The Non-Financial Ledger: What the Docket Doesn’t Measure

There is a woman in western North Carolina who is not in this lawsuit. She has no legal standing, no claim number, no attorney. She is identified in court documents only as “the Client.” She was on probation. She was fighting a substance use disorder. In March 2021, she was in enough pain to pick up the phone and call her counselor.

That call set off a week-long fight between three counselors who were trying to get her into inpatient care and a management structure that kept putting administrative obstacles in the way. The counselors knew what she needed. They wrote it down. They sent it up the chain. They asked again and again. They were told no.

Three days after the letter went out with the wrong words in it, she was dead.

Think about what those three days were like for the counselors. They had done the assessment. They had developed the crisis plan. They had pleaded with their supervisor to let the letter say what it needed to say. They had watched the probation officer push back too. All of it was futile. Then their phones rang or their email dinged, and they found out she was gone.

Then NCG made it worse. Counselor Kim Shook was the only NCG employee with direct, first-hand knowledge of the client’s condition. Completing the incident report after a patient death is a professional obligation under the same licensing rules NCG would later argue didn’t apply. When Shook tried to fulfill that obligation, supervisor Jessica Tewell blocked her and wrote the report herself. Tewell had never met the client. The official record of that woman’s final weeks in NCG’s care was written by someone who had never been in the same room as her.

John Szwyd, the clinical supervisor, did what a person of conscience does. He reported the situation up the chain. He went to Regional Director Ron Ross and told him that Tewell’s refusal to approve the care recommendation was clinically wrong and may have contributed to the death. Ross’s response was not concern. It was not a promise to investigate. It was a warning. Watch what you say and who you say it to.

Nine days later, all three counselors were fired. Kim Shook. Kylie Scolaro-Conti. John Szwyd. People with professional licenses, professional obligations, and professional consciences, terminated because they followed the rules their industry said they had to follow.

The thing that is hardest to sit with is the math of it. NCG spent over two years in federal court, hiring attorneys in Richmond, Virginia and Raleigh, North Carolina, fighting to keep these three people from having their day in court. All of that legal firepower, all of that institutional energy, directed at three counselors whose core crime was writing the word “higher” instead of “different” and then having the audacity to tell someone about it after their client died.

The woman who died does not benefit from the Fourth Circuit’s ruling. Her family does not get a settlement check. The law, as it is designed, protects the employment rights of the people who tried to help her. That is not nothing. The counselors deserve that protection. But there is a specific kind of grief that comes with knowing that the system worked just barely, just in time, for the living, and that the dead woman at the center of this story is still just a placeholder name in a legal document.

Legal Receipts: What They Actually Said

The following quotes come directly from the Fourth Circuit opinion, case No. 23-1406, decided August 14, 2024. These are not paraphrases. These are the words in the official record.

“If I were you, I would watch what you say and who you say it to.”

— Regional Director Ron Ross, responding to clinical supervisor John Szwyd’s report about Tewell’s actions and their possible connection to the client’s death. Quoted in the Fourth Circuit opinion, J.A. 14.

“[Tewell] failed to demonstrate competency — she failed to sign a letter for [the Client] that was requested by probation and forwarded to her by Substance Abuse Intensive Outpatient Program (‘SAIOP’) staff referencing a need for a higher level of care for 7 business days, from 3/22/21–4/2/21 and edited information in the letter; the edited information included inaccuracies regarding lack of progress in the program, and a recommendation for a different service that was not recommended by the clinicians; [Tewell] based her edits upon review of the client record. She had never met [the Client].”

— North Carolina Department of Health and Human Services, following an unannounced investigation of NCG facilities. Quoted in the Fourth Circuit opinion, J.A. 17.

“To safeguard the public health, safety, and welfare, to protect the public from being harmed by unqualified persons, to assure the highest degree of professional care and conduct on the part of credentialed substance use disorder professionals… and to ensure the availability of credentialed substance use disorder professional services of high quality to persons in need of these services.”

— North Carolina Substance Use Disorder Professional Practice Act (SUDPPA), N.C. Gen. Stat. § 90-113.30. Quoted in the Fourth Circuit opinion.

Societal Impact Mapping: Who Pays When Corporations Silence Caregivers

Public Health

The consequences of silencing clinical professionals extend far beyond one client, one letter, and one company in western North Carolina.

• The client in this case was denied inpatient hospitalization because a supervisor with no direct knowledge of her condition altered a clinical letter. She died three days later. The NCDHHS confirmed the alteration was a professional violation. The direct line between administrative interference and patient death is documented in the official record.
• NCG operates multiple mental health and substance use disorder treatment facilities across western North Carolina. Every client at every NCG facility was treated by counselors who now knew the consequences of escalating a concern about their supervisor. That chilling effect on clinical reporting is a structural threat to patient safety, not an isolated incident.
• Substance use disorder treatment depends on licensed professionals having the authority to advocate for care escalation. When that authority can be overruled by an administrator who has never met the patient, and when the professionals who object get fired, the entire therapeutic relationship is compromised. Clients cannot trust that their counselor’s recommendation carries weight.
• Rule 68.0503(h), the regulation requiring accurate incident reporting after adverse events, exists specifically so that deaths and near-deaths can be reviewed, analyzed, and prevented from recurring. Tewell completed the incident report for a client she had never met, blocking the only person with first-hand knowledge from creating an accurate record. That falsified record is what the facility’s quality review process would have used going forward.
• The counselors filed their complaint with NCDHHS only after they were fired. Had they still been employed, the threat implicit in Ross’s warning may have deterred them from filing at all. The number of similar incidents at NCG facilities that have gone unreported because current employees stayed silent is unknown.

Economic Inequality

This case exposes the specific financial vulnerability that makes at-will employment a mechanism of coercion in healthcare settings.

• Licensed substance use disorder counselors hold professional licenses that represent years of education, supervised clinical hours, and examination. NCG terminated all three counselors without cause, forcing them to fight a wrongful termination case through the federal court system for over two years before the Fourth Circuit reinstated their right to a hearing. The legal costs, lost income, and professional disruption during that period fall entirely on the individuals, not the corporation.
• NCG had attorneys from Williams Mullen in Richmond, Virginia and additional counsel in Raleigh. The counselors were represented by firms in Winston-Salem and Raleigh. The asymmetry in legal resources between a regional behavioral health corporation and three terminated clinical workers is the standard condition of this kind of litigation.
• The district court dismissed the case in December 2022 and confirmed dismissal in March 2023. The Fourth Circuit did not hear arguments until May 2024 and did not issue its ruling until August 2024. That is over two years during which the counselors had no legal remedy. For workers without financial reserves, that timeline effectively functions as a denial of justice even when the law is on their side.
• Western North Carolina is a rural, underserved region for behavioral health services. The counselors who were fired were providing services to clients in substance use disorder recovery, many of whom were on probation and dependent on NCG’s programs. Losing three experienced licensed professionals from that ecosystem harms clients who have limited alternatives. The economic and geographic barriers to care in that region are real, and the workforce that serves it is not easily replaced.
• The at-will employment doctrine, as applied here, creates a direct financial incentive for healthcare corporations to terminate clinical staff who create administrative friction by advocating for patients. The cost of a lawsuit is predictable and manageable. The cost of consistently approving higher levels of care, with the associated insurance and regulatory implications, is ongoing. The rational corporate calculation under at-will employment is to fire the friction, not fix the system.

The “Cost of a Life” Metric

What Now: How to Use This Information

The Fourth Circuit remanded this case for full proceedings. That means the fight over whether NCG fired these counselors in retaliation for doing their jobs is not over. Here is what accountability looks like at every level you can reach.

The People Accountable at NCG

• Jessica Tewell, Assistant Director of Outpatient and Community-Based Services at the time of the events. Her actions were the subject of the NCDHHS investigation and were found to violate North Carolina law.
• Ron Ross, Regional Director at the time of the events. He received the report about Tewell’s conduct, issued a warning to the counselor who made the report, and his facilities terminated all three counselors nine days later.
• NCG Acquisition, LLC (Appalachian Community Services) and NCG CARE, Inc. (ncgCARE), the corporate entities named as defendants. They directed and funded the legal campaign to dismiss the counselors’ case through two levels of federal court.

Watchlist: Regulatory Bodies with Jurisdiction

• North Carolina Department of Health and Human Services (NCDHHS): Already conducted one unannounced investigation of NCG facilities and found a violation. Has ongoing oversight authority over licensed behavioral health providers in North Carolina. File complaints about substance use disorder treatment facilities at dhhs.nc.gov.
• North Carolina Addictions Specialist Professional Practice Board (NCASPPB): The licensing board created by SUDPPA. Has the authority to discipline licensed substance use disorder professionals who violate the Act’s standards, including supervisors who alter clinical recommendations. Any licensed professional at NCG with knowledge of ongoing violations can report to the Board.
• North Carolina Department of Labor (Wage and Hour Bureau): Has jurisdiction over labor practices by North Carolina employers. The wrongful termination case in federal court does not preclude state-level labor complaints about the same conduct.
• The Occupational Safety and Health Administration (OSHA): Administers whistleblower protection programs under federal statutes. Depending on any federal funding NCG receives, additional protections may apply to employees who report patient safety concerns.
• The Centers for Medicare and Medicaid Services (CMS): If NCG receives Medicaid reimbursement for substance use disorder treatment services in North Carolina, CMS has oversight authority over the quality of care delivered and the integrity of clinical documentation. Falsified incident reports may implicate Medicaid documentation requirements.

Mutual Aid, Local Action, and Grassroots Resistance

• If you work in behavioral health in North Carolina: Know SUDPPA. Know Rules 68.0507, 68.0503(a), and 68.0503(h) by name. If your employer overrules a clinical recommendation without clinical authority, document it in writing immediately, date it, keep a personal copy, and send it to your licensing board. The Fourth Circuit just confirmed that doing your job is protected conduct. Make that protection real by creating a paper trail before anything escalates.
• If you are a client in substance use disorder treatment in North Carolina: You have the right to know your counselor’s clinical recommendations. Under North Carolina law, you can request your treatment records. If you believe your care was altered by someone who was not your treating clinician, you can file a complaint with NCDHHS and the NCASPPB.
• If you are in a union or organizing in healthcare: This case is a direct argument for collective bargaining agreements in behavioral health settings. At-will employment is the mechanism that made this retaliation possible. A CBA with just-cause termination provisions would have changed this outcome before the first lawyer was hired. Share this ruling with your organizing committee.
• If you want to support the counselors directly: The case is active in the Western District of North Carolina (Case No. 1:22-cv-00065-MR-WCM). Court records are public through PACER. Following the case’s progress and sharing developments keeps public pressure on NCG throughout the litigation.
• If you are a journalist or researcher: The NCDHHS investigation findings referenced in this ruling should be obtainable as a public record through a North Carolina public records request to DHHS. The full investigative findings, including any additional violations beyond those quoted in the opinion, are likely more detailed than what the court reproduced.