Licensure Terms

Assisted Living Residences

General Approach

The term assisted living residences (ALRs) covers two types of long-term residential care settings: (1) adult care homes (ACHs); and (2) multi-unit assisted housing with services facilities. 

The North Carolina Division of Health Service Regulation licenses ACHs based on size–family care homes for 2-6 residents and ACHs for seven or more residents. Both can choose to serve only elderly persons (55 years or older or any adult who has a primary diagnosis of Alzheimer’s disease or other form of dementia) and the license indicates that this is the population to be served. Facilities may provide respite services, but provision of this service is not a condition for licensure.

Multi-unit assisted housing with services settings are not licensed. They are only required to register with the Division of Health Service Regulation and to provide a disclosure statement.

Adult Foster Care. The state licenses ACHs located in private residences serving 2-6 residents–called family care homes. With the exception of building and staff requirements, the regulations for family care homes with fewer than seven residents and ACHs with seven or more residents are materially the same. Distinct regulatory provisions for family care homes are not included in this profile but a link to the provisions can found at the end.

The information in this profile, unless it specifically references multi-unit assisted housing with services facilities, applies to licensed ACHs with seven or more residents. This profile includes summaries of selected regulatory provisions. The complete regulations are online at the links provided at the end.

Definitions

Assisted living residence means any group housing and services program for two or more adults, by whatever name it is called, which makes available, at a minimum, one meal per day and housekeeping services, and provides personal care services directly or through a formal written agreement with one or more licensed home care or hospice agencies. The Department may allow the provision of nursing services to be provided on a case-by-case basis. Settings in which services are delivered may include self-contained apartment units or single or shared room units with private or shared bathrooms.

Adult care home means a type of ALR in which the housing management provides 24-hour scheduled and unscheduled personal care services to seven or more residents, either directly or through formal written agreement with licensed home care or hospice agencies. Some licensed ACHs provide supervision to persons with cognitive impairments whose decisions, if made independently, may jeopardize the safety or well- being of themselves or others and therefore require supervision. Medication in an ACH may be administered by designated, trained staff.

Multi-unit assisted housing with services means an ALR in which hands-on personal care services and nursing services, which are arranged by housing management, are provided by a licensed home care or hospice agency through an individualized written care plan. The housing management has a financial interest or financial affiliation or formal written agreement that makes personal care services accessible and available through at least one licensed home care or hospice agency. The resident may choose any provider for personal care and nursing services and the housing management may not combine charges for housing and personal care services.

Resident Agreements

ACHs must provide specific information in writing to a resident upon move-in, including house rules and facility policies, discharge criteria, residents’ rights, and grievance procedures; and specific information in the resident contract, including accommodation and service rates, and rate change and refund policies.

An ACH with a special care unit (SCU) for individuals with Alzheimer’s disease or other dementias must provide information about the unit’s policies and procedures for caring for the residents and the special services that are provided.

Disclosure Provisions

Adult care homes that market themselves as providing an SCU for persons with dementia must have a license indicating the number of SCU beds in the home, and provide written disclosure statements, which must be approved by the state. The content of the written disclosure statements must include, but is not limited to: the process and criteria for admission and discharge; the assessment and service planning and implementation process; staffing ratios; dementia-specific staff training; physical environment and design features that specifically address the needs of residents with dementia; frequency and type of programs and activities; involvement of families in resident care, and availability of family support programs; and additional costs and fees for special care.

Multi-unit assisted housing with services programs are required to provide a disclosure statement as part of the annual rental contract. The statement must be approved by the state and include a description of the following: emergency response system, service charges, service and tenancy limitations, resident responsibilities, the financial/legal relationship between housing management and home care or hospice agencies, a listing of all home care or hospice agencies and other community services in the area, an appeals process, and procedures for required initial and annual resident screening and referrals for services.

Admission and Retention Policy

Adult care homes may not admit or retain residents who meet the state’s eligibility criteria for nursing home care, or individuals with the following conditions or treatment needs: mental illness or alcohol or drug abuse, maternity care, the absence of a need for personal assistance and supervision, posing a direct threat to the health or safety of others, and individuals whose physician certifies placement as no longer appropriate.

Except when a physician certifies that appropriate care can be provided on a temporary basis to meet the resident’s needs and prevent unnecessary relocation, ACHs must not care for individuals with any of the following conditions or care needs: (1) ventilator dependency; (2) a need for continuous licensed nursing care; (3) health needs that cannot be met in the specific ACH as determined by the residence; and (4) other medical and functional care that cannot be properly met in an ACH. 

Residents may be discharged only for the following reasons: for their welfare, the facility determines that it cannot meet the resident’s needs, the resident no longer needs the services provided by the facility, the health or safety of other individuals in the facility is endangered, or discharge is mandated under other rules. All health reasons for discharge must be documented by a physician, physician’s assistant, or nurse practitioner.

Multi-Unit Assisted Housing with Services. All residents, or their representatives, must be capable, through informed consent, of entering into a contract and must not be in need of 24-hour supervision. Except when a physician certifies that appropriate care can be provided on a temporary basis to meet the resident’s needs and prevent unnecessary relocation, providers must not admit or retain individuals with major medical conditions or needs, including: (1) ventilator dependency; (2) Stage III and IV dermal ulcers (except Stage III ulcers that are healing); (3) intravenous therapy or injections; (4) communicable airborne disease requiring isolation or special precautions; (5) continuous licensed nursing care; or (6) total dependency in four or more of the seven activities of daily living (ADLs).

Services

Adult care homes must provide 24-hour staff monitoring and supervision, and assistance with scheduled and unscheduled personal needs, as well as transportation, activities, and housekeeping services. ACHs may provide personal care directly or through contracts, and may provide some specified health care services while licensed home care agencies provide other health care services that unlicensed staff cannot perform. 

Nursing services may be provided by the ACH on a case-by-case exception basis approved by the Department of Health and Human Services (DHHS), or through licensed home care agencies. Residents have the right to obtain services from providers other than the housing management, at their own cost. 

Multi-unit assisted housing with services facilities coordinate personal and health care services through licensed home care agencies.

Service Planning 

Adult care homes must assess each resident within72 hours of admission using a state-provided or approved form, and complete a functional assessment of each resident within 30 days after admission, and at least annually thereafter, using a state- provided or approved assessment instrument. The assessment is used to determine residents’ functional level, and includes measures of psychosocial well-being, cognitive status, and ADLs. Reassessments must be completed within 10 days following a significant change in a resident’s condition.

The person or persons designated by the administrator to perform resident assessments must successfully complete resident assessment training established by the DHHS before performing the required assessments. Registered nurses (RNs) are exempt from the assessment training requirement. 

The facility must complete a care plan based upon the resident’s assessment within 30 days following admission. The care plan is an individualized written program of personal care for each resident and must include a statement of the care or service to be provided based on the assessment or reassessment, as well as the frequency of service provision.

Assessments and care plans are reviewed during oversight visits to determine whether residents are appropriate for the facility, whether the assessment was appropriately done, whether the plan of care is appropriate, and whether the facility has the capacity to meet the residents’ needs.

Prior to admission, facilities must evaluate the appropriateness of an individual’s placement in an SCU. Within 30 days of admission to the SCU and quarterly thereafter, the facility must develop a written resident profile containing assessment data that describes the resident’s behavioral patterns, self-help abilities, level of daily living skills, special management needs, physical abilities and disabilities, and degree of cognitive impairment.

Multi-unit assisted housing with services facilities must screen prospective residents to determine if they need an in-depth assessment by a licensed home care agency, and if the facility has the capacity and legal authority to meet the prospective resident’s needs.

Third-Party Providers

In all licensed settings, a resident may request hospice and home health care, provided with appropriate physician orders. 

In multi-unit assisted housing with services facilities, personal care and nursing services are provided through licensed agencies. Facilities must have an arrangement with at least one licensed agency to meet the scheduled needs of residents, but residents may choose any agency to provide services.

Medication Provisions

Adult Care Homes. The facility must provide orientation to medication policies and procedures for staff responsible for medication administration prior to their administering or supervising the administration of medications.

Residents are permitted to self-administer medications as long as they are competent, physically able to do so, and have a physician’s order to do so. In addition, specific instructions for administering medications must be written on the medication label. 

Competency validation by an RN is required for unlicensed staff who perform any tasks related to medication administration. ACH staff who administer medications– called medication aides–and staff who directly supervise medication administration must successfully complete the clinical skills validation portion of the state’s competency evaluation prior to providing medication administration or supervision of same. 

Medication aides and their direct supervisors, except persons authorized by state occupational licensure laws to administer medications, must score at least 90 percent on the written standardized state examination within 90 days after successful completion of the clinical skills validation portion of the competency evaluation, and must complete 6 hours of continuing education related to medication administration annually.

A licensed pharmacist, prescribing practitioner, or RN must review at least quarterly each resident’s medications and the facility’s medication policies and procedures, or more frequently as required by the Department based on documentation of specific medication problems in the facility.

ACHs must ensure that training on the care of residents with diabetes is provided to unlicensed staff prior to the administration of insulin. The training must be provided by an RN, registered pharmacist, or prescribing practitioner and must cover a number of topics, including blood glucose monitoring; sliding scale insulin administration; insulin action; and mixing, measuring, and injection techniques for insulin administration.

Multi-Unit Assisted Housing with Services. Assistance with self-administration of medications may be provided by appropriately trained staff when delegated by a licensed nurse according to the home care agency’s established plan of care.

Food Service and Dietary Provisions

ACHs must provide three meals and three snacks a day (with at least 10 hours between the breakfast and evening meals), and modified or therapeutic diets when ordered by a physician. Menus for modified and therapeutic diets must be planned or reviewed by a registered dietician. Sufficient staff must be available for individual feeding assistance as needed.

Staffing Requirements

Type of Staff. At all times there must be one administrator or supervisor/administrator-in-charge who is directly responsible for ensuring that all required duties are carried out and that residents are never left alone. ACHs must also have a designated activity director.

On first and second shifts in facilities with a capacity or census of 31 or more residents and on the third shift in facilities with a capacity or census of 91 or more residents, the facility must have at least one supervisor of personal care aides (PCAs). This supervisor must not serve simultaneously as the administrator but may serve simultaneously as the administrator-in-charge in the absence of the administrator.

Facilities must ensure that an appropriate licensed health professional participates in the on-site review and evaluation of residents’ health status, care plan, and care provided for health or health-related tasks, such as bowel and bladder training and feeding techniques for residents with swallowing problems.

Each ACH must have at least one staff person on the premises at all times who has completed within the last 24 months a course on cardiopulmonary resuscitation and choking management, including the Heimlich maneuver.

Staff Ratios. The regulations include very detailed staffing requirements that vary by facility size and shift. Facilities serving 20-30 residents must have 16 hours of PCA time on the first and second shifts, and 8 hours on the third shift. The amount of PCA hours increases with the size of the facility and reaches 96 hours for facilities with 131- 140 residents.

Training Requirements

ACH administrators must complete 30 hours of continuing education every 2 years. Administrators-in-charge and supervisors-in-charge must complete 12 hours of continuing education per year.

Staff who directly provide personal care or who directly supervise those who do, must complete an 80-hour personal care training and competency evaluation program established by the state. Licensed health professionals, staff listed on the Nurse Aide Registry, or staff who document completion of a 40-45 hour or 75-80 hour training program or competency evaluation program are exempt from this training requirement.

The 80-hour training program includes at least 34 hours of classroom instruction and 34 hours of supervised practical experience. The competency evaluation includes observation and documentation; basic nursing skills, including special health-related tasks; personal care skills; cognitive and behavioral skills, including interventions for individuals with mental disabilities; basic restorative services; and resident’s rights.

Experienced staff may take the competency exam without undergoing training. 

Facilities must ensure that non-licensed and licensed personnel not practicing in their licensed capacity complete a one-time competency evaluation for specific personal care tasks (specified in regulation) before performing these tasks. The regulations have additional training requirements for ACHs that serve residents with specific conditions, such as diabetes and the need for restraints.

Provisions for Apartments and Private Units

Apartment-style units and private rooms are not required. In ACHs licensed after July 1, 2004, a bedroom may not be occupied by more than two residents. If licensed prior to that date, a bedroom may not be occupied by more than four residents. Bathroom and toilet facilities are shared with a minimum of one toilet and sink for every five residents and a tub or shower for every ten residents.

Provisions for Serving Persons with Dementia

Dementia Care Staff. At least one staff person is required for every eight residents on the first and second shift, plus 1 hour of staff time for each additional resident; and one staff person for every ten residents on the third shift, plus 0.8 hour of staff time for each additional resident. A care coordinator must be on-duty in the SCU at least 8 hours a day, 5 days a week. The care coordinator may be counted in the minimal staffing requirements. In SCUs with more than 16 units, the care coordinator is not counted in determining the minimal staffing requirement. 

Dementia Staff Training. Prior to establishing an SCU, the administrator must document receipt of at least 20 hours of training specific to the population to be served for each SCU to be operated, and must have in place a plan to train other staff assigned to the unit.

Within the first week of employment, each employee assigned to perform duties in the SCU must complete 6 hours of orientation about residents’ needs. Within 6 months of employment, staff responsible for personal care and supervision within the unit must complete 20 hours of training specific to the population being served, in addition to other specified orientation and training requirements. 

Dementia Facility Requirements. Private units are not required. A toilet and sink must be provided within the SCU for every five residents and a tub and shower for bathing must be in the unit. Facilities must provide direct access to a secured outside area and avoid or minimize the use of potentially distracting mechanical noises. Unit exit doors may be locked only if the locking devices meet the requirements outlined in the state building code for special locking devices. If exit doors are not locked, facilities must have a system of security monitoring.

Background Checks

All employees in all licensed facilities must have a criminal background check and must also have no findings of abuse or neglect listed on the North Carolina Health Care Personnel Registry. Administrators of ACHs must have a criminal background fingerprint check. A criminal background check is not required for licensees.

Inspection and Monitoring

All licensed facilities are subject to inspections at all times and are inspected on an annual basis. County Departments of Social Services monitor ACHs at least quarterly, investigate complaints, and accompany the state inspection teams for annual surveys. State staff provide consultation, technical assistance, and training to the county monitors; oversee monitoring by county staff; and perform annual surveys and licensing surveys of all ACHs, including follow-up surveys as needed. County staff are included on these surveys.

Every county with at least one licensed ACH has a community advisory committee that works with each home to ensure residents’ best interests. The committee’s purpose is to promote community involvement and cooperation with ACHs to ensure quality care for the elderly and disabled adults residing there. The state has a Star Rating program that was designed to be a tool to assist consumers in making informed decisions regarding care options for themselves or a loved one. The program provides consumers with information based on facility inspections by the licensing agency.

Public Financing

The Medicaid State Plan pays for personal care provided to eligible residents in ACHs.

Room and Board Policy 

In 2014, the maximum state/county special assistance payment for room and board in ACHs was $1,162 a month, including a $46 personal needs allowance and a $20 income disregard. The maximum payment for a resident in a SCU was $1,575 a month. The state/county assistance payment is a supplemental benefit standard that is based on the federal Supplemental Security Income payment and any other sources of income according to established eligibility requirements. 

Family supplementation to pay for a private room is permitted when the resident or family members request one.

Location of Licensing, Certification, or Other Requirements

North Carolina Administrative Code, Chapter 10A, Subchapter 13F: Licensing of Homes for the Aged and Infirm.

http://reports.oah.state.nc.us/ncac/title%2010a%20-%20health%20and%20human%20services/chapter%2013%20-%20nc%20medical%20care%20commission/subchapter%20f/subchapter%20f%20rules.html

North Carolina Division of Health Service Regulation, Adult Care Licensure Section: Legal Requirements for Registration and Disclosure for Multi-unit Assisted Housing with Services. http://www.ncdhhs.gov/dhsr/acls/multiunitlegal.html

North Carolina Administrative Code, Chapter 10A, Subchapter 13G: Licensing of Family Care Homes.

http://reports.oah.state.nc.us/ncac/title%2010a%20-%20health%20and%20human%20services/chapter%2013%20-%20nc%20medical%20care%20commission/subchapter%20g/subchapter%20g%20rules.html

Information Sources

Doug Barrick
Department of Health and Human Services
Division of Health Service Regulation