Adult Care Home Program Manual NC: A Comprehensive Guide to Regulations and Licensing

Navigating the landscape of adult care homes in North Carolina requires a thorough understanding of the regulations and licensing requirements set forth by the state. This guide serves as an informative resource, drawing from official North Carolina Administrative Code to provide clarity on the key aspects of operating an adult care home program in NC. While not a program manual itself, this article outlines the essential components and guidelines that any operator or administrator must be familiar with to ensure compliance and provide quality care.

Understanding Adult Care Home Definitions in North Carolina

To begin, it’s crucial to grasp the definitions that govern adult care homes in North Carolina. These definitions, as outlined in 10A NCAC 13F .0102, establish the foundation for all subsequent regulations. Key terms include:

• Adult Care Home: A facility, by whatever name called, providing residential care for aged or disabled adults.
• Activities of Daily Living (ADLs): Fundamental self-care tasks such as eating, dressing, bathing, toileting, transferring, ambulation, and communication.
• Abuse, Neglect, Exploitation: These terms are legally defined and carry significant weight in the operation and oversight of adult care homes, emphasizing resident safety and well-being.
• Administrator & Manager: Roles defined with specific responsibilities for the daily operations and overall management of the adult care home.
• Personal Care Aide: Staff members who provide direct personal care services to residents.
• Legal Representative & Responsible Person: Individuals authorized to act on behalf of the resident in various capacities.
• Long-term Care: Encompasses the continuum of services for individuals with persistent health conditions requiring ongoing support with ADLs or supervision.

Understanding these definitions is the first step in comprehending the scope and requirements of operating an adult care home program in NC.

Licensing Requirements for Adult Care Homes in NC

Operating an adult care home in North Carolina necessitates obtaining and maintaining a valid license from the Department of Health and Human Services (DHHS). Section .0200 Licensing of the NC Administrative Code details the specific requirements.

The License Itself (10A NCAC 13F .0202):

• Application: Applicants must submit material as per Rule .0204 and comply with all state statutes and rules. New license applications require disclosure of ownership details.
• Posting: The license must be displayed publicly within the adult care home. Provisional licenses must be posted with the reasons for their issuance.
• Non-transferable: Licenses are specific to the licensee and location and cannot be transferred or assigned.
• Level of Care: Licenses are solely for adult care homes and not for higher levels of care.

Applying for a License (10A NCAC 13F .0204):

• Certificate of Need: Meeting Certificate of Need requirements under G.S. 131E, Article 9 is a prerequisite.
• Application Submission: Applicants must submit an Initial License Application along with:
  • Detailed plans and specifications.
  • Construction review fees.
  • Approved fire and building safety inspection reports.
  • Approved sanitation reports.
  • Nonrefundable license fees.
  • Certificate of Occupancy.
• Issuance Basis: Licensure is contingent upon:
  • Completion and approval of all application materials.
  • Construction Section recommendation based on compliance with physical plant rules (Section .0300).
  • Compliance history review of the facility and its principals.
  • Approval of operational policies and procedures.
  • Successful pre-licensing survey demonstrating compliance with all statutes and rules.

Capacity and Change of Licensee:

• Capacity (10A NCAC 13F .0206): Licensed capacity is for seven or more residents, not exceeding the licensed number and physical space limitations. Compliance with Certificate of Need regarding bed capacity is mandatory.
• Change of Licensee (10A NCAC 13F .0207): Requires written notification to the Division of Health Service Regulation, county DSS, and residents 30 days prior to sale. Prospective licensees must submit a Change Licensure Application and updated inspection reports.

License Renewal and Termination:

• Renewal (10A NCAC 13F .0208): Annual renewal is required, involving a renewal application, fees, and consideration of compliance history, conduct of licensee, and potential hardship on residents if not renewed.
• Termination (10A NCAC 13F .0211): Licensees planning to close must provide 30 days written notice to the Division, county DSS, and residents, including closing date and resident relocation plans.

Denial, Revocation, and Appeal:

• Denial/Revocation (10A NCAC 13F .0212): Licenses can be denied or revoked for non-compliance with rules, with formal notification and reasons provided.
• Appeal (10A NCAC 13F .0213): Licensees have the right to appeal licensure actions through a contested case process.

Physical Plant Requirements for NC Adult Care Homes

Section .0300 – Physical Plant outlines the structural and environmental standards that adult care homes must adhere to. These requirements ensure resident safety, comfort, and accessibility.

General Application (10A NCAC 13F .0301):

• New Construction: Must comply with all requirements of Section .0300.
• Existing Facilities: Must meet requirements in effect at the time of construction, renovation, or alteration, but no less than the 1971 “Minimum and Desired Standards and Regulations.”
• Additions/Renovations: Must meet current technical requirements.
• Location and Safety (10A NCAC 13F .0303):
  • Zoning board approval is required.
  • Location must minimize hazards to residents.
  • Site must be accessible by roads and emergency services, with approved utilities.
  • Site must comply with local ordinances and be free from pollutants.

Design and Construction (10A NCAC 13F .0302):

• Building Codes: New facilities must meet the NC State Building Code for new construction, specifically I-2 Institutional Occupancy (13+ residents) or Large Residential Care Facilities (7-12 residents).
• Functionality: Facilities must be designed, constructed, equipped, and maintained to provide offered services.
• Conversions and Vacancies: Buildings converted from other uses or vacant for over a year must meet new facility requirements.
• Sanitation and Safety: Compliance with NC Division of Environmental Health rules, current sanitation, fire, and building safety inspection reports are mandatory.

Space and Environment (10A NCAC 13F .0305):

• Living/Recreation Areas: Minimum sizes based on capacity, windows required, located off lobby or corridor.
• Dining Room: Minimum sizes, windows, located off lobby or corridor.
• Bedrooms:
  • Capacity limits (max 2 residents per room).
  • Minimum square footage (100 sq ft single, 80 sq ft per bed double).
  • Located on outside wall, off corridor, not through other rooms.
  • Ventilation and lighting requirements, operable windows with screens.
  • Adequate closet/wardrobe space (min 48 cubic feet per resident).
• Bathrooms and Toilet Rooms:
  • Minimum ratios of toilets/lavatories and tubs/showers per residents.
  • Privacy partitions, hand grips, non-skid surfaces, water-resistant flooring.
  • Accessibility for handicapped residents as per NC State Building Code, Accessibility Code.
  • Mechanical ventilation and adequate lighting.
• Storage Rooms and Closets: General storage, linen storage, food storage, housekeeping storage (including locked areas for hazardous substances), handwashing facilities near drug storage, resident and staff personal article storage.
• Corridors: Handrails, night lights, unobstructed and clear of equipment.
• Entrances and Exits: Service entrances separate from resident areas, handrails and guardrails on steps/ramps, easily operable exit door locks, sounding devices on exit doors for homes with disoriented residents.
• Floors: Smooth, non-skid, easily cleanable, no scatter rugs, good repair.
• Soil Utility Room: Separate room for bedpan cleaning with handwashing facilities.
• Office: Area for administrative functions.
• Laundry Facilities: Adequate size, located to avoid soiled linen traffic through sensitive areas, residential washer/dryer provided.
• Outside Premises: Clean, safe, illuminated walkways and drives.

Housekeeping and Furnishings (10A NCAC 13F .0306):

• Cleanliness and Repair: Walls, ceilings, floors, furniture kept clean and in good repair. No unpleasant odors.
• Sanitation Ratings: DHHS approved sanitation classification (facilities ≤ 12 beds), scores ≥ 85 (facilities ≥ 13 beds).
• Supplies: Adequate bath soap, towels, linens, protective sheets, bedpans, commodes, walkers, wheelchairs available.
• Amenities: Television, radio, window coverings for privacy, recreational equipment, books, newspapers, clock, non-electric telephone.
• Bedroom Furnishings: Bed with appropriate mattress and linens, bedside table, chest of drawers/bureau, mirror, comfortable chair, lighting, towel bar.
• Living Room Furnishings: Functional, comfortable, easily cleanable.
• Dining Room Furnishings: Small tables, sturdy chairs for all residents.

Fire Safety Systems (10A NCAC 13F .0307 – .0309):

• Fire Alarm System: Automatically transmits signal to fire department, pull stations, audible alarms, smoke and heat detectors, emergency power.
• Fire Extinguishers: Minimum number and type (ABC) extinguishers required per floor area and in kitchen/maintenance areas.
• Evacuation Plan: Written plan approved by local Code Enforcement Official, posted, reviewed with residents and staff, quarterly rehearsals on each shift, records maintained, written disaster plan approved by local emergency management agency.

Electrical and Other Requirements (10A NCAC 13F .0310 – .0311):

• Electrical Outlets: Ground fault interrupters in wet locations.
• Maintenance: Building and equipment maintained in safe operating condition.
• Heating: Sufficient to maintain 75°F (24°C) in winter. Restrictions on heaters and cooking appliances for safety.
• Cooling: Air conditioning or fans when corridor temperature exceeds 80°F (26.7°C).
• Hot Water System: Adequate supply, temperature 100°F (38°C) min, 116°F (46.7°C) max at resident fixtures.
• Elevators: Required in multi-story facilities.
• Lighting: Minimum foot-candle power for reading, general lighting, and night corridors.
• Ventilation: Exhaust ventilation in soiled linen storage, soil utility room, bathrooms, housekeeping closets, laundry area (for newer facilities).
• Call System: Electrically operated call systems in resident bedrooms (to staff bedroom in 7-12 bed facilities, to staff station in newly licensed facilities without live-in staff).
• Signaling Devices: Hand bells or signaling devices for residents unable to evacuate without assistance in existing facilities.

Staff Qualifications and Training for NC Adult Care Homes

Section .0400 – Staff Qualifications and .0500 – Staff Orientation, Training, Competency and Continuing Education specify the necessary credentials and ongoing development for adult care home staff.

Staff Qualifications (Section .0400):

• Manager Qualifications (10A NCAC 13F .0402):
  • Minimum age 21.
  • High school graduate or GED (or alternative exam before Sept 1, 2024).
  • Six months management/supervision experience in long-term/healthcare or licensed health professional.
  • 12 hours annual continuing education in adult care home management or care of relevant populations.
• Medication Aide Qualifications (10A NCAC 13F .0403): Completion of training, clinical skills validation, and written exam as per G.S. 131D-4.5B. 6 hours annual continuing education in medication administration.
• Activity Director Qualifications (10A NCAC 13F .0404): High school graduate/GED (for hires after Sept 30, 2022). Completion of basic activity course within 9 months of hire (exemptions for licensed therapists, experienced professionals).
• Food Service Supervisor Qualifications (10A NCAC 13F .0405): Experienced in food service in commercial, healthcare, or congregate care settings, consults with dietitian/nutritionist as needed.
• Tuberculosis Test (10A NCAC 13F .0406): Administrator, staff, and live-in persons tested for TB upon employment/moving in, documented freedom from TB.
• Other Staff Qualifications (10A NCAC 13F .0407):
  • Job description signed by administrator and employee.
  • Ability to implement emergency procedures.
  • Maintain resident confidentiality.
  • Respect Resident’s Rights.
  • No findings on NC Health Care Personnel Registry.
  • Annual influenza immunization (documented).
  • Criminal background check (results on file).
  • Controlled substance screening (results on file).
  • Valid driver’s license (if transporting residents).
  • Cooperation with inspectors.
  • At least one staff member in charge of resident care (18+ years old) at all times.
  • RN availability if LPNs employed, per 21 NCAC 36 .0224 and 21 NCAC 36 .0225.
• Personal Care Aide Supervisor Qualifications (10A NCAC 13F .0408): (Facilities with 31+ residents) Minimum age 21, high school graduate/GED (or alternative exam before Sept 1, 2024), health requirements, 6 months relevant experience or licensed health professional, same training/competency as aides, 12 hours annual CE.

Staff Training and Competency (Section .0500):

• Personal Care Training and Competency (10A NCAC 13F .0501): 80-hour personal care training and competency program for staff providing personal care, completed within 6 months of hire (after Sept 30, 2022). Program includes observation/documentation skills, basic nursing, ADLs, cognitive/behavioral/social care, basic restorative services, resident’s rights. Exemptions for licensed professionals, Nurse Aide Registry listing, prior approved training programs.
• Medication Administration Competency (10A NCAC 13F .0503): Written exam (90% pass), clinical skills validation (by RN or pharmacist) in medication administration areas.
• Competency Evaluation for Licensed Health Professional Support Tasks (10A NCAC 13F .0504): Licensed health professional (RN, respiratory therapist, pharmacist, OT/PT) validates competency of non-licensed staff to perform delegated personal care tasks.
• Training on Care of Diabetic Residents (10A NCAC 13F .0505): Registered nurse, pharmacist, or prescribing practitioner provides training to unlicensed staff administering insulin, covering diabetes basics, insulin action/storage/administration, hypoglycemia/hyperglycemia management, blood glucose monitoring.
• Training on Physical Restraints (10A NCAC 13F .0506): RN-provided training on alternatives to restraints, restraint types, medical symptoms for restraint, negative outcomes, correct application, monitoring restrained residents, reducing restraint time.
• Training on CPR (10A NCAC 13F .0507): At least one staff member on premises at all times certified in CPR/choking management (American Heart Association, Red Cross, etc.), access to one-way valve pocket mask.
• Assessment Training (10A NCAC 13F .0508): Persons performing resident assessments must read and certify completion of Resident Assessment Self-Instructional Manual (RNs exempt).
• Food Service Orientation (10A NCAC 13F .0509): Food service supervisor and dietary staff complete food service orientation training within 30 days of hire (DHHS-established or equivalent). Licensed dietitians/nutritionists exempt.
• Documentation of Training (10A NCAC 13F .0512): Facility maintains documentation of staff training and competency validation, available for review.

Staffing Requirements for Adult Care Homes in NC

Section .0600 – Staffing details the required staffing levels and management responsibilities for adult care homes based on their resident census.

Management Responsibilities (Section .0600):

• General Administrator and Manager Responsibilities (10A NCAC 13F .0601):
  • Administrator responsible for total operation, compliance with all regulations, resident health/safety/welfare. Co-administrators share responsibility.
  • Manager responsible for day-to-day operations in administrator’s absence, under administrator’s direction.
  • Administrator must ensure investigation and reporting of abuse/neglect, drug diversion, elopements, incidents causing hospitalization/death.
  • Administrator must be informed of staffing shortages or law enforcement involvement.
  • Manager/staff to notify administrator of listed circumstances in facilities with 7-30 residents; manager/supervisor in facilities with 31+ residents.

Management and Staffing Levels Based on Census:

• 7-30 Residents (10A NCAC 13F .0602): Administrator or manager directly responsible, must be in facility or within 500 ft with 2-way communication at all times. Cluster facilities (≤12 residents each): one staff per facility, one administrator/manager within 500 ft of each.
• 31-80 Residents (10A NCAC 13F .0603): Administrator on-call, manager on-duty when administrator not on-duty. Supervisor may serve as manager.
• 81+ Residents (10A NCAC 13F .0604): Administrator on-duty at least 8 hrs/day, 5 days/week, not simultaneously supervisor/staff or administrator of another home (unless campus setting). Manager on-duty when administrator not on-duty. Administrator on-call at all other times.
• General Staffing Requirements (10A NCAC 13F .0605): Staffing based on census and resident needs. Residents never left alone. Daily census log maintained. Daily staffing information posted (administrator/manager contact, supervisors/aides per shift).
• 7-12 Residents Staffing (10A NCAC 13F .0606): Administrator/manager in facility or within 500 ft. Staff member on duty 1st/2nd shifts, staff available within building 3rd shift (call system to resident bedrooms). Awake staff 24/7 if disoriented/wandering residents. One staff member per shift for personal care/supervision (no food service during shift, limited housekeeping). Additional staff for housekeeping and food service. Cluster facility staffing outlined.
• 13-20 Residents Staffing (10A NCAC 13F .0607): Administrator/manager in facility or within 500 ft. Awake staff member on duty all shifts. One staff member per shift for personal care/supervision (no food service during shift, limited housekeeping). Additional staff for housekeeping and food service.
• 21+ Residents Staffing (10A NCAC 13F .0608): Staff to meet resident needs. Minimum aide duty hours per shift based on census (chart provided in rule). Aides primarily for personal care/supervision (limited housekeeping/food service). Additional staff for housekeeping and food service. Chart summarizes aide, supervisor, and management staffing requirements.
• Personal Care Aide Supervisors (10A NCAC 13F .0609): Supervisors responsible for direct supervision of aides, ensuring care quality and compliance. Supervisor duty hours per shift based on aide duty hours (chart provided in rule). Supervisors may perform limited aide duty under certain conditions. Supervisor cannot simultaneously serve as administrator but may serve as manager.

Resident Admission, Discharge, and Rights in NC Adult Care Homes

Sections .0700 – Admission and Discharge, .0909 Resident Rights, and related rules govern resident entry, exit, and protections within adult care homes.

Admission and Discharge (Section .0700):

• Admission of Residents (10A NCAC 13F .0701): Adults (18+) needing substitute home due to physical/mental conditions, services and accommodations must meet resident needs. Prohibited admissions: mental illness/substance abuse treatment, maternity care, continuous medical supervision, lodging only, individuals posing direct threat.
• Discharge of Residents (10A NCAC 13F .0702 – Effective April 1, 2024 version detailed here): Facility-initiated discharge conditions: resident welfare needs unmet, improved health, safety of others endangered, failure to pay. Notice requirements: Adult Care Home Notice of Discharge and Hearing Request Form hand-delivered to resident and responsible person, 30-day notice (exceptions for safety/urgent needs). Documentation of discharge reason required (physician documentation, safety endangerment details, payment warnings). Preparation and orientation for safe discharge required (DSS notification, explanation to resident/family, discharge destination info, material transfer to caregiver/facility). Appeal process outlined. Resident-initiated discharge: facility may require 14-day notice. Discharge requirements do not apply to temporary hospital transfers with bed hold policy.
• Tuberculosis Test, Medical Exam, Immunizations (10A NCAC 13F .0703): TB test upon admission, medical exam (FL-2 form) within 90 days prior or 72 hours post-emergency admission, annual medical exams thereafter. Pneumococcal and annual influenza immunizations required. Mental health evaluation within 30 days for residents with recent psychiatric hospitalization and no follow-up plan.
• Resident Contract, Facility Information, and Resident Register (10A NCAC 13F .0704): Provision and review of facility information (contract, house rules, Resident’s Rights, grievance procedures, civil rights compliance statement) upon admission. Resident Register (initial assessment form) completed within 72 hours of admission, updated information maintained.

Resident Rights (Section .0900):

• Resident Rights (10A NCAC 13F .0909): Adult care homes must ensure all Resident’s Rights under G.S. 131D-21 are maintained and exercised without hindrance.

Other Resident Care and Services (Section .0900):

• Personal Care and Supervision (10A NCAC 13F .0901): Staff provide personal care per care plans and attend to unmet needs, supervise residents per needs, and respond immediately to accidents/incidents.
• Health Care (10A NCAC 13F .0902): Care/services per care plan, referral/follow-up for routine/acute health needs, documentation of physician contacts/visits/orders/treatments. Resident choice of physician allowed.
• Licensed Health Professional Support (10A NCAC 13F .0903): Licensed health professional (RN, OT/PT, respiratory therapist) participates in on-site review/evaluation for residents needing specific personal care tasks (detailed list provided). Quarterly review and documentation required.
• Nutrition and Food Service (10A NCAC 13F .0904): Food procurement/safety per sanitation rules (15A NCAC 18A .1600 or .1300 depending on capacity), USDA-approved meat, 3-day perishable/5-day non-perishable food supply, proper food preparation/service temperatures, table service, feeding assistance, menus prepared weekly, substitutions documented, menus maintained, therapeutic diets planned/reviewed by dietitian, daily meals meeting USDA Dietary Guidelines, snacks, water at meals. Therapeutic diet orders in writing, supplement orders brand-specific.
• Activities Program (10A NCAC 13F .0905): Program designed to promote resident involvement, individual and group activities, monthly calendar posted, community resource involvement, program evaluation, encouragement of participation, activity supplies, 14+ hours/week of group activities (socialization, physical, creative, learning), opportunities for individual activities and outings, volunteer service opportunities.
• Other Resident Care and Services (10A NCAC 13F .0906): Transportation to resources/activities (no extra charge), prompt mail delivery (unopened unless authorized), uncensored outgoing mail, laundry services (no extra charge), private telephone access, personal lockable space, visiting hours (min 10 hrs/day), sign-out register, notification procedures for missing residents.
• Respite Care (10A NCAC 13F .0907): Temporary care for caregiver relief (max 30 days), subject to most rules except certain administrative/assessment rules, included in census, respite care contract required, FL-2 and TB test upon admission, assessment and short-term care plan. Respite care resident record requirements outlined. Emergency discharge conditions specified.

Medication Management in NC Adult Care Homes

Section .1000 – Medications outlines the stringent guidelines for medication management to ensure resident safety and proper administration.

• Medication Administration Policies and Procedures (10A NCAC 13F .1001): Written policies and procedures required, staff orientation to policies prior to medication administration, compliance with regulations (including NC Pharmacy Practice Act). Medications include herbal/non-herbal supplements.
• Medication Orders (10A NCAC 13F .1002): Verification/clarification of unclear/incomplete orders, maintenance of all medication orders in resident record, complete medication orders required (name, strength, dosage, route, directions, indication for PRN), verbal orders countersigned within 15 days, standing orders for individual residents only, physician review of orders every 6 months, specific requirements for PRN psychotropic medications (detailed instructions, exact dosage/time frames, max dosage). Annual staff training on psychotropic medications required.
• Medication Labels (10A NCAC 13F .1003): Detailed labeling requirements for prescription medications (resident name, date, prescriber, medication details, directions, expiration, pharmacy info). Labeling for multi-dose packaging specified. Procedures for direction changes. Non-prescription medications labeled with manufacturer’s label and resident name. No medication transfers between containers.
• Medication Administration (10A NCAC 13F .1004): Administration per physician orders and facility policies, only qualified staff administer medications, limited advance preparation of oral solids (within 24 hours), liquids/injectables prepared immediately before administration, crushing medications immediately before administration, detailed procedures for advance preparation to maintain identification and prevent contamination, administration within 1 hour of scheduled time, documentation of medication preparation and administration, accurate MAR (resident name, med details, directions, PRN reason, date/time, omissions, administrator initials), resident identification prior to administration, medication error/adverse reaction policies (notification, action, documentation), medication administration supplies available, infection control measures, no resident-to-resident medication transfer (except emergency, documented), limited medication routes for non-licensed staff (oral, topical, inhalant, rectal, vaginal, subcutaneous injections, gastrostomy tube, nebulizers), specific training required for insulin/subcutaneous injections.
• Self-Administration of Medications (10A NCAC 13F .1005): Allowed for competent/able residents with physician order and labeled prescription instructions. Physician notification required for changes in ability/non-compliance.
• Medication Storage (10A NCAC 13F .1006): Self-administered meds safely stored in resident room per policy, facility-stored meds under lock except during administration, clean/ventilated/well-lit medication storage area (not bathroom/kitchen/utility), locked storage accessible only to authorized staff, topical/external meds stored separately from oral/injectable meds (exceptions for ophthalmic/otic/transdermal), refrigerated meds stored 36-46°F, no non-medication items in medication refrigerator (unless separate locked container), stock non-prescription/certain prescription meds allowed, first aid supplies separate from medications, out of resident/visitor sight.
• Medication Disposition (10A NCAC 13F .1007): Medications released to resident upon discharge with physician order, expired/discontinued/deteriorated meds stored separately, non-controlled meds destroyed at facility or returned to pharmacy within 90 days, facility destruction witnessed by pharmacist/practitioner/designee, destruction records maintained (resident/med details, amount, method, signatures), contaminated/unadministered doses destroyed at facility.
• Controlled Substances (10A NCAC 13F .1008): Detailed records of receipt/administration/disposition, maintained for reconciliation, Schedule II meds under double lock if stored together, expired/discontinued controlled substances returned to pharmacy within 90 days (documented), facility destruction of controlled substances (witnessed, documented), destruction records maintained 3 years, secure storage for expired/discontinued controlled substances, contaminated/unadministered controlled substances destroyed at facility (documented on MAR/controlled substance record), drug diversion reporting to pharmacy/law enforcement/Health Care Personnel Registry.
• Pharmaceutical Care (10A NCAC 13F .1009): Quarterly pharmaceutical care services from licensed pharmacist/practitioner, including resident medication reviews (record review, side effect monitoring, recommendation, documentation), medication administration review, medication system review, medication disposition review, written report to facility/physician, in-service programs for staff (medication problems, new meds, side effects, policies). Facility action in response to reviews documented.
• Pharmaceutical Services (10A NCAC 13F .1010): Resident choice of pharmacy allowed if pharmacy meets requirements, written agreement with pharmacist/practitioner for pharmaceutical care, provision of pharmaceutical services (ordering, receiving, administering meds), procedures for resident leave of absence medications (sufficient quantity, instructions, labeled containers, documentation of release/return), accurate medication records maintained, written agreement with pharmacy provider for dispensing services (facilities ≥ 12 beds).

Resident Funds, Policies, Records, and Special Care Units

This section covers financial management, record keeping, policies, and specific regulations for special care units.

Resident Funds and Refunds (Section .1100):

• Management of Resident Funds (10A NCAC 13F .1101): Residents manage own funds if possible, legal representative/payee designated if unable, residents endorse checks unless authorized representative. Facility staff (except administrator as federal payee) cannot serve as authorized representative/payee/executor. Receipts for monies received on resident behalf required.
• Refund Policy (10A NCAC 13F .1102): Written refund policy signed by administrator, copy given to resident/responsible person, copy in resident record.
• Authorized Representative (10A NCAC 13F .1103): Contact responsible person/DSS for authorized representative if resident unable to manage funds. Administrator/staff cannot serve as representative/payee/executor (federal payee exception). Receipts for monies received required.
• Accounting for Resident’s Personal Funds (10A NCAC 13F .1104): Statement documenting receipt of personal needs allowance (resident/witness signature), administrator/designee handles funds with written authorization, accurate account balance/accounting provided, monthly written accounting to resident/representative (signature of receipt), no commingling of funds, resident fund access on request, personal needs allowance credited within one business day.
• Refund of Personal Funds (10A NCAC 13F .1105): Balance given to resident/responsible person within 14 days of leaving, to estate administrator/Clerk of Court within 30 days of death.
• Settlement of Cost of Care (10A NCAC 13F .1106): Refund policies for facility-initiated discharge (pro-rata refund), resident leaving without notice (charge for notice period, refund balance), exceptions for safety/facility closure (charge for nights spent, refund balance), resident leaving with notice (refund balance), bed hold policies (written agreement, refund policies for non-return). Refund within 14 days (30 days post-death).

Policies, Records, and Reports (Section .1200):

• Resident Records (10A NCAC 13F .1201): Detailed list of records to be maintained for each resident (FL-2, Resident Register, contract/house rules/rights receipts, care plan, physician contacts/orders, immunization records, discharge notices), financial records maintained (may be centralized in cluster facilities).
• Disposal of Resident Records (10A NCAC 13F .1202): Records filed for 1 year post-discharge/death, then stored for 2 more years.
• Health Care Personnel Registry (10A NCAC 13F .1205): Compliance with G.S. 131E-256 and 10A NCAC 13O .0101/.0102.
• Marketing (10A NCAC 13F .1206): Use licensed name, market only licensed services, disclose licensure status.
• Facilities to Report Resident Deaths (10A NCAC 13F .1207): Report deaths per G.S. 131D-34.1.
• Death Reporting Requirements (10A NCAC 13F .1208): Immediate written notice for deaths within 7 days of restraint or 24 hours of hospital transfer post-restraint, 3-day notice for deaths from violence/accident/suicide/homicide. Detailed information required in notice (facility/resident/death circumstances, other notifications). Written report form required. Notification of Division, law enforcement/medical examiner for deaths under medical examiner jurisdiction. Notification of next-of-kin for autopsy options.
• Definitions Applicable to Death Reporting (10A NCAC 13F .1209): Definitions of “accident,” “immediately,” and “violence.”
• Record of Staff Qualifications (10A NCAC 13F .1210): Staff qualification records maintained (may be centralized in cluster facilities).
• Written Policies and Procedures (10A NCAC 13F .1211): Policies and procedures required for medications, restraints, emergency procedures, infection control, refunds, missing residents, wandering residents, aggression management, grievances, visitation, smoking/alcohol. Staff training on listed policies within 30 days of hire and annually. Policies available to staff.
• Reporting of Accidents and Incidents (10A NCAC 13F .1212): County DSS notification for resident death or injury requiring emergency care/hospitalization/medical treatment. Written report to DSS within 48 hours (resident/incident details, actions taken). Immediate DSS/law enforcement notification for abuse/neglect/exploitation. Responsible person/contact person notification for injuries/illnesses/falls/elopements (timeframes specified). Law enforcement notification for resident violence risk. Procedures for physical assault by resident/resident violence risk (law enforcement assistance, supervision, medical care, mental health referral). Law enforcement report for assaults causing harm.
• Availability of Corrective Action and Survey Reports (10A NCAC 13F .1213): Recent annual/biennial and subsequent survey reports, other DHSR reports (past 12 months), county DSS corrective action reports (past 12 months) must be available to residents/families in accessible location.

Special Care Units for Alzheimer’s and Related Disorders (Section .1300):

• Definitions Applicable to Special Care Units (10A NCAC 13F .1301): Definitions of Alzheimer’s Disease, related disorders, special care unit, care coordinator.
• Special Care Unit Disclosure (10A NCAC 13F .1302): Only compliant facilities may advertise special care units. Disclosure required per G.S. 131D-8 and Rule .1305 policies/procedures.
• Licensure of Facilities with Special Care Units (10A NCAC 13F .1303): Facilities meeting requirements licensed as adult care home with special care unit indication on license.
• Special Care Unit Building Requirements (10A NCAC 13F .1304): Beyond general building codes: Construction Section plan review, physical separation from rest of facility by closed doors, exit door locking devices compliant with NC Building Code, security monitoring if exit doors unlocked, unit location avoiding routine traffic through unit, service/storage areas within unit (staff work, nourishment station, medication storage, records storage), living/dining space (30 sq ft/resident), secured outside access, toilet/lavatory ratio (1:5), tub/shower in unit, minimized distracting noises.
• Special Care Unit Policies and Procedures (10A NCAC 13F .1305): Policies addressing philosophy (safe/secure/consistent environment, structured lifestyle, individualized care plans, behavior management), admission/discharge process, special care services description, resident assessment/care planning (family involvement), safety measures (wandering, ingestion, falls, aggression), staffing, staff training, physical environment design, activity plans, family involvement/support programs, additional costs/fees.
• Admission to the Special Care Unit (10A NCAC 13F .1306): Physician diagnosis on FL-2 meeting unit’s population criteria, pre-admission screening, disclosure information to family (G.S. 131D-8 and Rule .1305 policies).
• Special Care Unit Resident Profile and Care Plan (10A NCAC 13F .1307): Written resident profile within 30 days/quarterly (behavioral patterns, self-help, ADLs, management needs, physical/cognitive status), care plan based on profile (environmental/social/health care strategies to maximize function).
• Special Care Unit Staffing (10A NCAC 13F .1308): Sufficient staff in unit at all times, minimum staffing ratios (1 staff per 8 residents 1st/2nd shift + 1 hr staff time/additional resident, 1 staff per 10 residents 3rd shift + .8 hrs staff time/additional resident), care coordinator on duty 8 hrs/day, 5 days/week (may be counted in staffing for ≤15 resident units, additional care coordinator required for ≥16 resident units and freestanding units).
• Special Care Unit Staff Orientation and Training (10A NCAC 13F .1309): Administrator 20 hrs training specific to unit population before unit establishment, staff 6 hrs orientation within first week, staff 20 hrs training within 6 months (plus general training), annual CE (6 hrs dementia-specific).
• Other Applicable Rules for Special Care Units (10A NCAC 13F .1310): Special care units must also meet all other applicable adult care home rules.

Use of Physical Restraints and Alternatives (Section .1500):

• Use of Physical Restraints and Alternatives (10A NCAC 13F .1501): Restraints only for medical symptoms warranting use (not discipline/convenience), physician order required (except emergency), least restrictive restraint, alternatives tried and documented, assessment/care planning prior to use (except emergency), correct application, use in conjunction with alternatives. Resident/representative informed consent for restraint use required. Detailed assessment and care planning process involving team (supervisor, RN, resident, family). Restraint order requirements (medical need, type, duration, check/release intervals). Documentation of restraint use (alternatives, type, medical symptoms, time/duration, care provided, resident behavior). Restraints applied only by trained/validated staff.

Star Rated Certificates (Section .1600):

• Definitions (10A NCAC 13F .1601): Definitions of demerits, merits, standard deficiency, star rated certificate, star rating, star rating worksheet, Type A1/A2/B violations.
• Issuance of a Star Rating (10A NCAC 13F .1602): Certificate/worksheet issued within 45 days of survey report mailing (or 15 days post-IDR decision), rating remains with facility ownership change until next survey, certificate/worksheet publicly displayed, worksheet posted online, facility right to contest rating.
• Statutory and Rule Requirements Affecting Star Rated Certificates (10A NCAC 13F .1603): List of regulations included in star rating assessment (Resident Rights, Physical Plant, Staff Qualifications, Admission/Discharge, Assessment/Care Plan, Resident Care/Services, Medications, Alzheimer’s Units, Restraints, Infection Control).
• Rating Calculation (10A NCAC 13F .1604): 100-point scale, merit/demerit points added/subtracted. Merit points for correcting deficiencies/violations, removing suspensions/provisional licenses, quality improvement participation, resident/family councils, staff infection control training, generator installation/contract, sprinkler system installation, resident/family satisfaction surveys. Demerit points for deficiencies/violations (standard, Type A1/A2/B), admissions suspensions, provisional licenses, license revocation/summary suspension. Star rating assignment based on score (4 stars: 100+ points on 2 consecutive surveys, 3 stars: 90-99.9 or 100+ on one survey, 2 stars: 80-89.9, 1 star: 70-79.9, 0 stars: <70).
• Contents of Star Rated Certificate (10A NCAC 13F .1605): Star rating, worksheet breakdown of merits/demerits, DHSR issuance.

Administrator Certification and Renewal (Section .1700):

• Certification of Administrator (10A NCAC 13F .1701): Administrators of facilities licensed after Jan 1, 2000, must be certified by the Department.
• Adverse Action on Certification (10A NCAC 13F .1702): Denial/suspension/revocation reasons (lack of CE, felony/misdemeanor convictions, prior facility license revocation/suspension, inability to perform duties, drug test failure, Health Care Personnel Registry finding, failure to report arrests/convictions). Suspension for alleged criminal conduct related to administrator duties.
• Renewal of Administrator Certification (10A NCAC 13F .1703): Annual renewal first year (prorated CE), biennial renewal thereafter (30 hrs CE, $30 fee). CE coursework examples provided (financial/HR management, medications, dementia/diabetes care, behavior management, infection control).

Infection Prevention and Control (Section .1800):

• Infection Prevention and Control Policies and Procedures (10A NCAC 13F .1801): Policies/procedures consistent with CDC guidelines, DHHS-approved policies available online, facility options (use DHHS-approved, develop consistent policies, develop policies based on national standards consistent with CDC). Policy content requirements: standard/transmission-based precautions (respiratory hygiene, cleaning, equipment reprocessing, hand hygiene, PPE, transmission types), reporting communicable diseases to local health department, outbreak measures (isolation, activity/dining limitations, visitation limits, screening, source control), staffing strategies during outbreaks. Implementation of policies and DHHS/local health department guidance during outbreaks/emerging threats. Staff training (within 30 days of hire and annually) on policies. Policies maintained and accessible in facility.
• Reporting and Notification of a Suspected or Confirmed Communicable Disease Outbreak (10A NCAC 13F .1802): Reporting communicable diseases per 10A NCAC 41A .0101/.0102. Resident/representative/staff notification within 24 hours of local health department confirmation (no personally identifiable information, measures taken by facility, resident measures to reduce spread). Bi-weekly updates until outbreak resolution, final update upon resolution.

This guide provides a comprehensive overview of the key regulations and licensing requirements for adult care homes in North Carolina, derived from the official administrative code. For complete and up-to-date information, always refer to the official North Carolina Administrative Code and consult with legal counsel specializing in healthcare regulations. While this guide aims to be informative, it is not a substitute for professional legal advice or the official “Adult Care Home Program Manual Nc” if one exists as a separate document beyond these regulations.