mg Methadone on 2/27/13
-DC #3 received 110 mg Methadone on 2/28/13
Interview on 5/17/13 with the Assistant Program
Director #1 revealed:
-She had been employed at the facility since
September 2012
- " To increase over 100mg (of Methadone) need
doctor ' s order and need SOWS and OOWS on
every increase. "
Interview on 5/22/13 with the Registered Nurse
#1/Director of Nursing (RN #1/DON) revealed:
- " Things were never quite clear before. "
-When asked to look through the file and find the
signed doctors order and the SOWS and OOWS
she could not locate any of these in DC #3 ' s file.
Division of Health Service Regulation
If continuation sheet 32 of 1396899STATE FORM DOBD11
![Page 33: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/33.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 118Continued From page 32 V 118
- " If doc (the Medical Director (MD)) gave me a
verbal order would not need the SOWS and
OOWS to be honest we probably don ' t have the
SOWS and OOWS because we would print an
order and counselor would grab it before doc (the
MD) would sign it and then that ' s what could
have happened. "
Interview on 5/16/13 with the Program Director #1
revealed:
-When asked why DC #3 ' s increase up to
110mg of Methadone did not have a signed
physician order or SOWS and OOWS he replied:
" shouldn ' t be a reason but a lot of times SOWS
and OOWs are in a big stack nurses have to go
through it and give it to counselors to file. "
Interview on 5/16/13 with the MD revealed:
-He had been employed at the facility for five
years
-When asked about the missing order for DC #3 '
s increase of Methadone to 110mg on 2/19/13 he
replied: " They call me on every increase so
there must have been one. Now they are faxing
me orders every day. "
-When asked if he would have approved the
increase to 110mg for DC #3 ' s Methadone on
2/19/13 without the SOWS and OOWS he
replied: " No. "
V 131 G.S. 131E-256 (D2) HCPR - Prior Employment
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
Personnel Registry and shall note each incident
V 131
Division of Health Service Regulation
If continuation sheet 33 of 1396899STATE FORM DOBD11
![Page 34: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/34.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 131Continued From page 33 V 131
of access in the appropriate business files.
This Rule is not met as evidenced by:
Based on record reviews and interviews, the
facility failed to access the Health Care Personnel
Registry (HCPR) prior to hire for 3 of 22 audited
staff (Counselors #2, #3, and #16). The findings
are:
Review on 5/14/13 of Counselor #2 ' s record
revealed:
- A hire date of 2/4/13
- A job description of Substance Abuse Counselor
- No HCPR check was completed
Review on 5/16/13 of Counselor #3 ' s record
revealed:
- A hire date of 6/27/12
- A job description of Substance Abuse
Counselor 1
- No HCPR check was completed
Review on 4/10/13 of Counselor #16 ' s record
revealed:
- A hire date of 11/21/11
- A job description of Substance Abuse Counselor
-Intern
- A HCPR was completed on 4/10/13
Interview on 7/23/13 with the Vice President of
Operations revealed:
- Couselor #16 was terminated on 7/9/13
Interview on 4/17/13 with the Program Director #1
(PD #1) revealed:
Division of Health Service Regulation
If continuation sheet 34 of 1396899STATE FORM DOBD11
![Page 35: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/35.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 131Continued From page 34 V 131
- It was the Corporate Office ' s responsibility to
ensure HCPR checks were conducted prior to
hire.
Interview on 5/22/13 with the Corporate Director
of Clinical Practices revealed:
- " [The PD #1] was not consistent with getting
the HCPR checks done. He was responsible for
that. "
V 133 G.S. 122C-80 Criminal History Record Check
G.S. §122C-80 CRIMINAL HISTORY RECORD
CHECK REQUIRED FOR CERTAIN
APPLICANTS FOR EMPLOYMENT.
(a) Definition. - As used in this section, the term
"provider" applies to an area authority/county
program and any provider of mental health,
developmental disability, and substance abuse
services that is licensable under Article 2 of this
Chapter.
(b) Requirement. - An offer of employment by a
provider licensed under this Chapter to an
applicant to fill a position that does not require the
applicant to have an occupational license is
conditioned on consent to a State and national
criminal history record check of the applicant. If
the applicant has been a resident of this State for
less than five years, then the offer of employment
is conditioned on consent to a State and national
criminal history record check of the applicant. The
national criminal history record check shall
include a check of the applicant's fingerprints. If
the applicant has been a resident of this State for
five years or more, then the offer is conditioned
on consent to a State criminal history record
check of the applicant. A provider shall not
employ an applicant who refuses to consent to a
criminal history record check required by this
V 133
Division of Health Service Regulation
If continuation sheet 35 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 133Continued From page 35 V 133
section. Except as otherwise provided in this
subsection, within five business days of making
the conditional offer of employment, a provider
shall submit a request to the Department of
Justice under G.S. 114-19.10 to conduct a
criminal history record check required by this
section or shall submit a request to a private
entity to conduct a State criminal history record
check required by this section. Notwithstanding
G.S. 114-19.10, the Department of Justice shall
return the results of national criminal history
record checks for employment positions not
covered by Public Law 105-277 to the
Department of Health and Human Services,
Criminal Records Check Unit. Within five
business days of receipt of the national criminal
history of the person, the Department of Health
and Human Services, Criminal Records Check
Unit, shall notify the provider as to whether the
information received may affect the employability
of the applicant. In no case shall the results of the
national criminal history record check be shared
with the provider. Providers shall make available
upon request verification that a criminal history
check has been completed on any staff covered
by this section. A county that has adopted an
appropriate local ordinance and has access to
the Division of Criminal Information data bank
may conduct on behalf of a provider a State
criminal history record check required by this
section without the provider having to submit a
request to the Department of Justice. In such a
case, the county shall commence with the State
criminal history record check required by this
section within five business days of the
conditional offer of employment by the provider.
All criminal history information received by the
provider is confidential and may not be disclosed,
except to the applicant as provided in subsection
Division of Health Service Regulation
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 133Continued From page 36 V 133
(c) of this section. For purposes of this
subsection, the term "private entity" means a
business regularly engaged in conducting
criminal history record checks utilizing public
records obtained from a State agency.
(c) Action. - If an applicant's criminal history
record check reveals one or more convictions of
a relevant offense, the provider shall consider all
of the following factors in determining whether to
hire the applicant:
(1) The level and seriousness of the crime.
(2) The date of the crime.
(3) The age of the person at the time of the
conviction.
(4) The circumstances surrounding the
commission of the crime, if known.
(5) The nexus between the criminal conduct of
the person and the job duties of the position to be
filled.
(6) The prison, jail, probation, parole,
rehabilitation, and employment records of the
person since the date the crime was committed.
(7) The subsequent commission by the person of
a relevant offense.
The fact of conviction of a relevant offense alone
shall not be a bar to employment; however, the
listed factors shall be considered by the provider.
If the provider disqualifies an applicant after
consideration of the relevant factors, then the
provider may disclose information contained in
the criminal history record check that is relevant
to the disqualification, but may not provide a copy
of the criminal history record check to the
applicant.
(d) Limited Immunity. - A provider and an officer
or employee of a provider that, in good faith,
complies with this section shall be immune from
civil liability for:
(1) The failure of the provider to employ an
Division of Health Service Regulation
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 133Continued From page 37 V 133
individual on the basis of information provided in
the criminal history record check of the individual.
(2) Failure to check an employee's history of
criminal offenses if the employee's criminal
history record check is requested and received in
compliance with this section.
(e) Relevant Offense. - As used in this section,
"relevant offense" means a county, state, or
federal criminal history of conviction or pending
indictment of a crime, whether a misdemeanor or
felony, that bears upon an individual's fitness to
have responsibility for the safety and well-being of
persons needing mental health, developmental
disabilities, or substance abuse services. These
crimes include the criminal offenses set forth in
any of the following Articles of Chapter 14 of the
General Statutes: Article 5, Counterfeiting and
Issuing Monetary Substitutes; Article 5A,
Endangering Executive and Legislative Officers;
Article 6, Homicide; Article 7A, Rape and Other
Sex Offenses; Article 8, Assaults; Article 10,
Kidnapping and Abduction; Article 13, Malicious
Injury or Damage by Use of Explosive or
Incendiary Device or Material; Article 14, Burglary
and Other Housebreakings; Article 15, Arson and
Other Burnings; Article 16, Larceny; Article 17,
Robbery; Article 18, Embezzlement; Article 19,
False Pretenses and Cheats; Article 19A,
Obtaining Property or Services by False or
Fraudulent Use of Credit Device or Other Means;
Article 19B, Financial Transaction Card Crime
Act; Article 20, Frauds; Article 21, Forgery; Article
26, Offenses Against Public Morality and
Decency; Article 26A, Adult Establishments;
Article 27, Prostitution; Article 28, Perjury; Article
29, Bribery; Article 31, Misconduct in Public
Office; Article 35, Offenses Against the Public
Peace; Article 36A, Riots and Civil Disorders;
Article 39, Protection of Minors; Article 40,
Division of Health Service Regulation
If continuation sheet 38 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 133Continued From page 38 V 133
Protection of the Family; Article 59, Public
Intoxication; and Article 60, Computer-Related
Crime. These crimes also include possession or
sale of drugs in violation of the North Carolina
Controlled Substances Act, Article 5 of Chapter
90 of the General Statutes, and alcohol-related
offenses such as sale to underage persons in
violation of G.S. 18B-302 or driving while
impaired in violation of G.S. 20-138.1 through
G.S. 20-138.5.
(f) Penalty for Furnishing False Information. - Any
applicant for employment who willfully furnishes,
supplies, or otherwise gives false information on
an employment application that is the basis for a
criminal history record check under this section
shall be guilty of a Class A1 misdemeanor.
(g) Conditional Employment. - A provider may
employ an applicant conditionally prior to
obtaining the results of a criminal history record
check regarding the applicant if both of the
following requirements are met:
(1) The provider shall not employ an applicant
prior to obtaining the applicant's consent for
criminal history record check as required in
subsection (b) of this section or the completed
fingerprint cards as required in G.S. 114-19.10.
(2) The provider shall submit the request for a
criminal history record check not later than five
business days after the individual begins
conditional employment. (2000-154, s. 4;
2001-155, s. 1; 2004-124, ss. 10.19D(c), (h);
2005-4, ss. 1, 2, 3, 4, 5(a); 2007-444, s. 3.)
This Rule is not met as evidenced by:
Based on record reviews and interviews the
facility failed to request the required state and/or
Division of Health Service Regulation
If continuation sheet 39 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 133Continued From page 39 V 133
nationwide criminal record checks within 5
business days of offering employment for 4 of 22
audited staff (Counselors #2, #3, #16 and the
Assistant Program Director #1 (APD #1). The
findings are:
Review on 5/14/13 of Counselor #2 ' s record
revealed:
- A hire date of 2/4/13
- A job description of Substance Abuse Counselor
- A criminal record check was completed on
2/19/13
Review on 5/16/13 of Counselor #3 ' s record
revealed:
- A hire date of 6/27/12
- A job description of Substance Abuse Counselor
- A criminal record check was completed on
11/9/12
Review on 4/10/13 of Counselor #16 ' s record
revealed:
- A hire date of 11/21/11
- A job description of Substance Abuse
Counselor-Intern
- A criminal record check was completed on
4/10/13
Interview on 7/23/13 with the Vice President of
Operations revealed:
- Couselor #16 was terminated on 7/9/13
Review on 7/23/13 of the APD #1 ' s record
revealed:
- A hire date of 9/10/12
- A job description of Assistant Program Director
- A criminal record check was completed on
11/9/12
Review on 7/25/13 of the Plan of Protection dated
Division of Health Service Regulation
If continuation sheet 40 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 133Continued From page 40 V 133
7/25/13 written by the Director of Nursing,
(Registered Nurse #1/Director of Nursing)
Assistant Program Director, (Assistant Program
Director #2) Program Director (Program Director
#2) and Vice President of Operations revealed:
- APD #1 was transferred to another role within
the agency outside of Greensboro on 6/3/13
Interview on 4/17/13 with the Program Director #1
(PD #1) revealed:
- It was the Corporate Office ' s responsibility to
ensure criminal record checks were requested
within 5 business days of offering employment
Interview on 5/22/13 with the Corporate Director
of Clinical Practices revealed:
- " Regarding the criminal record checks. Those
are done at the home office. "
V 235 27G .3603 (A-C) Outpt. Opiod Tx. - Staff
10A NCAC 27G .3603 STAFF
(a) A minimum of one certified drug abuse
counselor or certified substance abuse counselor
to each 50 clients and increment thereof shall be
on the staff of the facility. If the facility falls below
this prescribed ratio, and is unable to employ an
individual who is certified because of the
unavailability of certified persons in the facility's
hiring area, then it may employ an uncertified
person, provided that this employee meets the
certification requirements within a maximum of 26
months from the date of employment.
(b) Each facility shall have at least one staff
member on duty trained in the following areas:
(1) drug abuse withdrawal symptoms; and
(2) symptoms of secondary complications
to drug addiction.
(c) Each direct care staff member shall receive
V 235
Division of Health Service Regulation
If continuation sheet 41 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 235Continued From page 41 V 235
continuing education to include understanding of
the following:
(1) nature of addiction;
(2) the withdrawal syndrome;
(3) group and family therapy; and
(4) infectious diseases including HIV,
sexually transmitted diseases and TB.
This Rule is not met as evidenced by:
Based on record reviews and interviews the
facility failed to ensure a minimum of one certified
drug abuse counselor or certified substance
abuse counselor shall be on staff for each 50
clients for 6 out of 22 audited staff (Counselors
#2, #3, #6, #15, #16, & Senior Counselor #1).
The findings are:
Review on 4/18/13 of the facility ' s policy and
procedure manual, on Ensuring Adequate
Staffing, revealed:
- " ...It is the policy of CTC (Crossroads
Treatment Center) to have sufficient amount of
qualified staff members on duty during the
program ' s hours of operation. Sufficient qualified
staff is defined as the minimum number of
employees necessary to carry out the policies
and provide the services offered by the program
...Full-time substance abuse counselors shall
carry a caseload not exceeding fifty (50) OTP
(Opioid Treatment Program) patients. This will
help ensure that each counselor has adequate
capacity to provide all relevant services for
persons served ... "
Review on 5/14/13 of Counselor #2 ' s record
revealed:
-A hire date of 2/4/13
Division of Health Service Regulation
If continuation sheet 42 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 235Continued From page 42 V 235
Review on 5/13/13 of Counselor #3 ' s record
revealed:
- A hire date of 6/27/12
Review on 7/23/13 of Counselor #6 ' s record
revealed:
-A hire date of 3/18/13
Review on 4/11/13 of Counselor #15 ' s record
revealed:
-A hire date of 7/21/11
Review on 5/13/13 of Counselor #16 ' s record
revealed:
-A hire date of 11/2/11
Interview on 7/23/13 with the Vice President of
Operations revealed:
- Counselor #15 was terminated on 7/10/13
- Couselor #16 was terminated on 7/9/13
Review on 4/11/13 of Senior Counselor #1 ' s
record revealed:
-A hire date of 2/27/12
Interview on 5/16/13 with Counselor #1 revealed:
-His caseload was 52.
- " I have been trying to keep up with my
caseloads ...at first I really struggled with it...
$1 a day we are taking in more clients than we
can handle, are equipped for. The patients aren '
t getting what they need (services) if spread too
thin, can ' t do treatment for clients. "
Interview on 5/15/13 with Counselor #6 revealed:
-She had 52 patients on her caseload.
- " I was told I wouldn ' t get a caseload. [The PD
#1] assigned cases to me. I was to have
transition patients (new patients)
Division of Health Service Regulation
If continuation sheet 43 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 235Continued From page 43 V 235
-She was employed on 3/18/13 and reported "the
dollar per day was already going on when I got
here but will end on 6/1/13."
Interview on 5/15/13 with Counselor #3 revealed:
- The facility offered a fee reduction program
which allowed clients to pay a dollar per day for
their methadone for the first 30 days in treatment
-There was an increase in client intakes as a
result of this fee reduction
Interview on 7/24/13 with Counselor #2 revealed:
- " I was up to 55 clients. "
Interview on 5/14/13 with Counselor #3 revealed:
- She had a current caseload of 51
- She was not a certified drug abuse counselor or
certified substance abuse counselor but was
working towards it
- The Program Director #1 (PD #1) was aware
that her caseload exceeded 50
Interview on 5/21/13 with Counselor #15
revealed:
- " I have a caseload of 53 right now. It ' s not
manageable to provide care. It ' s good for case
management. If someone came in and needed
more I wouldn ' t have time. I got 4 new patients
while I was out on vacation "
-When asked who monitors patients while you ' re
on vacation she replied: " I don ' t know. "
-When asked what the policy was on getting a
new client when you ' re out on vacation she
replied: " I don ' t know. We would complain
about the caseloads and [The PD #1] would say '
Fifty thousand years ago I had 300 plus clients
and I did the paperwork and got all his stuff done '
. He didn ' t say fifty thousand but said a lot of
years ago had 300 plus clients and got all my
stuff done. "
Division of Health Service Regulation
If continuation sheet 44 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 235Continued From page 44 V 235
Interview on 5/13/13 with Counselor #16
revealed:
-She had worked at the facility since 11/21/11
- " I have 55 patients. Been like that past two
years ...We ' re not adequately staffed, we have
sent emails to Corporate. There ' s no way
possible to do all that you ' re asking us to do and
be in compliance. We have asked and asked for
more staff. No training Manual. We ' ve always
been understaffed. Should be no more than 50
patients. I don ' t think we should have any more
patients until we are adequately staffed. Eleven
presented for intake yesterday and then no
training provided. The operational policies that
should happen don ' t. I learned all of that by
myself. No training provided here. It ' s all about
the money. "
Interview on 4/11/13 with Senior Counselor #1
revealed:
- " Current caseload is 52. It was 53, discharged
1. This $1 a day we ' re offering, the treatment is
not effective been going on since we ' ve been
here ...I am not able to get all the intake
paperwork, doctor may leave, then they can ' t
dose ...It is not feasible to get it all done in the
time we have ...I understand people have died
and things weren ' t done right ...Some patients
want to see their counselor, it is hard to turn them
away ... "
Interview on 5/16/13 with The Program Director
#1 revealed:
-When asked if he was aware that all of his
counselors had over the 50 minimum clients on
their caseloads he replied: " Yes. I interviewed
three (perspective employees) this week but I
wouldn ' t hire any of them.
- I am aware staff is over the 50:1 ratio. Our plan
Division of Health Service Regulation
If continuation sheet 45 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 235Continued From page 45 V 235
or goal is to be 45:1. We are actively recruiting
(counselors) ...It is hard to find people ...more
counselors are leaving the field than coming. "
This deficiency is cross referenced into 10A
NCAC 27D .0304 Protection from Harm, Abuse,
Neglect or Exploitation (V512) for a Type A1 rule
violation and must be corrected within 23 days.
V 237 27G .3604 (A-D) Outpt. Opiod - Operations
10A NCAC 27G .3604 OPERATIONS
(a) Hours. Each facility shall operate at least six
days per week, 12 months per year. Daily,
weekend and holiday medication dispensing
hours shall be scheduled to meet the needs of
the client.
(b) Compliance with The Substance Abuse and
Mental Health Services Administration (SAMHSA)
or The Center for Substance Abuse Treatment
(CSAT) Regulations. Each facility shall be
certified by a private non-profit entity or a State
agency, that has been approved by the SAMHSA
of the United State Department of Health and
Human Services and shall be in compliance with
all SAMHSA Opioid Drugs in Maintenance and
Detoxification Treatment of Opioid Addiction
regulations in 42 CFR Part 8, which are
incorporated by reference to include subsequent
amendments and editions. These regulations are
available from the CSAT, SAMHSA, Rockwall II,
5600 Fishers Lane, Rockville, Maryland 20857 at
no cost.
(c) Compliance With DEA Regulations. Each
facility shall be currently registered with the
Federal Drug Enforcement Administration and
shall be in compliance with all Drug Enforcement
Administration regulations pertaining to opioid
treatment programs codified in 21 C.F.R., Food
V 237
Division of Health Service Regulation
If continuation sheet 46 of 1396899STATE FORM DOBD11
![Page 47: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/47.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 237Continued From page 46 V 237
and Drugs, Part 1300 to end, which are
incorporated by reference to include subsequent
amendments and editions. These regulations are
available from the United States Government
Printing Office, Washington, D.C. 20402 at the
published rate.
(d) Compliance With State Authority Regulations.
Each facility shall be approved by the North
Carolina State Authority for Opioid Treatment,
DMH/DD/SAS, which is the person designated by
the Secretary of Health and Human Services to
exercise the responsibility and authority within the
state for governing the treatment of addiction with
an opioid drug, including program approval, for
monitoring compliance with the regulations
related to scope, staff, and operations, and for
monitoring compliance with Section 1923 of P.L.
102-321. The referenced material may be
obtained from the Substance Abuse Services
Section of DMH/DD/SAS.
This Rule is not met as evidenced by:
Based on observations, record reviews and
interviews, the facility failed to comply with the
federal guidelines to diversion of medication
administration affecting 1 of 10 clients dosed
(Former Client #1 (FC #1). The findings are:
Observation on 4/17/13, at approximately
12:27pm, of the facility ' s American Disability Act
(ADA) dosing window, revealed:
- The ADA dosing window was 34 inches high
compared to the three other windows which were
41 inches high.
Review on 4/17/13 of the Federal Regulations
pertaining to Security Provisions revealed:
- " 21 CFR part 1300, specifically 21 CFR
Division of Health Service Regulation
If continuation sheet 47 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 237Continued From page 47 V 237
1301.71 (a) states ' all applicants and registrants
shall provide effective controls and procedures to
guard against theft and diversion of controlled
substances. "
Review on 4/12/13 of the facility ' s policy and
procedure manual revealed:
- " Accounting for Lost or Stolen Controlled
Substances - Local law enforcement agency, the
Bureau of Drug Control and the Drug
Enforcement Agency (DEA) will be notified within
five days of the discovery of the loss/theft of
controlled substances used by [The Crossroads
Treatment Center of Greensboro PC] as required
by regulations. "
Review on 4/11/13 and 4/12/13 of FC #1 ' s
record revealed:
- An admission date of 8/19/11
- A diagnosis of Opioid Dependence
- A discharge date of 1/9/13
- In a urinalysis report, dated 1/4/13, she tested
positive for Cocaine, TetraHydroCannabinol
(THC) and Benzodiazepines (Benzos).
Review on 4/11/13 of the Registered Nurse #2 ' s
(RN #2) record revealed:
- A hire date of 1/11/10
- A job description of Registered Nurse
Review on 4/10/13 of the facility ' s Inventory Bulk
Reconciliation form, dated 1/5/13, revealed:
- " Transaction Type/Transaction Detail:
Reconcile - Discrepancy Bottle Shortage -
Comment: Patient (pt.) (FC #1) attempted to
steal Methadone by reaching into the dosing
window when told [the Medical Director] ordered
a no dose due to (d/t) obvious impairment and a
positive drug screen for Cocaine, THC and
Benzos. She ran from the building chased by
Division of Health Service Regulation
If continuation sheet 48 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 237Continued From page 48 V 237
security guard. Five tablets were removed from
her possession but one is missing. "
Review on 4/16/13 of the facility ' s Supervisory
Meeting, dated 1/7/13, revealed:
- " 1) 1/5/13 incident (theft of 40mgs methadone
disk) - [Registered Nurse #2] was dosing - [FC
#1] became very upset when she was told she
would not be dosing due to a positive Urine
Analysis (U/A) for Benzos, THC and Cocaine per
[the Medical Director (MD)]. [FC #1] jumped into
the dosing window, grabbed several 40mg disks
and ran out of the clinic. [The Security Guard
(SG)] stopped [FC #1] from entering her vehicle.
All disks were recovered with the exception of
one 40mg. [The SG] searched the parking lot and
[FC #1]. The disk could not be located. According
to [the Security Guard], [FC #1] didn ' t have time
to swallow the disk ...Elimination of problem: 1)
Assure all medications are kept out of reach of all
patients (pts); 2) When a nurse leaves his/her
dosing window, make sure the window is locked
and medication is relocated to a place that can ' t
be accessed by patients (pts).. 3) Agitated
patients (pts) - have the security guard escort the
patient (pt) to the dosing window, observe dosing,
escort the patient (pt) to his/her vehicle ... "
Interview on 4/11/13 with FC #1 revealed:
- " ...There was a whole big bowl of them
(Methadone 40mg disks) sitting there (on the
counter at the dosing window). I was standing
there a long time ...anyone (clients) could have
grabbed the bowl ...it is just that certain nurse
(RN #2) that leaves them (pills) there (in the bowl)
...it was a Styrofoam bowl ...I grabbed 4 or 5
(pills) and I took (ingested) one of them ...I just
wanted my medication ...I lied saying I did not
take it (pill), but I did ...I gave [the SG] the pills I
had in my hand ... "
Division of Health Service Regulation
If continuation sheet 49 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 237Continued From page 49 V 237
- Further attempts to gain information from FC #1
were unsuccessful due to her statement " I don '
t want to answer any questions ...I have
something to do. "
Interview on 4/12/13 with the RN #2 revealed:
- " ...This was on a Saturday (1/5/13). I keep my
bowl of pills (Methadone 40mg disks) to my right
side on the counter. They (the pills) were pretty
close to the window. It is a lower window
(handicap accessible) than the other dosing
windows. When she came to the window, she
was acting silly and was slurring her words. I
informed her we would have to take a urine
analysis (u/a). It came back positive for Cocaine,
THC and Methadone. I called [the MD] and we
were told we could not dose her. I called her to
the window and told her. I was prepared for her
temper tantrum. She said ' I can ' t believe this
shit. ' She reached into the window where the
bowl was (on the counter) and grabbed the pills.
One nurse [Registered Nurse #1/Director of
Nursing (RN #1/DON)] chased after her and
yelled for [the SG]. Five (pills) were missing. We
recovered all but one. We are pretty sure she
popped (ingested) it. I am pretty sure I told [the
Program Director #1 (PD #1)] she took one. It
was a white 40mg Methadone pill. "
- When asked how the incident (on 1/5/13)
occurred, the RN # 2 stated, " It is easy for
clients to reach through the window. They could
see the pills when they were dosing. "
Interview on 4/11/13 with the RN #1/DON
revealed:
- " I was sitting two stations over ...I saw her (FC
#1) run towards the door to leave. I heard the
sound of the pills in the bowl and the reaching in.
I heard [RN #2] yell for [the SG] ...She (FC #1)
was impaired and was not getting her dose for
Division of Health Service Regulation
If continuation sheet 50 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 237Continued From page 50 V 237
the day, so she probably thought ' Here it (the
Methadone disk) is. I am just going to take it. ' I
think it was 5 pills taken and 1 was unaccounted
for. I know they searched her body. She did not
have anything in her mouth, but could have
swallowed them ...there is no way to know what
could have happened. It could have been lethal
(for her to swallow the pills) with what she had in
her system ...[RN #2] was using the handicapped
accessible window that day (1/5/13) and the shelf
under the dosing window is not high enough to
store medications under it, so she kept hers (pills)
in a bowl off to the side. [RN #2] ' s pills were not
out of sight (of the patients) ... "
Interview on 4/11/13 with the Licensed Practical
Nurse #2 (LPN #2) revealed:
- " I saw [RN #2] sitting at the handicapped
accessible window (dosing) that day (1/5/13)
...the handicapped accessible window (dosing)
does not have a cabinet shelf. [FC #1] came to
dose and when she was told she would not be
able to, she said ' what am I going to do over the
weekend? I will be sick. ' She ran out with a
handful of pills. I was not aware of how much she
had taken. We counted and ended up losing 1
pill. It was never accounted for ... [The SG]
frisked her and looked in her pocket which she
flipped inside out. She could have put them
anywhere. One option could be that she could
have hidden the one that was unaccounted for. It
is a possibility she could have taken the missing
pill or all of them. She could have gotten away
with all the pills in the bowl ...she could have
overdosed ...that window (the handicapped
accessible) did not lock. "
Interview on 4/11/13 with Counselor #15
revealed:
- When asked about the incident of FC #1
Division of Health Service Regulation
If continuation sheet 51 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 237Continued From page 51 V 237
stealing Methadone pills on 1/5/13, Counselor
#15 stated, " I was told she would not be
returning because she grabbed a handful (5 pills)
of Methadone (pill form). [The SG] stopped her
and one of the pills was unaccounted for. It is
possible she could have swallowed them. I am
surprised she did not take them all (five pills). She
could have overdosed. "
Interview on 4/10/13 with the Assistant Program
Director #1 (APD #1) revealed:
- " ... [FC #1] came in and appeared to be
impaired (on 1/5/13). She tested positive for
Benzos, Cocaine and THC. When they spoke
with [the MD], they were told they could not dose
her. She got very upset and said ' I am not
leaving here without my meds. ' That is when she
leaned over, reached in the window and grabbed
some tablets, maybe 4 or 5. I don ' t recall. [The
SG] was called and detained her. She gave all
but 1 pill back ...it is possible she could have
taken (ingested) the pill that was not recovered. If
she had overdosed, she could have died or had
health complications. "
Interview on 4/10/13 with the State Opioid
Treatment Authority Coordinator (SOTA)
revealed:
- " This is major (FC #1 grabbing Methadone pills
from the dosing window) ...this is a significant
event, very concerning because someone could
have died ... "
Interview on 4/10/13 with the Administrator/Co
Director for SOTA revealed:
- " ...How did the physical barrier (dosing
window) allow her (FC #1) to reach in? Had she
(FC #1) not been caught (with the Methadone 40
mg disks), it could have been lethal ... "
Division of Health Service Regulation
If continuation sheet 52 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 237Continued From page 52 V 237
Interview on 4/16/13 with the MD revealed:
- " [FC #1], if ingested a 40mg disk of
Methadone, in addition to testing positive for
Benzos, THC and Cocaine, she could have
respiratory distress (failure), she could have
overdosed on Methadone or had a heart attack. "
Interviews on 4/11/13 and 4/12/13 with the PD #1
revealed:
- " With one pill (40 mg) missing, I did not do an
investigation. The pill was reconciled as a theft. I
left a message for [the Drug Enforcement Agency
(DEA) representative] and never heard back. He
is usually good about returning calls. He never
got back to me. "
- When asked if he followed up with the DEA
representative, the PD #1 stated, " no. "
- When asked if he contacted the Bureau of Drug
Control or the local law enforcement agency, the
PD #1 stated " no. "
- When asked if he contacted the
Administrator/Co Director for the SOTA, the PD
stated " no. "
- When asked if he contacted the Division of
MH/DD/MA/SAS Community Policy Management
Section or the State Opioid Treatment
Coordinator, the PD #1 stated " no. "
- " ...I was the only one that observed the video
on that date (1/5/13). I saw her (FC #1) reach
through the window to the left and grab the pills
...the reach into the bowl was about 4 feet. If
anyone (clients) wanted to get the pills, they could
have. "
Review on 4/17/13 of the facility ' s Plan of
Protection, dated 4/17/13 and completed by the
PD #1 revealed:
- What immediate action will the facility take to
ensure the safety of the consumers in your care?
" The ADA (American Disability Act) dosing
Division of Health Service Regulation
If continuation sheet 53 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 237Continued From page 53 V 237
window has not been in use since the theft of a
40mg disk. All nurses have been instructed to
keep the window closed and locked at all times.
When dosing, all nurses keep all disks and 5mg
tablets under the counter and out of the patients
sight. The methadone pump is kept on the
opposite side of the open dosing window. The
security guard has been instructed to patrol the
lobby and dosing area more frequently. "
- Describe your plans to make sure the above
happens.
" The Program Director, Asst (Assistant)
Program Director, Clinical Director and RN
(Registered Nurse) monitor the pharmacy during
the dosing hours. The Clinical Director also
monitors the outside portion of the pharmacy.
The security guard also monitors the outside of
the pharmacy. To assure compliance with all
Federal, State, local rules and regulations, the
Administrative staff will be required to: complete
all IRIS (Incident Response Improvement
System) reports as soon as an incident occurs,
complete an incident report for the Program
Director, Asst Program Director and Clinical
Director to review, review all
SAMHSA/CARF/DEA (Substance Abuse and
Mental Health Services
Administration/Commission on Accreditation of
Rehabilitation Facilities/Drug Enforcement
Authority) rules and regulations regarding OTP ' s
(Opioid Treatment Program ' s). All reviews will
be documented and the documentation will be
kept in the Program Director ' s office. "
Describe the preventive measures in place prior
to the violation.
" The ADA dosing window has not been in use
since the theft of a 40mg disk. All nurses have
been instructed to keep the window closed and
locked at all times. When dosing, all nurses keep
all disks and 5mg tablets under the counter and
Division of Health Service Regulation
If continuation sheet 54 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 237Continued From page 54 V 237
out of the patients sight. The methadone pump is
kept on the opposite side of the open dosing
window. The security guard has been instructed
to patrol the lobby and dosing area more
frequently. Also, the PD, Asst PD, Clinical
Director have been reviewing the security
cameras on a random basis to assure the ADA
window is not used. "
- Describe how and when the violation was
corrected.
" The incident occurred on 1/5/13. On 1/7/13, this
Director contacted [the landlord] to repair the
broken dosing window. The window was repaired
on 1/7/13. "
- Describe the corrective measures the facility
implemented to achieve and maintain
compliance.
" The ADA dosing window has not been in use
since the theft of a 40mg disk. All nurses have
been instructed to keep the window closed and
locked at all times. When dosing, all nurses keep
all disks and 5mg tablets under the counter and
out of the patients sight. The methadone pump is
kept on the opposite side of the open dosing
window. The security guard has been instructed
to patrol the lobby and dosing area more
frequently. [Registered Nurse #2] and all other
nurses completed a course on Medication
Management in Essential Learning. All nurses
have been instructed to not pour any medication
in bowls and re-dispense medication from the
bowl. "
Describe the facility ' s system to ensure
compliance is maintained and how the system will
continue to be implemented.
" The incident occurred on 1/5/13. On 1/7/13, this
Director contacted [the landlord] to repair the
broken dosing window. The window was repaired
on 1/7/13. All nurses will continue Medication
Management Training in Essential Learning on an
Division of Health Service Regulation
If continuation sheet 55 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 237Continued From page 55 V 237
annual basis. Security cameras will continue to be
monitored on a random basis. "
Review on 7/25/13 of the Plan of Protection dated
7/25/13 written by the Director of Nursing, (RN
#1/DON) Assistant Program Director, (APD #2)
Program Director (PD #2) and Vice President of
Operations revealed:
" ... " 27G.0209
In regard to medication requirements:
1. Methadone disks are no longer dispensed out
of the handicap accessible window.
2. All medications are dispensed from the
original tamper-resistant manufacture ' s bottles.
3. When Methadone bottles are not being used
for dosing, they are kept under shelving and
therefore out of sight and inaccessible to patients
... "
This deficiency constitutes a Past Corrected Type
A2 rule violation. An administrative penalty of
$1000.00 is imposed. A plan of correction is
optional but not required for this violation.
V 238 27G .3604 (E-K) Outpt. Opiod - Operations
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
V 238
Division of Health Service Regulation
If continuation sheet 56 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 238Continued From page 56 V 238
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
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
treatment and a minimum of 90 days of
continuous program compliance at level 3, a
client may be granted for a maximum of five
take-home doses and shall ingest all other doses
Division of Health Service Regulation
If continuation sheet 57 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 238Continued From page 57 V 238
under supervision at the clinic each week;
(E) Level 5. After 364 days of continuous
treatment and a minimum of 180 days of
continuous program compliance, a client may be
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
continuous program compliance at level 5, a
client may be granted for a maximum of 13
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
continuous program compliance, a client may be
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
Division of Health Service Regulation
If continuation sheet 58 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 238Continued From page 58 V 238
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
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
Division of Health Service Regulation
If continuation sheet 59 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 238Continued From page 59 V 238
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,
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.
Division of Health Service Regulation
If continuation sheet 60 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 238Continued From page 60 V 238
(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;
(2) call-in's for bottle checks, bottle returns
or solid dosage form call-in's;
(3) call-in's for drug testing;
(4) drug testing results that include a
review of the levels of methadone or other
medications approved for the treatment of opioid
addiction;
(5) client attendance minimums; and
(6) procedures to ensure that clients
properly ingest medication.
This Rule is not met as evidenced by:
Based on record reviews and interviews the
facility failed to ensure that patients who receive
take home medications (methadone) must meet
the specified requirements for levels of eligibility
affecting 1 of 7 Deceased Clients (Deceased
Client #1)(DC #1). The findings are:
Review on 4/8/13 of DC #1 ' s record revealed:
-An admission date of 3/26/12
-A discharge date of 3/26/13
-A date of death of 3/16/13
-She was 37 years old
-Diagnoses of Opioid Dependence,
Polysubstance Abuse, Post Traumatic Stress
Division of Health Service Regulation
If continuation sheet 61 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 238Continued From page 61 V 238
Disorder, Anxiety Disorder, Major Depressive
Disorder, Recurrent, Moderate, Hearing Loss -
80% and History of Gastric Bypass
-A diagnosis of Substance Induced Psychotic
Disorder with Hallucinations added on 10/16/12
by clinician at a local mental health facility
-A treatment plan dated 3/4/13 and completed by
DC#1 ' s counselor (Counselor #16) which
documented the following goals: - " Patient will
continue to take methadone as prescribed and
not use illicit substances; to overcome feelings of
depression; and to monitor chronic illness signs
and symptoms. "
Review on 4/8/13 of DC #1 ' s drug screens from
3/27/12 - 3/5/13 revealed DC #1 was positive for
the following substances on these dates:
- 3/27/12 Benzodiazepines (BNZs) and
Opiates
- 7/12/12 BNZs and Alcohol (Etoh)
- 8/1/12 BNZs
- 8/28/12 Breathalyzer with a reading of
0.025
- 9/4/12 BNZs
- 10/5/12 Etoh - Breathalyzer reading of
0.029
- 11/23/12 Breathalyzer with a reading of
0.026
- 1/8/13 Breathalyzer with a reading of
0.011
- 2/5/13 Opiates
- 2/14/13 BNZs
- 2/23/13 BNZs
- 3/5/13 BNZs
Further review on 4/16/13 of DC #1 ' s record
revealed:
-A request for a take-home medication form was
completed on 1/22/13 and signed by the (The
Assistant Program Director #1 (APD #1) and
Division of Health Service Regulation
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 238Continued From page 62 V 238
Counselor #16 on 1/22/13
-The Medical Director signed the form also;
however, there was no date listed by the Medical
Director ' s signature
-A Patient Orders ' form dated 1/17/13 which
documented DC #1 was staffed and approved for
take-home medications to begin on 1/22/13
-The form documented that DC #1 would attend
the facility on Monday, Tuesday, Wednesday and
Thursday with take-homes for Friday, Saturday
and Sunday which indicated a change from Level
1 to Level 2
-This " Patient Orders " form was signed by
Counselor #16, the Registered Nurse #1/Director
of Nursing (RN #1/DON) and the Medical Director
(MD) with no dates listed by their signatures
-DC #1 continued on Level 2 until her death on
3/16/13 with her receiving three take home doses
of Methadone at 107 mg per bottle
Review on 4/8/13 of the facility ' s policy on Take
Home Medications revealed:
- " Requirements for Eligibility:
1. Absence of recent abuse of drugs (narcotic
and non-narcotic) including alcohol ...
Take-Home Eligibility. Any patient 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 patient 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.
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
Division of Health Service Regulation
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 238Continued From page 63 V 238
single dose each week and the patient shall
ingest all other doses under supervision at the
clinic;
b. Level 2. After a minimum of 90 days of
continuous program compliance, a patient may
be granted for a maximum of three take home
doses and shall ingest all other doses under
supervision at the clinic each week... "
Interview on 4/11/13 with Counselor #16
revealed:
- " I saw [DC #1] every day. Everyday was the
same as yesterday; she (DC #1) couldn ' t
remember anything ...
- [DC #1] was a high risk patient due to her dual
diagnoses ...
- Our facility (Crossroads Treatment Center)
(drug) tests do not show how much of the
substances she (DC #1) takes, only that it ' s
there (drugs in her system) ...
-We had discussed with the owners (of the
facility) whether we needed to MSW (Medically
Supervised Withdrawal) her out of the clinic (DC
#1), but she wasn ' t eligible for the Medically
Supervised Withdrawal because she was very
random with her drug use...She didn ' t hit
anything hard, no cocaine ...
-I don ' t see where she leveled down (in DC #1 '
s record), it could be in the computer because
she should have been (brought down to level 1).
We go to our supervisor (Program Director #1
(PD #1) to level down. There would be no reason
why she (DC #1) would not be leveled down (to
level 1) but what might have happened is at
minimum two failed because positive tests on
2/5/13 and 2/14/13 are only counted as one failed
drug test so there is a possibility that she could
still have been on level two when she passed.
[The PD #1] would have to look at that because
she (DC #1) has been discharged and I don ' t
Division of Health Service Regulation
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 238Continued From page 64 V 238
have access to that. "
Interview on 4/10/13 with the RN #1/DON
revealed:
-DC# 1 was admitted to the facility in April of 2012
-DC #1 was " a sweet patient with a traumatic
brain injury and mental health issues. "
-DC #1 had issues with alcohol and breathalyzers
were administered to her and she was educated
on the dangers of alcohol use
-DC #1 had been diagnosed with Substance
Induced Psychotic Disorder
- " If a client has three positive urine analyses in a
row, the client ' s counselor will speak with the
client about the positive urine analyses and
discuss the client with the Medical Director if
necessary "
-There is a list in the copy room where counselors
put patients that need to be leveled up and
RN#1/DON gives the Medical Director the list and
he does the Central Registry. The APD #1, the
Clinical Director (the CD) and the RN
#1/DON]look at registry.
- " I speak to him (the Medical Director) everyday,
so he knows if someone is a repeat offender
(continues to test positive for drugs and alcohol)
and he makes the decision for MSW or to
decrease methadone and level changes ...2 clean
drug screens a week apart is what doc (The
Medical Director) wants now. Back then (3/27/12
-3/5/13) we used 1 clean drug screen (to decide
on making changes with methadone and level
changes). "
Interview on 4/12/13 and 4/17/13 with the PD #1
revealed:
- " There was not a day that went by " that he did
not speak with the MD
-His nurses spoke to the MD every day
-When asked how the facility decides on leveling
Division of Health Service Regulation
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 238Continued From page 65 V 238
a patient up and down he replied: " Prior to
about 2 months ago, we would staff individuals
(patient) in meetings and counselor involved
would bring medical record to staff meeting, we
would review all criteria to see if they should be
leveled up. Recently we met and we actually
leveled down some people who were leveled up
erroneously... "
-When asked what criteria is met for a patient to
be leveled down he replied: ' 2 positives in 90
days, including alcohol, down one level, 3
positives 90 days go all the way down regardless
of where they are at. ' "
-When asked in looking through the charts for
patients and seeing that some had been leveled
up erroneously what would be done he replied: "
I would do a coaching note for whoever had the
error. "
-When asked if he had the opportunity to look
through DC #1 ' s record to see what happened
with her level error he replied: " I have not. "
Interview on 4/16/13 with facility ' s MD revealed:
-He had been employed by the facility for five
years. " I ' m basically on call every day of the
week, including Saturdays and available to
nurses every day. "
-When asked how testing positive (on drug
screens) impacts his decisions the MD replied: "
It ' s a case by case basis. A lot of it has to do
with when I ' m making decisions about a dose; I
look at current dose, history of dose. On a day to
day basis it comes down to impairment. You want
to keep them (clients) stable, not a scientific
algorithm, comes down to talking to nurses. If
they are impaired I would have to lower doses. If
you drop them too much they will go out on
streets. It ' s a tricky balance. I put a great bit of
trust on the nurses and also the counselors. "
-Clients are moved from Level to Level when they
Division of Health Service Regulation
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 238Continued From page 66 V 238
produce three months of clean drug screens and
no illicit drug use. " [PD #1] calls me on that
(level changes) and we make a decision. "
-When asked if alcohol is considered an illicit
substance he replied: " Yes and no. Depends on
the situation. If it ' s constantly positive (for
alcohol) then it ' s definitely failing (would be
considered a positive drug screen). "
-As a result of the information shared with the MD
during the interview, he stated " I ' m going to talk
to [PD #1] and he (the PD #1) will get with the
counselors. We will probably come up with a
check list. We (the facility) need to have a red
flags test for the counselors. "
V 366 27G .0603 Incident Response Requirments
10A NCAC 27G .0603 INCIDENT
RESPONSE REQUIREMENTS FOR
CATEGORY A AND B PROVIDERS
(a) Category A and B providers shall develop
and implement written policies governing their
response to level I, II or III incidents. The policies
shall require the provider to respond by:
(1) attending to the health and safety needs
of individuals involved in the incident;
(2) determining the cause of the incident;
(3) developing and implementing corrective
measures according to provider specified
timeframes not to exceed 45 days;
(4) developing and implementing measures
to prevent similar incidents according to provider
specified timeframes not to exceed 45 days;
(5) assigning person(s) to be responsible
for implementation of the corrections and
preventive measures;
(6) adhering to confidentiality requirements
set forth in G.S. 75, Article 2A, 10A NCAC 26B,
42 CFR Parts 2 and 3 and 45 CFR Parts 160 and
V 366
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 366Continued From page 67 V 366
164; and
(7) maintaining documentation regarding
Subparagraphs (a)(1) through (a)(6) of this Rule.
(b) In addition to the requirements set forth in
Paragraph (a) of this Rule, ICF/MR providers
shall address incidents as required by the federal
regulations in 42 CFR Part 483 Subpart I.
(c) In addition to the requirements set forth in
Paragraph (a) of this Rule, Category A and B
providers, excluding ICF/MR providers, shall
develop and implement written policies governing
their response to a level III incident that occurs
while the provider is delivering a billable service
or while the client is on the provider's premises.
The policies shall require the provider to respond
by:
(1) immediately securing the client record
by:
(A) obtaining the client record;
(B) making a photocopy;
(C) certifying the copy's completeness; and
(D) transferring the copy to an internal
review team;
(2) convening a meeting of an internal
review team within 24 hours of the incident. The
internal review team shall consist of individuals
who were not involved in the incident and who
were not responsible for the client's direct care or
with direct professional oversight of the client's
services at the time of the incident. The internal
review team shall complete all of the activities as
follows:
(A) review the copy of the client record to
determine the facts and causes of the incident
and make recommendations for minimizing the
occurrence of future incidents;
(B) gather other information needed;
(C) issue written preliminary findings of fact
within five working days of the incident. The
Division of Health Service Regulation
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 366Continued From page 68 V 366
preliminary findings of fact shall be sent to the
LME in whose catchment area the provider is
located and to the LME where the client resides,
if different; and
(D) issue a final written report signed by the
owner within three months of the incident. The
final report shall be sent to the LME in whose
catchment area the provider is located and to the
LME where the client resides, if different. The
final written report shall address the issues
identified by the internal review team, shall
include all public documents pertinent to the
incident, and shall make recommendations for
minimizing the occurrence of future incidents. If
all documents needed for the report are not
available within three months of the incident, the
LME may give the provider an extension of up to
three months to submit the final report; and
(3) immediately notifying the following:
(A) the LME responsible for the catchment
area where the services are provided pursuant to
Rule .0604;
(B) the LME where the client resides, if
different;
(C) the provider agency with responsibility
for maintaining and updating the client's
treatment plan, if different from the reporting
provider;
(D) the Department;
(E) the client's legal guardian, as
applicable; and
(F) any other authorities required by law.
This Rule is not met as evidenced by:
Based on record reviews and interview, the
Division of Health Service Regulation
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 366Continued From page 69 V 366
facility failed to implement written policies
governing their response to level I, level II, or
level III incidents. The findings are:
Review on 7/24/13 of "Policy 1031: Incident
Reporting & (and) Analysis" revealed:
- "Crossroads Treatment Center has a policy of
recording critical incidents that might occur in the
process of providing services. An annual review
and analysis (study) of all incident reports will be
conducted by The Program Director. Trends and
patterns will be evaluated and barriers to
treatment that might emerge will be recorded..."
Review on 5/13/13 of the facility ' s IRIS (Incident
Reporting Improvement System) reports from
10/1/12 to 5/13/13 revealed:
- No information on the deaths of Deceased
Client #2 (DC #2), Deceased Client #3 (DC #3),
Deceased Client #4 (DC #4) and Deceased Client
#5 (DC #5)
Review on 5/13/13 of the facility's Internal
Incident Reporting forms revealed:
- No documentation of the deaths of DC clients
#2, #3, #4 and #5
- No documentation to determine causal factors
- No documentation to analyze the facility's
system of care
- No documentation of corrective measures
Interview on 4/10/13 with the Assistant Program
Director #1 revealed:
- " Our policy is to file an incident report and write
it up. [The Program Director #1] is responsible for
the incident reports. "
Interview on 5/16/13 with the PD #1 revealed:
- " After the last visit by [the State Opioid
Treatment Authority Coordinator (SOTA)], I was
Division of Health Service Regulation
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 366Continued From page 70 V 366
told to contact the patient ' s emergency contact,
contact the local police department and complete
an IRIS report. I was cited for this because I did
not know I had to report deaths to the SOTA...it is
my responsibility to report (the deaths) ...I only
reported one death ...I am aware of the 4 other
deaths ...since they were discharged, I won ' t
report those (discharged patients deaths) ...I
would complete an IRIS report on active clients
that have died ...I don ' t know if a patient is
discharged, do I report to IRIS if they are
discharged and died afterwards? [The SOTA
Coordinator] did not interview me (when she was
out in April 2013). That would be a question I ' d
like answered ...I will be glad to do that (report
submitted in IRIS). When is a patient not a
patient? I can ' t find an answer to that. So, do I
go ahead and complete IRIS (on the deaths)? Am
I liable for these (the deaths)? Is it IRIS ' fault? I
did not know I had to file them (the deaths). If a
patient dies 6 months later, do we still do an IRIS
report? To be honest with you, I don ' t know (if
the IRIS reporting criteria has changed) ...I have
only done one (death report in IRIS). We haven ' t
had that many deaths until now. I did not know
they (the deaths) had to be reported. I apologize
for that. "
V 367 27G .0604 Incident Reporting Requirements
10A NCAC 27G .0604 INCIDENT
REPORTING REQUIREMENTS FOR
CATEGORY A AND B PROVIDERS
(a) Category A and B providers shall report all
level II incidents, except deaths, that occur during
the provision of billable services or while the
consumer is on the providers premises or level III
incidents and level II deaths involving the clients
to whom the provider rendered any service within
V 367
Division of Health Service Regulation
If continuation sheet 71 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 367Continued From page 71 V 367
90 days prior to the incident to the LME
responsible for the catchment area where
services are provided within 72 hours of
becoming aware of the incident. The report shall
be submitted on a form provided by the
Secretary. The report may be submitted via mail,
in person, facsimile or encrypted electronic
means. The report shall include the following
information:
(1) reporting provider contact and
identification information;
(2) client identification information;
(3) type of incident;
(4) description of incident;
(5) status of the effort to determine the
cause of the incident; and
(6) other individuals or authorities notified
or responding.
(b) Category A and B providers shall explain any
missing or incomplete information. The provider
shall submit an updated report to all required
report recipients by the end of the next business
day whenever:
(1) the provider has reason to believe that
information provided in the report may be
erroneous, misleading or otherwise unreliable; or
(2) the provider obtains information
required on the incident form that was previously
unavailable.
(c) Category A and B providers shall submit,
upon request by the LME, other information
obtained regarding the incident, including:
(1) hospital records including confidential
information;
(2) reports by other authorities; and
(3) the provider's response to the incident.
(d) Category A and B providers shall send a copy
of all level III incident reports to the Division of
Mental Health, Developmental Disabilities and
Division of Health Service Regulation
If continuation sheet 72 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 367Continued From page 72 V 367
Substance Abuse Services within 72 hours of
becoming aware of the incident. Category A
providers shall send a copy of all level III
incidents involving a client death to the Division of
Health Service Regulation within 72 hours of
becoming aware of the incident. In cases of
client death within seven days of use of seclusion
or restraint, the provider shall report the death
immediately, as required by 10A NCAC 26C
.0300 and 10A NCAC 27E .0104(e)(18).
(e) Category A and B providers shall send a
report quarterly to the LME responsible for the
catchment area where services are provided.
The report shall be submitted on a form provided
by the Secretary via electronic means and shall
include summary information as follows:
(1) medication errors that do not meet the
definition of a level II or level III incident;
(2) restrictive interventions that do not meet
the definition of a level II or level III incident;
(3) searches of a client or his living area;
(4) seizures of client property or property in
the possession of a client;
(5) the total number of level II and level III
incidents that occurred; and
(6) a statement indicating that there have
been no reportable incidents whenever no
incidents have occurred during the quarter that
meet any of the criteria as set forth in Paragraphs
(a) and (d) of this Rule and Subparagraphs (1)
through (4) of this Paragraph.
This Rule is not met as evidenced by:
Based on record reviews and interviews the
facility failed to ensure all level II and III incidents
were reported within 72 hours of the incident to
the Local Management Entity (LME) responsible
for the catchment area where services were
Division of Health Service Regulation
If continuation sheet 73 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 367Continued From page 73 V 367
provided. The findings are:
Finding #1:
Review on 5/13/13 of the facility ' s IRIS (Incident
Reporting Improvement System) reports from
10/1/12 to 5/13/13 revealed:
- No information on the deaths of Deceased
Client #2 (DC #2), Deceased Client #3 (DC #3),
Deceased Client #4 (DC #4) and Deceased Client
#5 (DC #5)
Review on 5/12/13 of DC #2 ' s record revealed:
- An admission date of 8/2/12
- A diagnosis of Opioid Dependence
- He was 29 years old
- A discharge date of 3/26/13
- A date of death of 3/18/13
Review on 5/13/13 of DC #3 ' s record revealed:
- An admission date of 12/28/12
- Diagnoses of Generalized Anxiety, Panic
Disorder, Post Traumatic Stress Disorder, Mood
Disorder, and Depressive Disorder
- He was 20 years old
- A discharge date of 3/8/13
- A date of death of 3/1/13
Review on 5/13/13 of DC #4 ' s record revealed:
- An admission date of 3/15/13
- A diagnosis of Opioid Dependence
- He was 35 years old
- A discharge date of 3/26/13
-A date of death of 3/18/13
Review on 5/13/13 of DC #5 ' s record revealed:
- An admission date of 3/15/13
- A diagnosis of Opioid Dependence
- She was 32 years old
- A discharge date of 3/26/13
Division of Health Service Regulation
If continuation sheet 74 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 367Continued From page 74 V 367
- A date of death of 3/18/13
Interview on 5/21/13 with Counselor #15
revealed:
- " It is my understanding that deaths must be
reported immediately. [The Program Director #1
(PD#1)] is responsible for that. "
Interview on 5/16/13 with the Clinical Director
(CD) revealed:
- " Deaths are reported to [the PD #1], [the
Assistant Program Director #1 (APD #1)] and now
me. [PD #1] does them (the IRIS report). I don ' t
know the requirements to report a death ... "
Interview on 5/17/13 with the APD #1 revealed:
- " [The PD #1] filled out the report in IRIS (for
patient deaths) ...Sometimes [PD #1] will do it
(IRIS reports) because he has the death report or
death certificate. All the death reports go to [the
PD #1] and he does IRIS then. "
Interview on 5/16/13 with the Medical Director
(MD) revealed:
- " Regarding patients ' deaths, there really is not
a protocol. My understanding is when there ' s
actual verification, [the CD] does a report. "
Interview on 5/16/13 with the PD #1 revealed:
- " After the last visit by [the State Opioid
Treatment Authority Coordinator (SOTA)], I was
told to contact the patient ' s emergency contact,
contact the local police department and complete
an IRIS report. I was cited for this because I did
not know I had to report deaths to the SOTA...it is
my responsibility to report (the deaths) ...I only
reported one death ...I am aware of the 4 other
deaths ...since they were discharged, I won ' t
report those (discharged patients deaths) ...I
would complete an IRIS report on active clients
Division of Health Service Regulation
If continuation sheet 75 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 367Continued From page 75 V 367
that have died ...I don ' t know if a patient is
discharged, do I report to IRIS if they are
discharged and died afterwards? [The SOTA
Coordinator] did not interview me (when she was
out in April 2013). That would be a question I ' d
like answered ...I will be glad to do that (report
submitted in IRIS). When is a patient not a
patient? I can ' t find an answer to that. So, do I
go ahead and complete IRIS (on the deaths)? Am
I liable for these (the deaths)? Is it IRIS ' fault? I
did not know I had to file them (the deaths). If a
patient dies 6 months later, do we still do an IRIS
report? To be honest with you, I don ' t know (if
the IRIS reporting criteria has changed) ...I have
only done one (death report in IRIS). We haven ' t
had that many deaths until now. I did not know
they (the deaths) had to be reported. I apologize
for that. "
Finding #2:
Review on 4/10/13 of FC #1 ' s record revealed:
- An admission date of 8/19/11
- Diagnosis of Opioid Dependence
- A discharge date of 1/9/13
Review on 4/11/13 of the RN #2 ' s record
revealed:
- A hire date of 1/11/10
- A job description of Registered Nurse
Review on 4/9/13 of the facility ' s Internal
Incident Reporting Form, dated 1/5/13 and
completed by Registered Nurse #2 (RN #2)
revealed:
- " Patient (Former Client #1 (FC #1)) appeared
at the dosing window impaired. A urine analysis
(u/a) was requested and after 3 attempts, she
said she couldn ' t urinate. [The Medical Director
(MD)] was notified. He ordered a no dose if she
Division of Health Service Regulation
If continuation sheet 76 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 367Continued From page 76 V 367
was positive for Benzodiazepines (Benzos).
When she did urinate, she was positive for
Cocaine, TetraHydroCannabinol (THC) and
Benzos. When told she would not be dosed, she
became very angry and accusatory. She then
reached into the window and grabbed a handful
of orange disks out of the dosing bowl and ran
out of the building. The Security Guard (SG)
chased her and when detained, 5 tablets were
confiscated and returned to the dosing nurse (RN
#2]. "
Review on 4/12/13 of a letter dated 4/10/13,
completed by the PD#1, to Administrator/Co
Director for State Opioid Treatment Authority
(SOTA) revealed:
" ...During this time, (when pills were stolen) I
failed to complete an IRIS and bear full
responsibility for the omission ... "
Reviews on 4/11/13, 4/12/13, 4/16/13 and 4/17/13
of the IRIS revealed:
- No documentation regarding FC #1 taking a
40mg tablet of Methadone from the dosing
window had been submitted.
Interview on 4/12/13 with the RN #2 revealed:
- She made the PD #1 aware of the incident on
1/5/13
- She worked part time at the facility, usually 1 or
2 days per month
- She gave the PD #1 her written statement
Interview on 4/11/13 with Counselor #15
revealed:
- " I don ' t know who did the incident report or if
one was even done at all. That would not be a
surprise to me. "
Interview on 4/10/13 with the RN #1/DON
Division of Health Service Regulation
If continuation sheet 77 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 367Continued From page 77 V 367
revealed:
- She spoke with the Assistant Program Director
#1 (APD #1) regarding the incident on 1/5/13
- She gave a written statement regarding the
incident on 1/5/13
- The staff (RN #2) involved is to write up the
incident and contact the PD #1
- "The [PD #1] was responsible for submitting
incident reports"
Interview on 4/11/13 with the Licensed Practical
Nurse #1 /Lead Dosing Nurse (LPN #1/LDN)
revealed:
- It was the PD #1 ' s responsibility to submit
Incident Reports.
Interview on 4/10/13 with the APD #1 revealed:
- " Our policy is to file an incident report and write
it up. [The PD #1] is responsible for the incident
reports. "
Finding #3:
Review on 5/17/13 of client #12 ' s record
revealed:
- An admission date of 8/11/12
- Diagnosis of Opioid Dependence
Review on 5/17/13 of the Licensed Practical
Nurse #3 ' s (LPN #3 ' s) record revealed:
- A date of hire of 1/21/13
- LPN #3 was terminated immediately
Interview on 5/17/13 with Counselor #3 revealed:
- Licensed Practical Nurse #3 (LPN #3) was
terminated because she administered client #12
a 100 mg dose of Methadone instead of her
prescribed dose of 50 mg of Methadone
- Counselor #3 was unable to recall the date
the dosing mistake occurred
- The mistake was caught by another nurse
Division of Health Service Regulation
If continuation sheet 78 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 367Continued From page 78 V 367
(name of nurse not provided) and attempts were
made to contact client #12
- It was her understanding the mistake was
caused because another client ' s name came up
prior to client #12 ' s name in the dosing queue
and client #12 received the other ' s client ' s dose
- Client #12 returned to the facility on the
following day.
Review on 5/17/13 of client #12 ' s " Case Notes
" completed by the Licensed Practical Nurse
#1/Lead Dosing Nurse (LPN#1/LDN) on 4/23/13
and on 4/24/13 revealed:
- " Nurse (LPN#1/LDN) Patient was dosed at
100mg (on 4/23/13). Patient ' s normal dose is
50 mg, dosing error was noticed and attempted to
contact patient. Doctor (the Medical Director
(MD)) was on site and notified, but reported that
patient may be drowsy and that patient should be
okay since patient had been at a higher dose
before, Dr (the MD) ordered for patient to go and
be assessed at hospital or come back to clinic to
be checked out. Patient could not be contacted.
Notified patient emergency contact [client #12 ' s
mother] to get where about of patient. Contacted
patient boyfriend and was able to speak with
patient she states ' I have been throwing up for
30min. ' Patient was instructed to come back to
clinic for observation, patient refused. Then told
patient to go to the ER and call clinic upon arrival.
Nurse called [local hospitals] to see if the patient
was in the ER department. Patient did not go to
the ER as instructed. [Law enforcement in the
county client #12 was located] was notified and
was asked to go and perform a wellness check. "
- " Nurse - Patient did not come to clinic to
receive dose today. Called and followed up with
patient, she states I didn ' t think I needed to dose
today, I just slept all day yesterday and my
mother was here to check up on me. I will come
Division of Health Service Regulation
If continuation sheet 79 of 1396899STATE FORM DOBD11
![Page 80: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/80.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 367Continued From page 79 V 367
in to dose tomorrow. "
Review on 5/17/13 and on 7/25/13 of the Incident
Response Improvement System (IRIS) revealed:
- No documentation of the medication error
which occurred when client #12 was administered
the incorrect dose of Methadone on 4/23/13
An attempt to interview LPN #3 on 5/17/13 was
unsuccessful as a request for a return phone call
was not met.
Interview on 4/10/13 with the PD #1 revealed:
- " IRIS was not filed because I forgot ... "
- " Should I got ahead and put the report in
IRIS or is it too late? "
V 512 27D .0304 Client Rights - Harm, Abuse, Neglect
10A NCAC 27D .0304 PROTECTION FROM
HARM, ABUSE, NEGLECT OR EXPLOITATION
(a) Employees shall protect clients from harm,
abuse, neglect and exploitation in accordance
with G.S. 122C-66.
(b) Employees shall not subject a client to any
sort of abuse or neglect, as defined in 10A NCAC
27C .0102 of this Chapter.
(c) Goods or services shall not be sold to or
purchased from a client except through
established governing body policy.
(d) Employees shall use only that degree of force
necessary to repel or secure a violent and
aggressive client and which is permitted by
governing body policy. The degree of force that
is necessary depends upon the individual
characteristics of the client (such as age, size
and physical and mental health) and the degree
of aggressiveness displayed by the client. Use of
intervention procedures shall be compliance with
V 512
Division of Health Service Regulation
If continuation sheet 80 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 512Continued From page 80 V 512
Subchapter 10A NCAC 27E of this Chapter.
(e) Any violation by an employee of Paragraphs
(a) through (d) of this Rule shall be grounds for
dismissal of the employee.
This Rule is not met as evidenced by:
Based on record reviews and interviews, the
facility staff failed to protect 1 of 37 audited clients
(#12) ,1 of 2 Former Clients (FC #2) and 3 of 7
Deceased Clients (DCs #1, #4 and #5) from harm
and neglect. The findings are:
Cross Reference: 10A NCAC 27G .0203
Competencies of Qualified Professionals and
Associate Professionals (V109)
Based on record reviews and interviews 2 of 9
Qualified Professionals (QPs) failed to
demonstrate knowledge, skills and abilities
required by the population served (the Program
Director #1 (PD #1) and Assistant Program
Director #1 (APD #1).
Cross Reference: 10A NCAC 27G .3603 Staff
(V235)
Based on record reviews and interviews, the
facility failed to ensure a minimum of one certified
drug abuse counselor or certified substance
abuse counselor shall be on staff for each 50
clients for 7 out of 16 audited staff (Counselors
#1, #2, #3, #6, #15, #16 and Senior Counselor
#1).
Finding #1:
Interview on 5/17/13 with Counselor #3 revealed:
- Licensed Practical Nurse #3 (LPN #3) was
terminated because she administered client #12
a 100 mg dose of Methadone instead of her
prescribed dose of 50 mg of Methadone
Division of Health Service Regulation
If continuation sheet 81 of 1396899STATE FORM DOBD11
![Page 82: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/82.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 512Continued From page 81 V 512
- Counselor #3 was unable to recall the date
the dosing mistake occurred
- The mistake was caught by another nurse
(name of nurse not provided) and attempts were
made to contact client #12
- It was her understanding the mistake was
caused because another client ' s name came up
prior to client #12 ' s name in the dosing queue
and client #12 received the other client ' s dose
Review on 5/17/13 of Client #12 ' s record
revealed:
- An admission date of 8/11/12
- A diagnosis of Opioid Dependence
Review on 5/17/13 of LPN #3 ' s record revealed:
- A date of hire of 1/21/13
- LPN #3 was terminated " immediately. "
Review on 5/17/13 of Client #12 ' s " Patient
Medication Record " revealed:
- Client #12 ' s most recent written doctor ' s
order dated 4/12/13 indicated Client #12 was to
be administered 50 mg of Methadone
- On 4/23/13, LPN #3 administered Client #12
100 mg of Methadone instead of 50 mg of
Methadone
- On 4/24/13, Client #12 was absent from the
facility
- On 4/25/13, Client #12 returned to the facility
for dosing and resumed her regular dosing
regimen of 50 mg of Methadone
Review on 5/17/13 of Client #12 ' s " Case Notes
" completed by the Licensed Practical Nurse
#1/Lead Dosing Nurse (LPN#1/LDN) on 4/23/13
and on 4/24/13 revealed:
- " ...Patient was dosed at 100mg (on 4/23/13).
Patient ' s normal dose is 50 mg, dosing error
was noticed and attempted to contact patient.
Division of Health Service Regulation
If continuation sheet 82 of 1396899STATE FORM DOBD11
![Page 83: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/83.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 512Continued From page 82 V 512
Doctor (the Medical Director (MD)) was on site
and notified, but reported that patient may be
drowsy and that patient should be okay since
patient had been at a higher dose before. Dr (the
MD) ordered for patient to go and be assessed at
hospital or come back to clinic to be checked out.
Patient could not be contacted. Notified patient
emergency contact [Client #12 ' s mother] to get
where about of patient. Contacted patient
boyfriend and was able to speak with patient she
states ' I have been throwing up for 30min. '
Patient was instructed to come back to clinic for
observation, patient refused. Then told patient to
go to the Emergency Room (ER) and call clinic
upon arrival. Nurse called [local hospitals] to see
if the patient was in the ER department. Patient
did not go to the ER as instructed. [Law
enforcement in the county Client #12 was
located] was notified and was asked to go and
perform a wellness check. "
- " Nurse - Patient did not come to clinic to
receive dose today. Called and followed up with
patient, she states I didn ' t think I needed to dose
today. I just slept all day yesterday and my
mother was here to check up on me. I will come
in to dose tomorrow. "
Review on 5/17/13 of Client #12 ' s " Case Notes
" completed by the Registered Nurse #1/Director
of Nursing (RN #1/DON) on 4/23/13 revealed:
- " Nurse (RN #1/DON) - Per (LPN #1/LDN), pt
(patient) was instructed to go to the ED
(Emergency Department) for evaluation as she
refused to return to clinic after an incorrect dose
of methadone was administered this morning. Pt.
is unable to be reached by phone. Calls made to
emergency departments at [local hospitals].
Each hospital emergency room stated there were
no admissions by pt name. "
Division of Health Service Regulation
If continuation sheet 83 of 1396899STATE FORM DOBD11
![Page 84: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/84.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 512Continued From page 83 V 512
Review on 5/17/13 of Client #12 ' s " Case Notes
" completed by the Program Director #1 (PD #1)
on 4/23/13 revealed:
- " Program Director (PD #1) - This PD met
with [LPN #1/LDN], [RN #1/DON], and [the MD] in
regards to the dosing error of [Client #12]. [The
MD] was told [Client #12 ' s] current dose was 50
mg qd (every day) and that she had been
incorrectly dosed at 100 mgs. [The MD]
recommended that we continue to attempt to
contact [Client #12] via her cell phone, a landline,
her emergency contact, or 911 if needed. [Client
#12 ' s] primary counselor [Counselor #16] was
informed of the situation. [The MD]
recommended [Client #12] be referred to a local
hospital or to have someone drive her back to the
clinic for observation. [The MD] asked to be
advised of the situation on a regular basis. "
- " Program Director - This PD (PD #1) spoke
to [Client #12] at 10:10 AM on this date. She was
told she was given an incorrect dose of
methadone. Her regular dose is 50 mgs. She
was given 100 mgs. [Client #12] reported she
had been ' throwing up for about 10 minutes.
After I threw up, I felt a lot better. ' This PD (PD
#1) told [Client #12] she needed her boyfriend to
bring her back to the clinic for observation. [Client
#12] refused stating ' I live in [name of city] I ' ll
go to the Emergency Room because it ' s closer. '
[Client #12 ' s] boyfriend agreed to take her to the
ER. [Client #12] was asked to contact this PD
(PD #1), [LPN#1/LDN] or [Clinical Director (CD)]
upon arrival at the ER. She was also asked to
have the admitting MD (Medical Doctor) contact
this clinic to receive her dosing information. She
agreed. This PD (PD #1) asked [LPN#1/LDN] to
contact [Client #12] in approximately 30 minutes if
[cCient #12] hasn ' t contacted the clinic. "
- " Program Director - This PD (PD #1)
contacted the [law enforcement in the county
Division of Health Service Regulation
If continuation sheet 84 of 1396899STATE FORM DOBD11
![Page 85: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/85.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 512Continued From page 84 V 512
Client #12 was located] in regards to this patient.
During an earlier telephone call with the
[LPN#1/LDN], the patient refused to go to the ER.
She had also refused to return to the clinic for
observation. The Police Department was given
this information. According to [name] (the
dispatcher for the law enforcement agency the
PD #1 had contacted], a patrolman would be
dispatched to [Client #12 ' s] residence for a
wellness check and to ask if [Client #12] would go
to the local hospital for observation. [The
dispatcher] agreed to contact this PD (PD #1) as
soon as the wellness check was completed. "
- " Program Director - This PD (PD #1) spoke
with [Deputy with the Sheriff ' s Department]. He
stated, ' I checked on [Client #12]. She was fine.
She told me she threw up some and felt better. I
asked her if she needed to go to the hospital.
She refused and stated, ' I feel fine, I ' m not
even sleepy. She appeared to be alert. She knew
what time it was. In my judgment, she was not
appropriate for hospitalization. ' This PD (PD #1)
thanked the deputy and contacted [the MD] to
inform him of the situation. "
Interview on 5/21/13 with Counselor #15
revealed:
- She was made aware of Client #12 being
double dosed on 4/23/13
- " [The LPN #1/LDN] busted into my office
freaking out (about the double dose). "
- " We all tried to contact her and couldn ' t get
in touch with her; [the LPN#1/LDN] reached her
later that day through her boyfriend. "
- " I talked to her about it the next day. "
An attempt to interview the Licensed Practical
Nurse (LPN #3) on 5/17/13 was unsuccessful as
a request for a return phone call went unmet.
Division of Health Service Regulation
If continuation sheet 85 of 1396899STATE FORM DOBD11
![Page 86: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/86.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 512Continued From page 85 V 512
Interview on 5/22/13 with Registered Nurse
#1/Director of Nursing (RN #1/DON) revealed:
- Client #12 was mistakenly dosed 100 mg of
Methadone instead of 50 mg by LPN #3 on
4/23/13
- The dosing error occurred as a result of LPN
#3 having administered Client #12 the dose of the
client who came before Client #12 in the dosing
line
- The nursing staff attempt to dose the clients
as quickly as possible because the clients
become irritable; however the clients must be
dosed safely
- Symptoms of a Methadone overdose include,
nausea, vomiting, diarrhea, lethargy and a
change in the mental status
- " Lying down or going to sleep is one of the
worst things to do. "
An attempt on 5/21/13 to interview the MD was
unsuccessful as the MD was out of the country
and could not be made available for interview.
-Review on 5/17/13 of the effect and the signs of
a methadone overdose on www.opiates.com
<http://www.opiates.com/> revealed:
- "Accidentally or intentionally ingesting too
much Methadone can lead to an overdose which
can be fatal ... "
- "Methadone is a powerful narcotic medication
that is most often used to treat addiction to heroin
or other opiates including Oxycontin, Percocet
and Vicodin. What ' s considered to be a normal
dose for one person could be deadly for another
... "
- " Signs of a Methadone overdose can vary
from person to person so it ' s essential to be
familiar with all potential symptoms. They include
slowed or labored breathing, loss of breath,
pinpoint pupils, weak pulse, low blood pressure,
Division of Health Service Regulation
If continuation sheet 86 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 512Continued From page 86 V 512
muscle or stomach spasms, blue lips, dizziness,
extreme drowsiness, confusion, fainting, cold and
clammy skin, seizures and coma... "
Finding #2:
Review on 5/14/13 of Counselor #2 ' s record
revealed:
- A hire date of 2/4/13
- A job description of Substance Abuse
Counselor (SAC)
Review on 7/22/13 of Former Client #2 ' s (FC #2
' s) record revealed:
- An admission date of 10/5/12
- Diagnoses of Opioid Dependence, Major
Depression and Anxiety Disorder
- A discharge date of 7/1/13
Review on 7/22/13 of a " Crossroads Treatment
Center Incident Reporting Form " revealed:
- Counselor #2 completed the Incident
Reporting Form on 6/20/13 and the Program
Director reviewed and signed the Incident
Reporting Form on 6/20/13
- " Description of the Incident: [FC #2 ' s]
girlfriend reported to counselor on 6/20/13 @ 9:30
am that [FC #2] had cut his wrist last night and
police were called and ambulance took client to
hospital. He was admitted. "
- " Was Physician Notified? Yes No via
_____________. " There was no documented
response to this question listed on the form
Interview on 7/24/13 with Counselor #2 revealed:
- " I was the counselor for [FC #2]. He was
discharged on 7/1/13. I made several attempts to
contact his psychiatrist at [a local behavioral
health facility]. I started contacting them right after
he was admitted in October (2012). "
Division of Health Service Regulation
If continuation sheet 87 of 1396899STATE FORM DOBD11
![Page 88: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/88.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 512Continued From page 87 V 512
- " Originally, I tried to fax his consent several
times. One was sent back showing me he had a
prescription for Klonopin by his psychiatrist. "
- " On the day of his attempted suicide
(6/20/13), I talked to one of the nurses at [a local
behavioral health facility]. I don ' t know if [the
MD] had contact with his psychiatrist or not. I
have no clue to be honest with you. "
- " He was not really referred to [the MD] for his
withdrawal symptoms. He did sit in the office with
me and [the MD], after the fact (the suicide
attempt) on June 25, 2013. His withdrawal
symptoms started after he no longer had regular
employment and he could not dose on a regular
basis. "
- " I started seeing a pattern ...in March (2013)
he did not have the money to regularly dose. I felt
it would be best for him to have gone through
Medically Supervised Withdrawal (MSW). That
did not happen. Why? I don ' t know. I did talk to
[Registered Nurse #1/the Director of Nursing (RN
#1/DON)] about it, but I did not document it. "
- " I would probably say I just missed
documenting it and writing it down. I was up to 55
clients in my caseload at the time. I should have
written it down. "
- " Honestly, he was probably not assessed for
depression by [the MD]. I don ' t think that ever
took place. I cannot explain it. I did not talk with
nursing about having him assessed for
depression. "
- " I got [FC #2] on my caseload on February
18, 2013. I did not do a behavior contract with
him either. The only signs of depression I saw
was he just seemed frustrated because he could
not dose. "
- " After he attempted suicide, we did make a
referral to a higher level of care. He declined to
take us up on the offer. It would have been
important to get his medical records from [a local
Division of Health Service Regulation
If continuation sheet 88 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 512Continued From page 88 V 512
hospital] after he was released from attempting
suicide. "
- " I am not sure who was responsible for that
(obtaining the medical records). I did not see any
documentation by [RN #1/DON] regarding a
behavioral support plan. It would have been
important to do. The behavior support plan would
be a precursor to Medically Supervised
Withdrawal. "
- " Since I have been here, it should have been
done (referrals to the MD for MSW). "
- " Hell yea, that should have been done in [FC
#2 ' s] ' s case. I have dudes that are on
behavioral support plans that need to be
addressed for MSW. "
- " [FC #2] stated his depression started when
his father died several years ago. I sometimes
have issues when we accept people who need a
higher level of care. "
- " He was one of the clients that needed a
higher level of care (inpatient) because his drugs
of choice were Oxymorphine, Cocaine and
Intravenous Opiate user. "
- " He continued to test positive for
Benzodiapines. Our screening system is flawed
(for positive urine screens.) We keep admitting
patients for the money. "
- " We have trouble taking care of the clients
we have. We just roll them through ... "
Review on 7/24/13 of the faxes sent by Counselor
#2 to FC #1 ' s psychiatrist that requested a
completed Coordination of Care (COC) form
revealed:
- Faxes were sent to the psychiatrist on
10/29/12, 3/15/13, 4/22/13, 5/14/13 and 6/26/13
Review on 7/22/13 of FC #2 ' s " Case Notes " ,
from 10/2/12 to 7/1/13, written by Counselor #2
revealed:
Division of Health Service Regulation
If continuation sheet 89 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 512Continued From page 89 V 512
- " 10/29/12, Counselor had a scheduled
appointment (apt) with patient (pt) ...counselor
was informed by nurse that pt had a prescription
for Klonopin. Nurse indicated pt that he needed to
make an apt to see our doctor (the Medical
Director) to discuss the matter further. Counselor
communicated to pt that he would have to sign a
coordination of care form, so that prescribing
clinic can communicate with doctor [at the facility]
to monitor his use ...Plan: Pt will overcome
feelings of depression ... "
- " 10/30/12, pt will follow up with [a psychiatrist]
concerning his benzo (benzodiazepam) use ... "
- " 12/5/12, pt reported he takes medication for
depression and anxiety per his primary care
doctor. Counselor reminded pt to continue to be
careful with his prescriptions while on Methadone
and to only take them as indicated due to risk of
interaction ...Plan: Pt will continue care with his
primary care physician to continue to address and
treat his anxiety/depression ... "
- " 4/2/13, This patient visually looked ill, skin
being semi pale, his affect being a little flat and
he seemed very nervous ...this patient ' s
condition seems to be questionable at this time
...Plan: pt will overcome feelings of depression ...
"
- " 4/8/13, Patient and counselor met for 1:1
counseling session today ...counselor is
agreeable to monitor patient for possible referral
to higher level of care ...Assessment: this patient
continues to use illicit substances and may need
a higher level of care ... "
- " 4/22/13, This patient signed an updated
Coordination of Care (COC) form to coordinate
with [a psychiatrist] at [a local behavioral health
center] on his prescription for benzos ...it seems
that patient is using cocaine to overcome or self
medicate from the withdrawal symptoms of
Division of Health Service Regulation
If continuation sheet 90 of 1396899STATE FORM DOBD11
![Page 91: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/91.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 512Continued From page 90 V 512
Methadone since he is not regularly dosing ... "
- " 5/3/13, This patient states he is struggling to
stay abstinent from needles. He reports that he
has been using cocaine to cope with withdrawal
symptoms ...pt expressed that he has been using
Intravenous (IV) cocaine about one a week ...pt
will continue to be monitored and possibly
referred to a higher level of care ... "
- " 5/14/13, pt reports many times he gets sick
while working ...he expressed that he started to
use illicit substances again to cope with the
withdrawal symptoms ...this patient may be put on
a behavioral contract if he continues to use illicit
substances ... "
- " 6/3/13, this patient presented to session in
somewhat of a sickly manner ... "
- " 6/19/13, pt expressed that he has been feeling
quite sick after not being able to dose for several
days (due to financial issues). Pt reports constant
cramping, vomiting, loose bowel movements and
looks (very sickly), visually. Pt reported that ' I
am so cold ' when it was about 75 degrees. Pt
reports that using is the only way that he copes
with his withdrawal symptoms ... "
- " 6/20/13, Case Manager: On this date, pt ' s
girlfriend came into counselor ' s office and
voluntarily informed him that [FC #2] had slit his
wrists (attempted suicide). This girlfriend
informed counselor that pt had gotten paid for
work and had spent it all on crack cocaine. The
girlfriend reported that [FC #2] had slit his wrists
(very deep) the night before (6/19/13) and she
had called 911. She said ' he said just let me
bleed out! ' , but the girlfriend was able to perform
first aid until Emergency Medical Services (EMS)
got to scene ...the girlfriend reported that [FC #2]
was in [a local hospital] Emergency Room and
scheduled to have a second surgery today
(6/20/13) ... "
" 6/25/13, this patient reluctantly presented to
Division of Health Service Regulation
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 512Continued From page 91 V 512
session after counselor approached pt in the
parking lot ...pt came into counselor ' s office and
reported significant withdrawals. Pt reported ' I
have been using crack, benzos and opiates for
the last few weeks to deal with the withdrawals
from not being able to regularly dose ...Pt and
counselor met/consulted with [the Medical
Director], [the Vice President of Operations], [the
Program Director] in order to discuss options for
referral. Pt signed a release of information to
consult with [a local behavioral health center] and
[the psychiatrist], who prescribes him with
benzos. Counselor called and spoke with [the
nurse] at [the behavioral health center] about the
situation regarding pt slitting wrists on suicide
attempt on 6/19/13. Pt reported getting out of [a
local hospital] on 6/22/13. This patient declined
an immediate referral to detox. This patient
seems agreeable to keep in daily contact with
counselor to assess his suicidality. Pt did report
to session with large cast on his arm and seemed
to be in pain. This patient will definitely need to be
monitored for suicidality risk assessment,
continued use and possible overdose.
Assessment: this patient seems to be at elevated
risk to harm self as evidenced by recent suicide
attempt. Plan: Pt will be referred to a higher level
of care ... "
Review on 7/22/13 of Former Client #2 ' s (FC #2
' s) record revealed FC #2 was positive for the
following substances on these dates:
- 1/10/13 Benzodiazepines (BNZs)
- 2/8/13 BNZs, Cocaine and Opiates
- 3/13/13 BNZs, Cocaine and Opiates
- 4/15/13 BNZs and Cocaine
- 5/13/13 BNZs
- 6/19/13 Cocaine and Opiates
An attempt to interview FC #2 on 7/23/13 was not
Division of Health Service Regulation
If continuation sheet 92 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 512Continued From page 92 V 512
successful as a request for a return telephone
call was not met.
Interview on 7/24/13 with the RN #1/DON
revealed:
- " I remember [FC #2] was taking Klonopin for
anxiety. The counselor would have been
responsible for completing the Coordination of
Care (COC) paperwork. "
- " If the counselor tried 3 or 4 times to contact
them [a local behavioral health center], then they
should have conveyed that to me and he
(Counselor #2) did not do that. "
- " There would be a nursing note if a
counselor came to me to assist them and I do not
remember [Counselor #2] coming to me. I would
have followed up on that. We like to have a
Coordination of Care form and be able to make
the outside doctor [psychiatrist] aware that a
client is in Methadone treatment since they are
prescribing other medications. "
- " We like to make informed decisions when
other medications are prescribed. With all the
other drugs [FC #2] was testing positive for, he
would be at high risk for overdose, respiratory
depressors. It would magnify the intensity (of an
overdose). "
- " I was made aware of his suicide attempt the
day we met with him on June 25, 2013. I know
[Counselor #2] did not come to me regarding [FC
#2 ' s] signs and symptoms of withdrawal. "
- " We would like to keep the lines of
communication open. I would have staffed this
case with [the Medical Director]. "
Interview on 7/25/13 with the Program Director #2
(PD #2) revealed:
- " I don ' t recall much about [FC #2]. I do
know that [Counselor #2] came into my office
because [FC #2 ' s] girlfriend revealed he tried to
Division of Health Service Regulation
If continuation sheet 93 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 512Continued From page 93 V 512
cut his wrist. I did ask [Counselor #2] to try and
contact [FC #2]. "
- " The next day we learned he had cut his
tendons. He came to the facility with his arm
bandaged. We talked to him about a higher level
of care, but he declined. We even talked to him
about MSW. "
- " He was willing to be hooked back up with [a
local behavioral health center]. I asked
[Counselor #2] to coordinate that. We also talked
with [the MD]. I also talked with [RN #1/DON] and
she contacted [the MD]. "
- " He [the MD] was ambivalent as to whether
he was an actual patient at [a local behavioral
health center]. We needed to have talked to his
psychiatrist there and I am not sure if he was
even involved with [a local behavioral health
center]. "
- " I do not even know it [FC #2 ' s] psychiatrist
was even notified. I don ' t know if this fell
through. I am finding that a Coordination of Care
form was faxed several times, but I don ' t know if
[Counselor #2] was able to speak with the
psychiatrist or not. I don ' t think there was any
follow through. "
- " I don ' t know if [the PD #1] gave them (the
counselors) the mentality not to follow through. I
don ' t even know if the counselors are getting it
or not (their job and client care). "
- " I have requested the counselors to bring
their cases for a treatment team meeting if the
client has tested positive for 2 urine analyses. [FC
#2 ' s] ' s case would have been perfect to staff in
a treatment team meeting. "
- " I don ' t remember if we discussed a
behavioral contract with [FC #2] specifically. We
usually do that within the first 30 days. That is the
first step into shaping them back into reality. "
- " I was not aware [FC #2] was having signs
and symptoms of withdrawals. That is where the
Division of Health Service Regulation
If continuation sheet 94 of 1396899STATE FORM DOBD11
![Page 95: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/95.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 512Continued From page 94 V 512
miscommunication came in. We don ' t like cases
like [FC #2 ' s]. "
- " I remember when his [FC #2 ' s] girlfriend
came into my office; she said his tendons were
showing when he cut his wrists. I know we never
got his hospital records. That should have been
the responsibility of his counselor. "
- " From what you are describing to me from
the counselor ' s notes, he was having withdrawal
symptoms. To me, that (FC #2 ' s withdrawal
symptoms) would have been brought to our
attention by the counselor. "
- " We needed to have had a Subjective Opiate
Withdrawal Scale (SOWS) and Objective Opiate
Withdrawal Scale (OOWS) updated on him. The
counselor should have filled that out. "
- " It becomes much more severe when a client
is using illicit drugs and having to deal with
withdrawal. Was his [Counselor #2 ' s] judgment
impaired? Good judgment would have been to
bring this to nursing ' s attention. "
Interview on 7/24/13 with the MD revealed:
- In reviewing FC #2 ' s record, the MD stated
" I am not sure if I was made aware of this suicide
attempt or not. I don ' t remember this and that is
not okay. I did not hear about this until you (the
surveyor) pointed out the progress notes written
by [Counselor #2] on June 25, 2013. "
- " I don ' t remember hearing the word
suicidal, but here (in the progress notes) it looks
like I was consulted by telephone regarding
seeking a higher level of care for him. "
- " This is strange because I always remember
the scenarios with clients, but I do not remember
this one. I was not even here that day. "
- " It was appropriate that they wanted to seek
a higher level of care for him. I did not know he
had slit his wrists until after the fact. "
- " I was not aware he was exhibiting any signs
Division of Health Service Regulation
If continuation sheet 95 of 1396899STATE FORM DOBD11
![Page 96: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/96.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 512Continued From page 95 V 512
and symptoms of [FC #2] going through
withdrawal. That is concerning that he was self
medicating with cocaine to deal with the
withdrawal. "
- " I would have liked to have been contacted
about that. This is a medical condition. He should
have immediately been evaluated by a nurse. If
not, then he should have been sent to the hospital
immediately. "
- " He needed to be careful as to not have
overdosed with all of his positive urinalyses. I am
also concerned because he was taking
Oxymorphene in pill form. That is also an Opioid.
"
- FC #2 being placed on a behavior contract
was a possibility because " with a behavioral
contract, we would have started MSW after 30
days of non compliance with our 8 point criteria. "
- " The counselor should have informed
nursing staff about his symptoms and continued
illicit drug use. That would have been clinical
judgment by our nurses as well, the more
information in the chart of a client; the better. "
- " I know I never had any contact with [FC #2 '
s] psychiatrist. I know him personally. The
counselor should have come to me with his
concerns. I also know [the psychiatrist] ' s Nurse
Practioner. "
- " It would have been very easy for me to
contact them and get confirmation if [FC #2] was
a patient of theirs and if he did indeed have a
prescription for Klonopin. "
- " I know if the counselor was having trouble
getting a COC result, then he [Counselor #2]
should have talked with the nursing staff. "
- " The signs of withdrawals are very well
known to our counselors. It would have been
ideal for the counselors to have gone to nursing
and then nursing come to me. "
Division of Health Service Regulation
If continuation sheet 96 of 1396899STATE FORM DOBD11
![Page 97: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/97.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 512Continued From page 96 V 512
Interview on 7/25/13 with the Vice President of
Operations (VPO) revealed:
- On 6/25/13, " [Counselor #2] brought him
(FC #2) into [the Program Director #2 ' s] office. I
just happened to be in her office working on the
computer. "
- " [Counselor #2] told us he (FC #2) had
attempted suicide and wanted to know what to
do. [The MD] was here that day, but didn ' t do
much because [FC #2] walked back into the
office within 10 minutes. We were trying to make
referrals for him (FC #2). "
- " It was [the MD ' s] mentality to just follow
our protocol and try to get him help (higher level
of care). "
- " We asked [Counselor #2] to follow up with
[FC #2] the next day. Really, [Counselor #2]
should have done a behavioral contract with him
right away for testing positive for illicits. That way,
we would be able to address a higher level of
dose to see if it was warranted especially if he
was showing all the signs and symptoms of
withdrawals. "
- " If he (FC #2) was a poly substance user and
not stopping, perhaps inpatient would have been
best for him. "
- " It would have also been a good case to staff
in a treatment team meeting. After hearing and
watching what was not done, it would have been
an incompetent counselor not to have brought
this to someone ' s attention. "
- " The assessment for depression for [FC #2]
probably did not happen with [the MD]. "
- " It is the counselor ' s job to follow up with
the COC paperwork. If you are not successful
with it (COC form), then you need to be talking to
nursing, especially [RN #1/DON]. Also, [the MD]
is also very approachable. He has an open door
policy. "
Division of Health Service Regulation
If continuation sheet 97 of 1396899STATE FORM DOBD11
![Page 98: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/98.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 512Continued From page 97 V 512
Review on 7/24/13 of the facility ' s policy and
procedures manual revealed:
- " ...If a patient received a prescription from
any doctor, the case manager (Counselor) may
ask for a release signed by the patient and
contact said doctor and complete documentation
to coordinate care. At this time information
concerning reason for medication, length of
treatment, and prior knowledge of methadone
treatment is discussed ... "
Finding # 3:
Review on 4/8/13 of Deceased Client #1 ' s (DC
#1 ' s) record revealed
- An admission date of 3/26/12
- Diagnoses of Opioid Dependence,
Polysubstance Abuse, Post Traumatic Stress
Disorder, Anxiety Disorder, Major Depressive
Disorder, Recurrent, Moderate, Hearing Loss -
80% and History of Gastric Bypass
- A diagnosis of Substance Induced Psychotic
Disorder with Hallucinations added on 10/16/12
by clinician at a local mental health facility
- DC #1 was found dead in her home on
3/16/13 and transported to a local hospital and
declared deceased by the Medical Examiner on
3/16/13
- She was 37 years of age
- A discharge date of 3/26/13
- A treatment plan dated 6/26/12 and
completed by DC #1 ' s counselor (Counselor
#16) which documented the following goals and
interventions: " Goal: The Patient (Pt.) reports
feelings of depression. Intervention: Pt will be
referred to [The MD] for assessment for
depression. Goal: The patient will continue to
take methadone as prescribed and not use illicit
substances. Intervention: Counselor will meet
with Pt a minimum of 2xs (times) a month to offer
Division of Health Service Regulation
If continuation sheet 98 of 1396899STATE FORM DOBD11
![Page 99: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/99.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 512Continued From page 98 V 512
supportive counseling
- A treatment plan dated 9/25/12 and
completed by DC #1 ' s counselor (Counselor
#16) documented the same goals and
interventions as listed in the treatment plan dated
6/26/12
- A treatment plan dated 3/4/13 and
completed by DC #1 ' s counselor (Counselor
#16) documented the same goals and
interventions as listed in the treatment plan dated
6/26/12. One additional goal and intervention was
added - " Goal: To monitor chronic illness signs
and symptoms. Intervention: Counselor will have
Pt sign a coordination of care form to allow
effective communication between medical
facilities. "
Review on 4/8/13 of DC #1 ' s drug screens from
3/27/12 - 3/5/13 and nurses notes completed by
RN #1/DON from 8/28/12 -1/8/13 revealed DC #1
was positive for the following substances on
these dates:
- 3/27/12 Benzodiazepines (BNZs) and
Opiates
- 7/12/12 BNZs and Alcohol (Etoh)
- 8/1/12 BNZs
- 8/28/12 Breathalyzer with a reading of
0.025
- 9/4/12 BNZs
- 10/5/12 Etoh - Breathalyzer reading of
0.029
- 11/23/12 Breathalyzer with a reading of
0.026
- 1/8/13 Breathalyzer with a reading of
0.011
- 2/5/13 Opiates
- 2/14/13 BNZs
- 2/23/13 BNZs
- 3/5/13 BNZs
Division of Health Service Regulation
If continuation sheet 99 of 1396899STATE FORM DOBD11
![Page 100: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/100.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 512Continued From page 99 V 512
Review on 4/8/13 of " Case Notes " completed
by the RN #1/DON revealed:
- 8/14/12 - " Pt presented with significant
non-pitting edema in Rt (Right) leg. Swelling in Lt
(Left) leg was minimal. Instructed pt to go to PCP
(Primary Care Physician) or urgent care to be
evaluated for thrombus. Pt verbalized
understanding and stated she would go
immediately. "
- 8/28/12 - " Pt came to speak with RN
#1/DON about MD (doctor) appt. Pt breath
smelled of alcohol. Gave pt breathalyzer. Pt blew
0.025. Explained to pt she would be unable to
dose today and could return tomorrow to dose as
normal. Reviewed zero alcohol tolerance policy
with her. Pt. verbalized understanding. "
- 10/5/12 - " Pt. ' s breath smelled of alcohol
this morning. Pt. given a breathalyzer with results
of 0.029. Explained to pt. that she would not be
dosed today due to positive breathalizer and
breath smelling of alcohol. Pt. denies use of
alcohol and states that ' it must be my cough
syrup. ' "
- 11/23/12 - " Pt breath smelled of alcohol. Pt
given breathalizer and blew a 0.026. Pt states
she did drink yesterday evening and early this
morning with family. Explained to pt that we
would be unable to dose her today and dangers
of drinking alcohol while taking methadone. Pt
verbalizes understanding. Requested pt return to
clinic tomorrow to dose. "
- 1/8/13 - " Breathalyzer today reads 0.011.
Pt. admits to having strawberry daiquiris
yesterday at her sister ' s birthday party.
Explained again to pt dangers of mixing alcohol
with methadone and due to her positive
breathalyzer test, we would not be able to dose
her today. Pt. verbalized her understanding. "
- 3/15/13 - " Instructed pt today as well as
yesterday to go to ED (Emergency Department)
Division of Health Service Regulation
If continuation sheet 100 of 1396899STATE FORM DOBD11
![Page 101: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/101.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 512Continued From page 100 V 512
to be evaluated for falls and gait imbalance. Pt is
unable to get out of the seated position without
assistance or falling. Pt has fallen in clinic or in
parking lot 3 times in the past two weeks. Pt has
also informed staff of having a " seizure " at
home and falling at home. At each of these
instances, pt was instructed to go to ED to be
evaluated but pt did not go. "
Review on 4/17/13 of " Case Notes " completed
by Counselor #16 revealed:
- 7/19/12 - " This Pt. reported to her Counselor
' s office this morning as a result of being flagged
for missing time her Counseling session; she said
that she still struggles terribly with the fact of not
being stable on her dose and with constant
[nagging] thoughts of using. This Counselor
reminded this Pt. that it would be of benefit for her
to attend the clinic daily, keep all scheduled
Counseling sessions, and discontinue all use of
illicit substances. This Pt agreed; however she
said that she has been going through so many
stressful situations at home that it is the only thing
she knows how to do in order to maintain her
sanity. This Pt. reports she has been feeling so
terribly sick on her stomach all the time and
vomiting almost every day. She said, ' I believe it
' s my nerves, I ' ve always had a bad nerve
problem. ' This Pt. reports she is in the process
of seeing her Primary Care Physician or
psychologist regarding her history with anxiety
and panic disorder. "
- " Assessment - Assessment Here: Dimension
1: This Pt. is addicted to opiates; she is alert and
oriented 3x ' s. Dimension 5: This Pt. is at med
(medium) to high risk for relapse or continued use
potential due to her recent relapse on BNZ ' s
(Benzodiazepines) and Ethol. "
- " Plan - Plan Here: This Pt. will remain on
MMT (Methadone Maintenance Treatment) at
Division of Health Service Regulation
If continuation sheet 101 of 1396899STATE FORM DOBD11
![Page 102: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/102.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 512Continued From page 101 V 512
their current dose (120 mg) and level (Level 2)
until otherwise indicated by Medical Staff. This
Pt. will meet with their Counselor 2x (times)
monthly, provide 1 negative UA (Urine Analysis)
and continue working on building new life
management skills and relapse prevention skills
moving forward in treatment. "
- 7/26/12 - " This Pt. presented for their 1:1
Counseling appt. this morning; this Pt. firstly
indicated that they are doing well on MMT and
has positive plans for their family ' s future without
the use of drugs and/or alcohol she said that
since she and her counselor spoke about the
dangers of mixing methadone, alcohol, and BNZ '
s she hasn ' t drank or taken another Xanax.
However she did indicate not being stable on her
current dose and will be scheduling an upcoming
peak and trough. She did make this Counselor
aware that she is scheduled for upcoming MH
(Mental Health) appt. ' s and has been addresses
multiple biomedical/medical conditions including
stomach ulcers, dental, chronic low back issues
that make for an unhealthy recovery/environment.
This Counselor and Pt. agreed that until her
medical issues are resolved it will make the
recovery process more of a challenge. "
- " Plan - Plan Here: The Plan remained the
same plan as noted in the 7/19/12 case note;
however, with the following addition " This Pt. will
loose any take-home privileged if the following
drug screen is evident of alcohol or
non-prescribed BNZ ' s. "
- 8/2/12 - " This Pt. reported to her scheduled
appt. this morning; she told her Counselor that
her family has told her that if she is leveled back
down to a Level 1 and she has to start coming
back to clinic daily (from [a local county]) they will
discontinue finances and transportation
necessary for this Pt. to remain in treatment.
This Pt. said, ' I really didn ' t know that I wasn ' t
Division of Health Service Regulation
If continuation sheet 102 of 1396899STATE FORM DOBD11
![Page 103: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/103.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 512Continued From page 102 V 512
allowed to drink; I mean I ' ve been drinking a lot
everyday! ' This Counselor reviewed the 8 pt
(point) criteria [again] with this PT, and was clear
she understood that she wouldn ' t be allowed to
remain a Level 2 Pt with 1 more failed UA for any
illicit substance . Additionally, this Counselor
reviewed the dangers associated with
self-medicating particularly BNZ ' s and alcohol in
combination with MMT. She agreed to
discontinue use immediately and seek additional
services with [local mental health facility.] A
referral was given [again] to this Pt. for [a local
mental health facility] and further treatment was
discussed as this Pt. needs additional care at a
higher level for issues revolving around a history
of abuse, anxiety, & depression. "
- " Plan - Plan Here: This Pt. will remain on
MMT at her current dose (120 mg) and level
(Level 2) until otherwise indicated by Medical
Staff ... " " She agrees with her Counselor that
she will discontinue use of BNZ ' s (unprescribed)
and alcohol. This Counselor reiterated the 8 pt.
criteria for level patients in the clinic and
reminded this Pt. that alcohol is a drug and there
is a zero tolerance for alcohol while on MMT.
She agreed to discontinue use. This Pt.
understands that another failed UA (Urine
Analysis) for any illicit substance will result in her
being leveled back down from a Level to a Level.
" (There is no documentation of which Levels
the Counselor is speaking about.)
- 8/23/12 - " This Pt. reported to her Counselor
' s office this morning for her scheduled session;
she told her Counselor she is having a lot of
difficulty with cravings and thoughts of using due
to the recent passing of her grandfather and now
with her grandmother being in the Intensive Care
Unit at the hospital. She admits to taking BNZ ' s
without a prescription, but she says she has
always been on BNZ ' s due to a history with
Division of Health Service Regulation
If continuation sheet 103 of 1396899STATE FORM DOBD11
![Page 104: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/104.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 512Continued From page 103 V 512
Anxiety and depression. She will follow up with [a
local mental health] facility on 8/27/2012 to be
further evaluated ... "
- " Plan - Plan Here: This Pt. will remain on
MMT at her current dose (120 mg) and level
(Level 2) until otherwise indicated by Medical
Staff. This Pt. will meet with her Counselor ' s 2x
' s monthly, provide 1 negative UA and continue
working on building new life management skills
and relapse prevention skills moving forward in
treatment. This Counselor will speak with RN
[RN #1/DON] in regards to this Pt. ' s MH issues
and coordinate a follow up apt. with [a local
mental health center]. This Pt. agrees to attend a
Therapy session at [a local mental health center]
on 8/27/2012 to address issues revolving around
MH. She will report back to her Counselor on her
follow up appt. to make her aware of the changes
in medications and therapy. "
- 8/30/12 - " This Pt. reported to her Counselor
' s office this morning as a result of being flagged
for not passing her breathalyzer on 8/29/12. This
Pt. was staffed on yesterday and the staff agreed
this Pt. should not be allowed to handle her own
methadone; as she has been positive for BNZ
and alcohol for two consecutive UA ' s (July and
August). She said that she still struggles terribly
with the fact of not being stable on her dose and
with constant [nagging] thoughts of using. Plus,
she admits that her home life isn ' t stable, she
doesn ' t work, and has no transportation of her
own to clinic, and they are still in the middle of
court proceedings regarding her teenage
daughter that was kidnapped and raped. This
Counselor spent time explaining the 8 pt. criteria
in detail to this Pt. she agreed that she should
loose her take-home medications. This Pt. said,
' I can promise you one thing; this has really been
an eye opener for me! I don ' t want to stop
coming to the clinic and now I see why I have
Division of Health Service Regulation
If continuation sheet 104 of 1396899STATE FORM DOBD11
![Page 105: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/105.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 512Continued From page 104 V 512
been feeling so sick (and throwing up daily) it was
from the alcohol not the methadone. I didn ' t
drink a drop yesterday and I don ' t plan on
drinking anymore. ' This Counselor explained
there is a 0 tolerance for alcohol in this clinic
[again] and to this Pt. and explained that drinking
and methadone can produce fatal results. This
Pt was referred [again] to [a local mental health
facility] and a [community medical facility]. This
Pt. will be observed and re-evaluated in the next
30 days. "
- " Plan - Plan Here: This Pt. will return to a
Level 1 pt due to her failure of the past 2 UA ' s
(for July and August). In addition, this Pt.
presented to clinic yesterday after drinking in the
AM (morning); this Pt. didn ' t pass the
breathalyzer administered by the RN (RN
#1/DON). This Pt will come to the clinic daily,
meet with her counselor 2x monthly, provide 1
negative UA per month and be re-evaluated for
level up in the next 30-days per she comply wit
the 8 pt. criteria for take-home medications . "
- 9/7/12 - " ...She (DC #1) indicated that since
she was leveled down and stopped using alcohol
completely she is feeling so much better: she
doesn ' t throw up daily, has been feeling more
stable on MMT, and is able to eat ... "
- " Plan - Plan Here: ...This Counselor will
speak with RN (RN #1/DON) in regards to this Pt.
' s MH issues and coordinate a follow up apt. with
[the Medical Director] for this Pt. she will
additionally meet with Medical Staff daily/weekly
in order to keep a check on her vitals as well as
her alcohol intake moving forward. "
- 9/25/12 - This Pt. presented for her 1:1
Counseling Re-assessment appt. this morning;
she firstly indicated that she is doing well on her
MMT; however she continues to struggle
financially with issues revolving around her MH.
This Pt. didn ' t follow up with [a local mental
Division of Health Service Regulation
If continuation sheet 105 of 1396899STATE FORM DOBD11
![Page 106: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/106.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 512Continued From page 105 V 512
health agency] as had been discussed and she
said she wouldn ' t be able to anytime soon
seeing as her mother-in-law was violently
attacked by her [own] son and she would now be
caring for her during the day. This Pt. was
referred to [health care facility in another county]
as another option for addressing MH issues .... "
- " Plan - Plan Here: ...This Counselor will
speak with RN [RN #1/DON] in regards to this Pt.
' s MH issues and coordinate a follow up apt. with
[the Medical Director] for this Pt. This Pt. has not
been followed up with the referral given for [a
local mental health facility] even though she
clearly has severe issues with MH ... "
- 10/5/12 - " ...She (DC #1) had been flagged
by the dosing LPN (Licensed Practical Nurse
#1/Lead Dosing Nurse) [LPN #1/LDN] as
presenting with symptoms of intoxication. The
RN [RN #1/DON] administered the breathalyzer
and this Pt. and the results were conclusive she
did in fact have alcohol in her system. This Pt. ' s
breathalyzer presented with 0.029 EtOH in her
system prior to being denied dosing today. This
Pt. explained to her Counselor she had been sick
and has been taking ' NightTime ' cough
medicine which does contain alcohol. This Pt.
provided a UA for her Counselor; the specimen
was dipped and proved positive for methadone
only; however the results of alcohol will be
reported by the Clinical Lab at which time this
Counselor will send a confirmation report in order
to determine if the presence of Etoh was a result
of over-the-counter cough medicines or whether
this Pt. continues to abuse the zero tolerance to
alcohol policy in this clinic. " Further review of the
10/5/12 " case note " revealed " This Pt. told her
counselor she had been back to [a local mental
health facility] for a follow up appt. in regards to
her [overwhelming] MH issues; she says, ' I will
go back to [a local mental health agency] on
Division of Health Service Regulation
If continuation sheet 106 of 1396899STATE FORM DOBD11
![Page 107: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/107.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 512Continued From page 106 V 512
Tuesday 10/9/12 and attempt to get myself the
MH care I need. ' "
- " Plan - Plan Here: This Pt will remain on
MMT at her current dose (110 mg) and level
(Level 1) until otherwise indicated by Medical
Staff. This Pt. will met with her Counselor 2x ' s
monthly, provide 1 negative UA and continue
working on building new life management skills
and relapse prevention skills moving forward in
treatment. She will be continually observed for
difficulties presenting as a result of alcohol; this
Counselor will speak with this Pt. about a possible
higher level of care and/or detox program that
can more effectively address the issues revolving
around her MH and continue use of EtOH... " "
This Counselor will speak with RN [RN #1/DON]
in regards to this Pt. ' s MH issues and coordinate
treatment that is in the best interest and needs of
this particular Pt. "
- 11/8/12 - " This Pt. presented for her 1:1
Counseling session this morning; firstly she made
this Counselor aware of her most recent accident
with the stove. This Pt. received 3rd degree
burns on her arm and is being treated at the
Health Department in [the county the DC #1
resided]; she denies any opioid being prescribed
for pain and said ' They treat my arm bi-daily, put
pain ointment on my burn, and don ' t give me
anything to take at home as a result of my
injuries. ' This Pt. did admit to continuing to drink
from time to time and says she is taking her
Zoloft as prescribed by [a local mental health
facility.] She says that things have gotten so bad
in the home that her husband has asked her to
leave; she was upset that after 21 years of
marriage he wants to end the relationship. This
Pt. says she doesn ' t know how much more she
can handle and has even thought most recently
of suicide and this Pt. confirmed that she didn ' t
have a plan or the means to kill herself. She has
Division of Health Service Regulation
If continuation sheet 107 of 1396899STATE FORM DOBD11
![Page 108: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/108.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 512Continued From page 107 V 512
a follow up appointment at [a local mental health
facility] on 11/16/2012; however this Counselor
will flag her on 11/13/12 in order to see where she
is with her SI (Suicidal Ideation). This Pt. provided
a UA on 11/2/12 which was negative of any illicit
substances. "
- " Plan - Plan Here: This Counselor will speak
with RN [RN #1/DON] in regards to this Pt. ' s MH
issues and coordinate a follow up apt. with [the
Medical Director] for this Pt. She is currently
receiving MH treatment through [a local mental
health facility]; however she isn ' t stable and
functioning at her current dose. A Peak and
Trough may be in order for this Pt. to get her
where she needs to be in treatment. "
- 11/9/12 - " This Pt. was observed in the
lobby ' appearing impaired ' prior to dosing; the
dosing LPN [LPN/LDN] called this Counselor and
requested a session to determine her level of
intoxication. This Counselor and Pt. met,
discussed [again] the importance of NOT taking
illicit medications and/or drinking alcohol in this
clinic as neither are tolerated. This Counselor
explained to this Pt. that this would [in fact] be her
final warning and moving forward if she presented
to the clinic after drinking or taking unprescribed
BNZ she would be placed on a ' Behavior
Contract. ' This Pt. admitted to taking one 0.5
Xanax last night and one 0.5 Xanax this AM
(morning) combined with ½ a beer. This Pt. was
able to carry on a normal conversation and
provided urine for this Counselor the dipped
provide positive for BNZ and Methadone. "
- " This Pt. was further encouraged to keep her
up-coming appt. with [a local mental health
facility] and her Counselor on 11/16/2012; she
was walked to the dosing window where this
Counselor spoke briefly with the LPN [LPN/LDN]
to make her aware of the UA results and the Pt. '
s confession of illicit use. "
Division of Health Service Regulation
If continuation sheet 108 of 1396899STATE FORM DOBD11
![Page 109: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/109.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 512Continued From page 108 V 512
- " Plan - Plan Here: This Pt. ' s dose will be
reduced today per [the Medical Director]; Medical
Staff will continue to keep a close observance on
this Pt. she will be staffed on 11/14/2012 as a
potential Pt. requiring ' In-patient ' detox care or
at the very least a higher level of care than that of
an OTP (Opioid Treatment Program) setting.
This Pt. will meet with her Counselor 4x ' s
monthly, provide 1 negative UA (more if asked for
or required) and continue working on building new
life management skills and relapse prevention
skills moving forward in treatment. "
- " ... " This Counselor will speak with RN [RN
#1/DON] in regards to this Pt. ' s MH issues and
coordinate a follow up apt. with [the Medical
Director] for this Pt. "
- 12/3/12 - " This Pt. attended her scheduled
1:1 Counseling session this morning; she firstly
talked about not being stable in areas revolving
around her MH and that the voices guide her
throughout the night to get up and begin doing
about the house, redecorating rooms, cooking
meals, and having detailed conversations. The
voices and hallucinations are becoming
frightening to the Pt. and to her family and this
Counselor encouraged this Pt to speak with her
Therapists at [a local mental health facility]
regarding the changes she has been
experiencing on an auditory and hallucinatory
level. She agreed she would. She said, ' They
are treating me for the wrong things at [a local
mental health facility], even though I like it over
there they seem to believe my problem is related
to my drug use and it is not! The whole reason I
started taking the drugs was to try to quiet the
voices. "
- " This Pt. says the Zoloft make her condition
worse and she would really like to be placed on
the appropriate medication to become more
stable in her cognitions. She said ' I ' m afraid
Division of Health Service Regulation
If continuation sheet 109 of 1396899STATE FORM DOBD11
![Page 110: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/110.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 512Continued From page 109 V 512
they will put me in a place for ' crazy people '
and I don ' t want that. I do just fine once I ' m on
the right meds. ' "
- " Plan - Plan Here: This Pt. will remain on
MMT at her current dose (110 mg) and level
(Level 1) until otherwise indicated by Medical
Staff. This Pt. will meet with her Counselor 2x ' s
monthly, provide 1 negative UA and continue
working on building new life management skills
and relapse prevention skills moving forward in
treatment. "
- 12/17/12 - " ...This Pt. discussed the issues
revolving around her MH and stated, ' The voices
are getting much worse; in fact they are now
becoming violent and causing me to fall, pushing
me around, and insisting I take them '
somewhere/anywhere ' for a drive. I don ' t drive,
so this is very frightening to me. ' This Counselor
suggested this Pt. contact [a local mental health
facility] today and make them aware of the
urgency with the voices and see if there is
anyway they could work her in on today or
tomorrow. She agreed she would call [a local
mental health facility] today. "
- " Plan - Plan Here: This Pt. will remain on
MMT at her current dose (120 mg) and level
(Level 1) until otherwise indicated by Medical
Staff. The remainder of the plan remained the
same as the plan documented on 12/3/12.
- 1/3/13 - " ...Her (DC #1 ' s) primary concern
was when she would be able to begin '
taking-home. ' " This Pt. explained that the
transportation to the clinic daily is borrowed from
a family member and it would make her recovery
a lot easier if she didn ' t have to attend clinic 6x
weekly. This Counselor advised this Pt. she had
[again] earned take-home status and she would
be staffed on 1/9/2013 in order to request
take-home status. The Pt. said ' I ' m attending
to all my appt. ' s at [a local mental health facility]
Division of Health Service Regulation
If continuation sheet 110 of 1396899STATE FORM DOBD11
![Page 111: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/111.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 512Continued From page 110 V 512
as we talked about, my Medicaid card should be
here soon and I will start scheduling other needed
medical appt. and I am taking my medication for
MH issues as prescribed. ' "
- " The Pt. provided a UA today which was
negative for any illicit substance (90-days
consecutive). "
- 1/8/13 - " This Pt. presented to her
Counselor ' s office this morning as a result of
being flagged for missing her scheduled appt. on
1/7/2013. This Pt. signed a consent to release
information from [a local mental health facility]
and a new COC (Coordination of Care) form was
signed and faxed in lieu of this Pt. ' s new
prescriptions for MH. This Pt. met with the RN
(RN#1/DON) on staff this morning and a result of
being flagged for a breathalyzer. She did present
with an alcohol count of .0011 and was unable to
dose today as a result. This Pt. presented with a
negative UA on 1/3/13 ... "
- Assessment - Assessment Here: Dimension
I: This Pt. is addicted to opiates; she is alert and
oriented 3x ' s; however she admits to drinking
one alcoholic beverage on 1/7/2013 due to her
sister ' s 40th birthday party. She describes this
as a ' special occasion ' and that she hasn ' t
drank in more than 90 days prior. "
- " Plan - Plan Here: This Pt. will remain on
MMT at her current dose (130 mg) and level
(Level 1) until otherwise indicated by Medical
Staff. This Pt. will meet with her Counselor 2x ' s
monthly, provide 1 negative UA and continue
working on building new life management skills
and relapse prevention skills moving forward in
treatment. "
- 2/6/13 - " This Pt. presented to her
Counselor ' s office this morning in a mode of
panic. She told her Counselor, ' I had such a
terrible seizure last night that I felt like I was going
to die! ' This Pt. was assessed by this Counselor
Division of Health Service Regulation
If continuation sheet 111 of 1396899STATE FORM DOBD11
![Page 112: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/112.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 512Continued From page 111 V 512
regarding Axis I diagnoses and a determination
was concluded: this Pt. rates highly on Dimension
3 criterion as suffering from current psychiatric,
psychological, and emotional needs that need
addressing. She was immediately taken to the
RN (no indication as to who this was) on duty for
further evaluation. She was also instructed to
contact her MH provider as she has yet to stable
on her psychotropic medications yet continues to
drink alcohol and partake of additional illicit drugs.
The RN on staff asked this Pt. to go straight from
the clinic to the ER (Emergency Room) whereas
she could gain further Medical care. This Pt.
provided a UA: 2/5/13 which presented positive
for illicit opiates. "
- " Assessment - Assessment Here: Dimension
1: this Pt. appeared to be extremely agitated and
stressed regarding last nights seizure; she fails to
realize she is putting herself in imminent danger
by continuing to combine methadone, BNZ,
alcohol and opiates, She spoke about the trauma
incurred due to the seizure and her condition has
greatly worsened since her last session. "
- " Plan - Plan Here: This Pt. will remain on
MMT at her current dose (130 mg) and level
(Level 2) until otherwise indicated by Medical
Staff. This Pt. will meet with her Counselor 4x ' s
monthly, provide 1 negative UA and continue
working on building new life management skills
and relapse prevention skills moving forward in
treatment. "
Review on 4/8/13 of DC #1 ' s " Patient
Medication Record " revealed:
- On 12/4/12, DC #1 ' s Methadone dosage
was increased from 110 mg of Methadone to 120
mg of Methadone
- On 1/3/13, DC #1 ' s Methadone dosage was
increased from 120 mg to 130 mg of Methadone
- On 2/12/13, DC #1 ' s Methadone dosage
Division of Health Service Regulation
If continuation sheet 112 of 1396899STATE FORM DOBD11
![Page 113: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/113.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 512Continued From page 112 V 512
was decreased from 130 mg to 97 mg of
Methadone
- No documentation a " Peak and Trough "
had been completed on behalf of DC #1 which
was discussed in Counselor #16 " case note "
for 11/8/12 " in order for to get her where she
needs to be in treatment. "
Review on 4/16/13 of DC #1 ' s record revealed:
- A request for a take-home medication form
was completed on 1/22/13 and signed by the
(Assistant Program Director #1 (APD #1) and
Counselor #16 on 1/22/13
- The MD signed the form also; however, there
was no date listed by the MD ' s signature
- A " Patient Orders " form dated 1/17/13
which documented DC #1 was staffed and
approved for take-home medications to begin on
1/22/13
- The form documented that DC #1 would
attend the facility on Monday, Tuesday,
Wednesday and Thursday with take-homes for
Friday, Saturday and Sunday which indicated a
change from Level 1 to Level 2
- This " Patient Orders " form was signed by
Staff 16, the RN #1/DON and the Medical
Director with no dates listed by their signatures
- DC #1 continued on Level 2 until her death
on 3/16/13 with her receiving three take home
doses of Methadone at 107 mg per bottle
Review on 4/17/13 of DC #1 ' s record revealed:
- No documentation of a staffing held on
11/14/12 on behalf of DC #1 to discuss the need
for a possible higher level of care than that of an
OTP (Opioid Treatment Program)
- No documentation any appointments were
scheduled on behalf of DC #1 with the facility ' s
Medical Director prior to 3/7/13, when DC #1 ' s
yearly physical was completed
Division of Health Service Regulation
If continuation sheet 113 of 1396899STATE FORM DOBD11
![Page 114: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/114.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 512Continued From page 113 V 512
Review on 4/9/13 of a " case note " written by
the Program Director #1 (PD #1) and dated
3/26/13 revealed:
- " This PD (PD #1) met with [DC #1 ' s]
husband on this date. He was able to verify that
[DC #1] had passed away on 3/16/2013. He
reported ' for the last several months, she had
trouble keeping her balance. She would be
walking and then just fall. I tried and tried to get
her to go to the doctor be she didn ' t want to.
She wanted to help me because I had just had
hernia surgery. ' This PD (PD #1) asked if he
was aware of the cause of [DC #1 ' s] death. He
reported ' she told me she was tired and she was
going to take a nap. I went to the other bedroom
so I wouldn ' t wake her up. I went to sleep and
woke up a couple of hours later. I got up and
went into the other bedroom and saw blood on
her face. It looked like she had been bleeding
from her nose and her mouth. I called 911. They
took her to the hospital and said it looked like she
had a brain aneurysm. They sent her for an
autopsy. ' This PD (PD #1) asked if a copy of the
death certificate was available. [DC #1 ' s
husband] reported the certificate ' would be
ready ' in about 2-3 weeks. ' He agreed to bring
a copy to this clinic. This PD (PD #1) referred [DC
#1 ' s husband] to grief counseling at [a local
counseling facility.] "
Review on 4/15/13 of DC #1 ' s death certificate
revealed:
- DC #1 was " found dead in bed " at
approximately 5:39 pm on 3/16/13
- DC #1 ' s immediate cause of death was "
Pending OCME (Office of Chief Medical
Examiner) Autopsy Findings "
Interview on 4/23/13 with a Detective with the
Division of Health Service Regulation
If continuation sheet 114 of 1396899STATE FORM DOBD11
![Page 115: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/115.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 512Continued From page 114 V 512
Sheriff ' s Department who investigated
(Deceased Client #1 ' s (DC #1 ' s) death
revealed:
- DC #1 was found dead in her home on
3/16/13 and transported to a local hospital and
declared deceased by the Medical Examiner on
3/16/13
- While at DC #1 ' s home, he observed a lock
box in the client ' s purse with three bottles of
methadone still intact
- He also observed an empty pill bottle near
the DC #1 with DC #1 ' s name on the bottle;
however, he could not determine what if any type
of medication may have been in the bottle
- The bottles of methadone and the one empty
pill bottle were sent with the DC #1 ' s body to the
state Medical Examiner ' s office as DC #1 was to
be autopsied
- In speaking with a member of DC #1 ' s
family, he learned that DC #1 had " quite a
history of drug use. "
- The family member also reported DC #1 had
been falling quite often, especially when she
attempted to go up steps
- The family member reported that on one
occasion, while he was present, he observed DC
#1 fall in the parking lot of the facility and had to
be attended to by the medical staff
- The family member stated while DC #1 did
not experience any bleeding from her injury, she
did sustain a " knot on her head. "
Review on 7/19/13 of DC #1 ' s " Report of
Autopsy Examination " completed by a physician
with the Office of the Chief Medical Examiner ' s
(OCME ' s) on 3/18/13 and signed by the same
physician on 7/18/13 revealed:
- DC #1 ' s cause of death was " Methadone
and dextromethorphan toxicity. "
- Additional diagnoses included Obesity (BMI
Division of Health Service Regulation
If continuation sheet 115 of 1396899STATE FORM DOBD11
![Page 116: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/116.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 512Continued From page 115 V 512
(Body Mass Index) = 45, Microvesicular hepatic
steatosis and Myocardial fibrosis. "
- " ...Received with the body are three full
bottles of liquid methadone and one bottle of
citalopram (containing approximately 20 pills). "
Review on 7/22/13 of DC #1 ' s toxicology report
from the OCME ' s office revealed:
- Based on the analysis of DC #1 ' s liver
tissue, it was determined " 41 mg/kg of
Dextromethorphan, 7.7 mg/kg of Doxylamine and
24 mg/kg of Methadone " were present in DC #1
' s system
- Based on the analysis of a 8.0 ml blood
specimen from DC #1 ' s vena cava, it was
determined " 0.055 mg/L of Alprazolam, 2.3
mg/L of Dextromethorphan, 0.83 mg/L of
Doxylamine and 1.9 mg/L of Methadone " were
present in DC #1 ' s blood were present in DC #1
' s blood
-Review on 7/22/13 of the following medications
on www. <http://www.drugs.com/> revealed:
- " Alprazolam belongs to a group of drugs
called benzodiazepines
(ben-zoe-dye-AZE-eh-peens). It works by slowing
down the movement of chemicals in the brain that
may become unbalanced. This results in a
reduction in nervous tension (anxiety).
Alprazolam is used to treat anxiety disorders,
panic disorders... "
- Dextromethorphan is an ingredient in cough
suppressant medication
- " The nervous system side effects of
dextromethorphan have included drowsiness and
dizziness. Other side effects such as excitation,
mental confusion, and opioid like respiratory
depression have been rare and occurred at
higher dosages. In some cases of abuse, patients
experienced euphoria, hyperactivity, mania, and
Division of Health Service Regulation
If continuation sheet 116 of 1396899STATE FORM DOBD11
![Page 117: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/117.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 512Continued From page 116 V 512
auditory and visual hallucinations. "
- "Doxylamine is an antihistamine that reduces
the effects of natural chemical histamine in the
body. Histamine can produce symptoms of
sneezing, itching, watery eyes, and runny nose.
Doxylamine is used to treat sneezing, itching,
watery eyes, and runny nose caused by allergies
or the common cold. "
Interview on 4/11/13 with Counselor #16 and DC
#1 ' s primary counselor revealed:
- " I saw [DC #1] every day. Everyday was the
same as yesterday; she (DC #1) couldn ' t
remember anything. "
- " [DC #1] was a high risk patient due to her
duel diagnosis.
- She was a client of [local mental health
agency] and they had diagnosed her with
Substance Induced Psychotic Disorder with
Hallucinations. "
- " It ' s bull crap, (the diagnosis of Substance
Induced Psychosis) because her family had
schizophrenia and she (DC #1) said she had
been diagnosed with schizophrenia " ; however
she could not remember what physician had
given her the diagnosis
- " I don ' t see how she (DC #1) was on
enough substances for the Substance Induced
Psychosis Diagnosis. Our facility (Crossroads
Treatment Center) (drug) tests do not show how
much of the substances she (DC #1) takes, only
that its there (drugs in her system). "
- " They (the local mental health agency) had
been changing her medications and DC #1 had
started falling. "
- DC #1 went to the emergency room for a
variety of physical complaints.
- DC #1 was illiterate; she could not read or
write, " Post It " notes were given to her to
provide to her parents to assist her with
Division of Health Service Regulation
If continuation sheet 117 of 1396899STATE FORM DOBD11
![Page 118: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/118.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 512Continued From page 117 V 512
remembering what she had been told while she
was at the facility and to remind her of her
appointments
- " We (Counselor #16 and unnamed others)
think there might have been some domestic
violence with her husband. We had discussed
with the owners (of the facility) whether we
needed to MSW (Medically Supervised
Withdrawal) her out of the clinic, but she wasn ' t
eligible for the Medically Supervised Withdrawal
because she was very random with her drug use.
"
- " She did have paranoia depending on
whether she was manic or not. "
- " She didn ' t hit anything hard, no cocaine. "
- " I know that she (DC #1) was not good on
that last day (3/15/13); not only her cognitions but
her gait. We really came down on her, me and
the nurse (RN #1/DON) because we realized how
unstable she was. "
- DC #1 would not allow someone from the
facility to contact Emergency Medical Services
(EMS) on her behalf
- It was DC #1 ' s choice to not have EMS
called on her behalf
- DC #1 stated " I ' m going to the house (DC
#1 ' s home) because I ' m not going to leave my
husband by himself. "
- DC #1 ' s husband had recently had hernia
surgery and was recovering at their home.
Interview on 4/10/13 with the facility ' s Registered
Nurse #1/Director of Nursing (RN #1/DON)
revealed:
- DC# 1 was admitted to the facility in April of
2012
- DC #1 was " a sweet patient with a traumatic
brain injury and mental health issues. "
- Counselor #16 worked hard to getting her to
a local mental health agency for treatment as DC
Division of Health Service Regulation
If continuation sheet 118 of 1396899STATE FORM DOBD11
![Page 119: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/119.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 512Continued From page 118 V 512
#1 had difficulty with her memory and the
memory issues may have been related to her
traumatic brain injury
- DC #1 had issues with alcohol and
breathalyzers were administered to her and she
was educated on the dangers of alcohol use
- DC #1 had been diagnosed with Substance
Induced Psychotic Disorder
- DC #1 had reported that she had been
diagnosed with Schizophrenia while in her 20 ' s;
however she could not remember the doctor who
diagnosed with Schizophrenia
- " We were trying to get her back to [the local
mental health facility] to look at the Substance
Induced Psychotic Disorder. "
- If a client has three positive urine analyses in
a row, the client ' s counselor will speak with the
client about the positive urine analyses and
discuss the client with the Medical Director if
necessary
- Counselors can talk with their clients,
determine what their stressors are and assist
them with addressing their stressors
- If there are concerns regarding the clients '
doses, the Medical Director would be contacted
- Based on a review of DC # 1 ' s record, it did
not appear a Peak and Trough test was
administered to DC #1
- " Sometimes he (the Medical Director) will go
up to 130 milligrams (of Methadone) without a
Peak and Trough. " If the client does not have
the income for the Peak and Trough and there is
no positive urine analysis an increase may be
ordered with the Peak and Trough
- A client can receive a Medical Supervised
Withdrawal (MSW), if there are health problems
which are interfering with their treatment.
- The client ' s counselor and the RN #1/DON
discuss the client ' s progress and if there is still a
problem; the client could be put on a " behavior
Division of Health Service Regulation
If continuation sheet 119 of 1396899STATE FORM DOBD11
![Page 120: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/120.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 512Continued From page 119 V 512
contract " and the Medical Director could reduce
the client ' s dose
- " I speak to him (the Medical Director)
everyday, so he knows if someone is a repeat
offender and he makes the decision for MSW or
to decrease. "
- It was difficult at times to determine if DC #1 '
s mental health issues were affecting what DC #1
was reporting
- DC #1 did mention that she was falling and
she was advised to go to the Emergency Room
(ER); however, DC #1 would refuse to go
- DC #1 would state that she could not go to
the ER and leave her husband alone.
Interview on 4/9/13 with Licensed Practical
Nurse/Lead Dosing Nurse (LPN/LDN) revealed:
- If clients have health issues, the facility staff
would refer the client to their primary care
physician, if clients did not have health insurance,
facility staff referred the client to a local heath
care
- If clients have health issues the facility refers
them to their primary doctors. If clients have no
health insurance the facility refers them to a
health care facility. If clients refuse to follow up
with an outside physician then the facility ' s
Medical Director would see the client.
Interview on 4/16/13 with the facility ' s Medical
Director (MD) revealed:
- He had been employed by the facility for five
years. " I ' m basically on call every day of the
week, including Saturdays and available to
nurses every day. "
- " I do all of the annuals (yearly physical
exams) ...If people want to set up appointments
to come in to discuss methadone or other issues
(non methadone issues) they go to the RN (RN
#1/DON) if they (the clients) need to set up an
Division of Health Service Regulation
If continuation sheet 120 of 1396899STATE FORM DOBD11
![Page 121: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/121.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 512Continued From page 120 V 512
appointment to see me. "
- " [RN#1/DON] handles most of the medical
issues when it comes to methadone issues. Any
of the nurses can call me but [RN#1/DON] is
usually the one to call me unless she ' s close to
overtime then [the LPN #1/LDN] calls. "
- With regard to clients with dual diagnoses,
the MD stated, " Honestly it ' s hard to
differentiate because we are not a dual diagnosis
clinic. We recommend clients going to Primary
Care Physician or Emergency Room. "
- " If it ' s an acute situation here when they ' re
unstable and you think they are in danger, call the
EMS (Emergency Medical Services). "
- " The problem comes in when we don ' t
know if it ' s Benzos (Benzodiazepines) or
something else then we recommend they follow
up. It ' s difficult to know. "
- " When I saw her (DC #1) for her yearly,
(annual physical exam) she did not tell me she
was falling down, her main concern was [a local
mental health facility]. She was not unstable in
my medical opinion; she was walking around,
looked fine. "
- " Sounds like she had an aneurysm, with an
aneurysm it goes like that. You could be stable
and then just go. "
- " It wasn ' t her mental status as to why she
wasn ' t going to follow up. These folks have so
much going on in their life they ' re just trying to
become stable. It seemed like whatever you told
her she didn ' t take it that seriously. "
- It was initially the understanding of the MD
that DC #1 had not been on any psychotropic
medications
- After reviewing DC #1 ' s record, he realized
that DC #1 had been put on Zoloft in October of
2012.
- When asked how testing positive (on urine
analysis) impacts his decisions, the Medical
Division of Health Service Regulation
If continuation sheet 121 of 1396899STATE FORM DOBD11
![Page 122: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/122.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 512Continued From page 121 V 512
Director replied: " It ' s a case by case basis ...I
look at current dose, history of dose. "
- " On a day to day basis it comes down to
impairment. You want to keep them (the clients)
stable ...if they are impaired I would have to lower
doses. If you drop them too much they will go out
on the streets. It ' s a tricky balance. I put a great
bit of trust on the nurses and also the counselors.
"
- " Psychosocial is important as to why we
think they need a higher level of care. No support
at home and relapse we would have to look at
higher level. Sometimes we can ' t get them a
higher level they don ' t meet criteria etc. so it ' s a
tricky situation. "
- " I ' m not sure if [PD #1] talked to [Counselor
#16] about the higher level. "
- He did not attend treatment team meetings;
however, he had the option of reviewing the
clients ' case notes
- He was not aware of DC #1 ' s diagnosis of a
Substance Induced Psychotic Disorder
- He had about five conversations about DC #1
via the phone with RN #1/DON. Some of the
conversations were about DC #1 ' s complaining
about falls; however, most were about her
positive drug screens and how she should be
dosed.
- " Even if I knew about the Substance Induced
Psychotic Disorder, I would not have changed the
doses. There were no signs of any neurological
symptoms at the time I saw her on 3/5/13. The
aneurysm wasn ' t related to the behaviors. "
- As for a client who continues to use alcohol
or illicit drugs and continued Methadone
treatment, " It is a case by case basis. If we see
9 months to year and still dirty (positive drug
screens), then we will consider dosing an MSW. "
- The MD was not aware of DC #1 having had
hallucinations
Division of Health Service Regulation
If continuation sheet 122 of 1396899STATE FORM DOBD11
![Page 123: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/123.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 512Continued From page 122 V 512
- Clients are moved from one level to the next
when they produce three months of clean drug
screens and are not engaged in any illicit drug
use
- Alcohol may or may not be considered as an
illicit drug as it depends on the situation. If a
client is constantly positive for alcohol, then it
could be considered a positive drug screen
- The danger of mixing Benzodiazepines with
Methadone was that both drugs could cause "
respiratory distress ...you stop breathing. "
- As a result of the information shared with the
MD during the interview, he stated " I ' m going to
talk to [PD #1] and he (PD #1) will get with the
counselors. We will probably come up with a
check list. We (the facility) need to have a red
flags test for the counselors. "
Interview on 4/12/13 and 4/17/13 with facility ' s
PD #1 revealed:
- " There was not a day that went by " that he
did not speak with the Medical Director (MD)
- His nurses spoke to the MD every day
- My guess is [DC #1] was having a lot of
financial difficulties; he (the MD) will override his
standing order if patient is doing well. For [the
MD], this would be the exception, not the norm to
increase dose without " peak and trough. "
- Since DC #1 ' s death he had come up with a
new system to ensure all information was shared
with him and the MD
- He was not sure if the facility had staffed DC
#1 for a higher level of care
- The facility had not done an internal review
regarding DC# 1 ' s death
Review on 4/16/13 of the facilities policy and
procedures regarding " Medical Director ' s
Standing Orders " revealed:
- " When Patient appears to be intoxicated:
Division of Health Service Regulation
If continuation sheet 123 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 512Continued From page 123 V 512
The patient will not be dosed. The patient shall
be referred to the nurse or to a counselor for
observation and evaluation.
If in doubt, alert the Program Director and the
patient ' s counselor. Discuss any concerns
before dosing the patient. You may opt to
observe and monitor the patient ' s condition
before deciding whether or not to dose the
patient.
The patient is not to be dosed on that day without
both the nurse and the counselor agreeing that
the patient can safely be dosed. If there are
questions remaining about safety, then the
patient should not be dosed unless the case is
reviewed with the Medical Director.
The decision to dose or not to dose should be
clearly documented in the patient ' s record. If
patient is dosed, the patient should be observed
after dosing for at least 30 minutes to document
the patient is safe to leave the clinic. "
Further review on 4/17/13 of facility ' s policy and
procedures manual regarding levels and take
home criteria revealed:
- " Take Home Eligibility: Any patient 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 patient must also meet the
specified 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 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
Division of Health Service Regulation
If continuation sheet 124 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 512Continued From page 124 V 512
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 patient shall
ingest all other doses under supervision at the
clinic;
b. Level 2. After a minimum of 90 days of
continuous program compliance, a patient may
be granted for a maximum of three take home
doses and shall ingest all other dose under the
supervision at the clinic each week. "
Finding #4:
Review on 5/13/13 of Deceased Client #4 ' s (DC
#4 ' s) record revealed:
- An admission date of 3/15/13
- A diagnosis of Opioid Dependence
- Two obituary listings which documented DC
#4 died on Monday, March 18, 2013
- He was 35 years of age
- A discharge date of 3/26/13
- An intake assessment completed on 3/15/13
which documented DC #4 had entered treatment
with his girlfriend (DC #5) on the same date
- DC #4 reported no depressive thoughts in the
previous 30 days
- " The Physician ' s Initial Orders For A New
Patient " completed and dated by the MD on
3/15/13 documented DC #4 would be receive a
30 mg dose of Methadone on 3/15/13
- " A Patient Medication Record " which
documented that DC #4 received a 30 mg dose
of Methadone on 3/16/13 and a take-home dose
of 30 mgs for 3/17/13
- A " Patient Medication Record " which
documented that DC #4 was absent from the
facility from 3/18/13-3/26/13
Division of Health Service Regulation
If continuation sheet 125 of 1396899STATE FORM DOBD11
![Page 126: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/126.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 512Continued From page 125 V 512
- The " Patient Medication Record " indicated
staff (no staff listed) " attempted to contact pt
(DC #4) - couldn ' t connect to telephone " from
3/18/-3/22/13
- On 3/25/13 staff (no staff listed) " attempted
to contact emergency contact - no vm
(voicemail). "
- A " Patient Discharge " form with a
discharge date of 3/26/13 for DC #4. The form
was not dated and did not indicate who
completed the form
- The " Patient Discharge " form documented
" Patient ' s Current Condition/Gains: Unknown;
Treatment Summary: Did not complete treatment;
Reason for Discharge: Left against staff advice -
missed 7 consecutive days after being contacted.
Could not contact pt (patient). Follow up Plans:
None. "
- A " Report of Investigation By Medical
Examiner " dated 3/19/13 and completed by the
Medical Examiner for the county in which DC #4
resided included a " Narrative Summary of
Circumstances Surrounding Death " which
documented " ...He (DC #4) and his girlfriend
were living together at [address of DCs #4 and
#5]. His girlfriend (DC #5) had apparently been
taking some Methadone and inhaling air
freshener. When he woke up, he found her lying
beside him. She was unresponsive and
apparently dead. He then called his mother and
told her that his girlfriend was dead. He then
hung up and wrote a suicide note and got back
into bed next to her. She was on her right side
and he got up on his right side up close to her.
He then used a 9mm (millimeter) handgun and
shot himself in the left side of the head. The
bullet went through his head and then into his
right upper arm which was above his head.
There were also rose petals on him as well as
her. We do not know if he put the rose petals in
Division of Health Service Regulation
If continuation sheet 126 of 1396899STATE FORM DOBD11
![Page 127: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/127.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 512Continued From page 126 V 512
the bed after he found her dead or if they had
rose petals in the bed from the night before. In
examining the body, there was an odor of alcohol
on the body. "
- No autopsy was completed on DC #4
Review on 7/5/13 of DC #4 ' s toxicology report
from the OCME ' s office revealed:
- Based on the analysis of a 6.0 ml blood
specimen from DC #4 ' s subclavian vessel, it
was determined DC #4 had 30 mg/dL of Ethanol
in his blood
Review on 5/15/13 of the facility ' s " Patient List
By Counselor " revealed:
- DC #4 was assigned to Counselor #6 on
3/15/13
Review on 5/14/13 of Counselor #6 ' s record
revealed:
- A hire date of 3/18/13
- A job description of Substance Abuse
Counselor-Registered (SAC-R)
Interview on 5/15/13 with Counselor #3 revealed:
- The PD #1 and the APD #1 learned of DCs
(#4 ' s) death during the late afternoon of 3/22/13
- They learned of DCs (#4 ' s) death via the
internet
- " No one contacted the client because no
counselor had been assigned "
Finding #5:
Review on 5/13/13 of Deceased Client #5 ' s (DC
#5 ' s) record revealed:
- An admission date of 3/15/13
- A diagnosis of Opioid Dependence
- An obituary listed by a funeral home in a
Division of Health Service Regulation
If continuation sheet 127 of 1396899STATE FORM DOBD11
![Page 128: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/128.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 512Continued From page 127 V 512
newspaper documented DC #5 " passed
Monday, March 18, 2013 at her home. "
- She was 32 years of age
- A discharge date of 3/26/13
- A screening completed by Counselor #3 on
3/15/13 which documented that DC #5 ' s primary
drug of use was " pain pills of any kind. "
- She had used opiates for ten years with a
cost of $200.00 per day
- Her last opiate use was on 3/15/13 as she
had had a prescription for five Oxycodone pills
filled the morning of 3/15/13
- She had taken all five Oxycodone pills prior to
her arrival at the facility for her intake
- No evidence a History and Physical Exam
was completed by nursing staff
- A urine analysis (UA) conducted via " intake
dip " on 3/15/13 indicated DC #5 was positive for
Benzodiazepines, Opiates, Oxycodone and THC
(TetraHydroCannabinol)
- " A Physician ' s Exam " completed by the
facility ' s Medical Director (MD) on 3/15/13 which
documented the MD ' s " assessment " of DC #5
indicated diagnoses of " Opioid Dependence,
Epilepsy, Kidney Stones. "
- DC #5 ' s " Plan " included "
Methadone/Counseling and Dilantin. "
- An " Addiction Verification Form " completed
and signed by the MD on 3/15/13 on behalf of DC
#5 documented " The above named patient (DC
#5) has applied to Crossroads Treatment Center
for treatment. The following items, which are
checked and have been documented, are used to
verify addiction to opiate drugs and to warrant
admission into our program. "
- Further review on 3/151/3 of the " Addiction
Verification Form " revealed: " The patient has
been assessed with regards to signs and
symptoms of opiate withdrawal (See Physical
Assessment). "
Division of Health Service Regulation
If continuation sheet 128 of 1396899STATE FORM DOBD11
![Page 129: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/129.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 512Continued From page 128 V 512
- " The patient ' s initial urine test was positive
for opiates. "
- The patient has submitted testimonies
regarding at least a one year history of addiction
to opiate drugs. "
- " The patient has tried unsuccessfully to stop
using drugs. "
- An initial note completed by the MD indicated
the " Patient Is A Good Candidate for treatment.
"
- " The Physician ' s Initial Orders For A New
Patient " completed and dated by the MD on
3/15/13 documented DC #5 would receive a 30
mg dose of Methadone on 3/15/13
- " A Patient Medication Record " which
documented that DC #5 received a 30 mg dose
of Methadone on 3/16/13 and a take-home dose
of 30 mgs for 3/17/13
- A " Patient Medication Record " which
documented that DC #5 was absent from the
facility from 3/18/13-3/26/13
- The " Patient Medication Record " indicated
staff (no staff listed) " attempted to contact pt
(DC #5) - couldn ' t connect to telephone " from
3/18/-3/22/13
- On 3/25/13 staff (no staff listed) " attempted
to contact emergency contact - no vm
(voicemail). "
- A discharge date of 3/26/13 with the reason
for discharge entered by the PD #1 as " Left
against staff advice - missed 7 consecutive days
after being contacted. "
- A " Patient Discharge " form with a
discharge date of 3/26/13 for DC #5. The form
was not dated and did not indicate who
completed the form
- The " Patient Discharge " form documented
" Patient ' s Current Condition/Gains: Unknown;
Treatment Summary: Pt did not complete
treatment; Reason for Discharge: Left against
Division of Health Service Regulation
If continuation sheet 129 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 512Continued From page 129 V 512
staff advice - missed 7 consecutive days after
being contacted. Follow up Plans: None. "
Review on 7/22/13 of DC #5 ' s " Report of
Autopsy Examination " completed by a physician
with the Office of the Chief Medical Examiner ' s
(OCME ' s) office on 3/19/13 and signed by the
same physician on 7/18/13 revealed:
- DC #5 ' s cause of death was " Cocaine,
methadone and morphine toxicity. "
- " Personal effects received with the body
include one Glade air freshener aerosol bottle,
one empty liquid methadone container, and one
short plastic straw. "
Review on 7/22/13 of DC #5 ' s toxicology report
from the OCME ' s office revealed:
- Based on the analysis of a 4.0 ml blood
specimen from DC #5 ' s aorta, it was determined
Benzodiazepines, Cocaine metabolite,
Levamisole, and Opiates/Opioids were present in
DC #5 ' s blood
- Based on the analysis of a 8.0 mg/L blood
specimen from DC #5 ' s vena cava, it was
determined " 0.37 mg/L of 7-Aminoclonazepam;
0.43 Benzoylecgonine mg/L; 0.039 mg/L Cocaine;
0.38 Methadone mg/L; and 0.17 mg/L Morphine "
were present in DC #5 ' s blood
- Based on the analysis of a 15.0 ml sample of
urine from DC #5 ' s bladder, it was determined "
6.8 ml of Morphine " was present in DC #5 ' s
urine
-Review on 7/22/13 of the following medications
on www. <http://www.drugs.com/> revealed:
- " Aminoclonazepam is used to monitor the
use of the parent drug Clonazepam which is a
benzodiazepine that is used to treat seizures and
sometimes panic disorders. It is a muscle
relaxant, sedative and has hypnotic properties. "
Division of Health Service Regulation
If continuation sheet 130 of 1396899STATE FORM DOBD11
![Page 131: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/131.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 512Continued From page 130 V 512
- Benzoylecgonine is a metabolite of Cocaine
which serves as a marker for Cocaine ingestion
- Levamisole is a cancer medication used to
treat colon cancer
- Morphine is and opioid pain medication used
to treat moderate to severe pain
Review on 5/15/13 of the facility ' s " Patient List
By Counselor " revealed:
- DC #4 was assigned to Counselor #6 on
3/15/13
Review on 5/14/13 of Counselor #6 ' s record
revealed:
- A hire date of 3/18/13
- A job description of Substance Abuse
Counselor-Registered (SAC-R)
Interview on 5/15/13 with Counselor #6 revealed:
-She was hired on 3/18/13
-"Got my caseload almost 2 weeks later."
-"There are 2 (DC #s 4 and 5) on my caseload
that passed away."
-"I never put in notes in, never met them, never
talked to them."
Interview on 5/15/13 with Counselor #3 revealed:
- The PD #1 and the APD #1 learned of DCs
(#5 ' s) death during the late afternoon of 3/22/13
- They learned of DCs (#5 ' s) death via the
internet
- " No one contacted the client because no
counselor had been assigned "
Interview on 5/17/13 with Assistant Program
Director #1 (APD#1) revealed:
- DCs #4 & 5 were transition clients (clients
awaiting assignment of a counselor)
-"They had not been assigned a counselor.
[PD#1] may have been contacting clients."
Division of Health Service Regulation
If continuation sheet 131 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 512Continued From page 131 V 512
Interview on 5/16/13 with the MD revealed:
- The facility does not admit clients on Fridays
any longer
- There had been a standing order for clients to
receive take-homes for Sundays; however, the
facility has now become a Level Zero facility with
all new clients beginning in the induction phase
and required to attend the clinic seven days per
week
- Five Hydrocodone is not unusual for these
clients; Dilantin also lowers blood levels and 30
mgs of Methadone would feel more like 20 mgs
- If a History and Physical were not completed
by the RN #1/DON, it would not impact the MD ' s
evaluation of the client ' s need for services as he
completes his own physical examination.
- " My evaluations are more than enough to
determine what levels to start dosing "
Review on 7/25/13 of the Plan of Protection dated
7/25/13 written by the Director of Nursing,
(Registered Nurse #1/Director of Nursing)
Assistant Program Director, (Assistant Program
Director #2) Program Director (Program Director
#2) and Vice President of Operations revealed:
" ...26G .0203
Specific actions taken to date to address issues
related to the competencies of qualified
professionals and associate professionals
include:
Former Program Director, [Program Director #1],
was terminated on May 25, 2013.
Former Assistant Program Director, [Assistant
Program Director #1] is no longer employed by
Crossroads Treatment Center of Greensboro
effective June 3, 2013. She has since been
transferred to another role within Crossroads
outside of Greensboro.
Division of Health Service Regulation
If continuation sheet 132 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 512Continued From page 132 V 512
New Program Director, [Program Director #2],
was hired on 6/20/2013.
New Assistant Program Director, [Assistant
Program Director #2] was promoted to that
position on 7/16/2013.
New Senior Counselors, [Senior Counselor #1]
and [Senior Counselor #2], were promoted to
their positions on 7/19/2013. "
" 27G.3603
Concerning treatment center staffing:
1. All current caseloads are equal to or under 50
per counselor.
2. Current hiring of qualified counselors will
continue to keep up with demand. "
" 27D.0304
Patient protection is addressed through the
following measures:
1. An improved intake process was
implemented on May 27, 2013.
2. A new Intake Coordinator, [Counselor #6]
was promoted to this position on May 24, 2013 to
ensure the new intake process provides the
desired quality improvements.
3. We became a " Level 0 " clinic (dosing 7
days per week) on April 29, 2013 to provide a
higher level of monitoring for induction patients.
Therefore, patients in this higher risk phase of
treatment no longer receive take-home
medication. Should we again decide to conduct
intakes on Friday at some point in the future,
induction patients will be doubly protected by the
absence of take-home medications for Sundays
and the restriction prohibiting dose increased
over the weekend.
4. As stated above, a High Risk Binder was
created in May 2013 for patients identified as "
high risk " due to pregnancy, co-occurring
disorders or medical fragility. This binder was
Division of Health Service Regulation
If continuation sheet 133 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 512Continued From page 133 V 512
created and is maintained by the Director of
Nursing and presented to the program physician
bi-weekly for review. Further, the Director of
Nursing meets weekly with these patients and
completes an individual health status update.
5. A Medication list is completed for each
patient upon intake and placed in the chart for
review by medical staff. All medications are then
checked against the Epocrates database to
identify potential adverse reactions with
Methadone. This check is conducted by the
Intake Coordinator prior to each patient meeting
with the program physician. All medications are
reviewed by the program physician and must
receive physician approval.
6. The two Senior Counselors (#1 and #2)
provide immediate quality clinical supervision of
all staff. The counseling staff has been divided
into two groups to be managed by the Senior
Counselors (there are currently 5 counselors per
Senior counselor).
7. The Senior Counselors meet with their team
weekly for Mini-Treatment Team meetings to
discuss treatment decisions, patient record
issues, patient behavior, treatment planning,
coordination of care issues and quality of
counseling.
8. As of June 25, 2013, counselors are able to
staff patients with the center ' s Medical Director
at a weekly meeting specifically designated for
this purpose.
9. All Staff Treatment Team Meetings will be
held bi-weekly and chaired by [Program Director
(Program Director #2 (PD #2)], LCAS (Licensed
Clinical Addiction Specialist) to discuss cases
from the Mini-Treatment Teams that need further
clinical care and decisions. Patients will be
eligible to attend these meetings (as needed) for
treatment decisions such as discussion of
eligibility for continued treatment or MSW
Division of Health Service Regulation
If continuation sheet 134 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 512Continued From page 134 V 512
(Medically Supervised Withdrawal).
10. Coordination of Care documentation that is
not received back from health care providers
within seven business days will be followed up
directly by the Lead Nurse or Director of Nursing
to ensure documentation was received and is
being acted upon.
11. On or before August 2, 2013, the Director of
Nursing (Registered Nurse #1/Director of Nursing
(RN #1/DON) will re-train all staff that work on
Saturdays and/or Sundays on the procedures
associated with screening patients prior to dosing
for signs of impairment and the proper steps to
take if impairment is suspected. "
This deficiency constitutes a Type A1 rule
violation and must be corrected within 23 days.
An administrative penalty of $20,000.00 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 536 27E .0107 Client Rights - Training on Alt to Rest.
Int.
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
V 536
Division of Health Service Regulation
If continuation sheet 135 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 536Continued From page 135 V 536
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;
(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
Division of Health Service Regulation
If continuation sheet 136 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 536Continued From page 136 V 536
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.
(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
Division of Health Service Regulation
If continuation sheet 137 of 1396899STATE FORM DOBD11
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A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 536Continued From page 137 V 536
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.
(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.
Division of Health Service Regulation
If continuation sheet 138 of 1396899STATE FORM DOBD11
![Page 139: STATEMENT OF DEFICIENCIES (X2) MULTIPLE ...EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ID PREFIX TAG (X4) ID TAG SUMMARY STATEMENT](https://reader031.vdocuments.us/reader031/viewer/2022030414/5a9fdf647f8b9a71178d4abc/html5/thumbnails/139.jpg)
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 08/20/2013 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Division of Health Service Regulation
MHL041-879 07/25/2013
NAME OF PROVIDER OR SUPPLIER
CROSSROADS TREATMENT CENTER OF GREENSBORO, PC
STREET ADDRESS, CITY, STATE, ZIP CODE
2706 NORTH CHURCH STREET
GREENSBORO, NC 27405
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
V 536Continued From page 138 V 536
This Rule is not met as evidenced by:
Based on record reviews and interviews, the
facility failed to have initial and updated annual
training in alternatives to restrictive interventions
for 2 of 22 audited staff (Counselor #2 and the
Medical Director (MD)). The findings are:
Review on 5/14/13 of Counselor #2 ' s record
revealed:
- A hire date of 2/4/13
- A job description of Substance Abuse Counselor
- No documentation of a training certificate for
North Carolina Interventions (NCI) Part A.
Review on 4/10/13 of the MD ' s record revealed:
- A hire date of 06/01/09
- A job description of Medical Director
- No documentation of a training certificate for
North Carolina Interventions (NCI) Part A.
Interview on 5/14/13 with Counselor #2 revealed:
- He was not aware NCI Part A training was
required
Interview on 4/17/13 with the Program Director #1
(PD #1) revealed:
- He was not sure why some staff had training
and some did not.
Division of Health Service Regulation
If continuation sheet 139 of 1396899STATE FORM DOBD11