Fillable LIST OF REQUIRED MATERIALS FOR INITIAL AND CHANGE (North Carolina)

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LIST OF REQUIRED MATERIALS FOR INITIAL AND CHANGE (North Carolina)

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ROY COOPER
• Governor
MANDY COHEN, MD, MPH
• Secretary
MARK PAYNE
• Director, Division of Health Service Regulation
Page 1 of 2
10/28/2021
LIST OF REQUIRED MATERIALS FOR INITIAL AND CHANGE LICENSURE
Below is a list of materials that are required and must be reviewed by the Mental Health Licensure
Certification Section (MHLC) before a facility is licensed. Fillable Check-sheet
The amount of time it takes to process an application weighs heavily if the licensee is prepared and has all the
necessary material completed for the application process. Therefore, MHLC allows an applicant six months for
licensure. For day programs, six months from the date an application is received. For residential programs, six
months from the date approved from the Construction Section.
Policy and Procedures
Mental Health Licensure requires the licensee to submit their policies and procedures manual
MH Licensure
Policies and Procedures Worksheet must be compl
eted and attached to
with P&P. (The
worksheet is not a substitution for the rules. The licensee is responsible for complying with all applicable
rules and statutes. The information below is only a snapshot of the actual regulations and is not a
substitute for obtaining a licensure rule book)
Personnel Records
This includes All personnel working at the facility and with clients. Direct Care, Qualified Professionals, Licensed
Professionals all staff)
Staff's Name and Date of Hire
A signed Job Description
The Qualified Professional's (QP) and Staff resume or application must be submitted
Verification of Education (Must be official transcripts or diploma)
Licensed Professionals credentials as applicable
Health Care Personnel Registry Verification checks (including the Licensee) Must be completed within
90 days of licensure review
*State/National criminal check documentation
Criminal Check(s) must be completed within 180 days of initial licensure review
CPR Heimlich Maneuver or equivalent. Will not accept if a course if training is online only
First Aid Training
Physical and Tuberculosis Screening (per agency policy)
General organization orientation (organization of agency) training
Training in client rights
Training in confidentiality
Training to meet the needs of the population served - based on licensure category (MH/DD/SAS needs)
Training in seizure management
Medication Administration Training (RN, pharmacist or legally qualified person and privileged to administer medications)
Training in infectious Diseases and Bloodborne Pathogens
Training in Alternatives to Restrictive interventions
Training in Seclusion, Physical Restraint and isolation Time Out
ROY COOPER
• Governor
MANDY COHEN, MD, MPH
• Secretary
MARK PAYNE
• Director, Division of Health Service Regulation
Page 2 of 2
10/28/2021
Training Curriculums
Bloodborne Pathogens curriculum
Client Rights curriculum
Confidentiality curriculum
Medication Administration curriculum (if applicable)
General Orientation curriculum
Seizure Management curriculum
Training to meet the needs of the population served - based on licensure category curriculum
Instructor Credentials for staff training
Medication Administration (RN, pharmacist or legally qualified person and privileged to prepare and administer medications)
CPR
First Aid
Restrictive Interventions
Disaster Plan
Written Disaster Plan *
The applicant must include documentation verifying the local county emergency management
services reviewed the plan
Additional Documents
Appropriate Building Code documentation for facility
For 24-hour facilities: Facility Rules (house rules) about clients' rights (i.e., making & receiving phone
calls; receiving visitors; being outdoors, exercise; personal clothing; religious worship; driver's license;
individual storage space; vocational training; access to own money)
For DUAL SERVICES ONLY
Days & hours of operation for each service
The location of each service will be provided (i.e., offices/ conference rooms)
Flow sheet documenting the set up of a client record (see requirements below)
Identification Face Sheet
Emergency Information Sheet
Consent for Treatment/Client Rights
Assessment/Treatment Plan
Progress Notes
Medication Orders/Lab Test (if applicable)
*For applicants trying to contact the "local authority," North Carolina's Division of Emergency Management has a list of phone
numbers for each county's Emergency Management(EM) office on their web site: https://www.ncdps.gov/emergency-
management/em-community/directories/counties
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LIST OF REQUIRED MATERIALS FOR INITIAL AND CHANGE (North Carolina)

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Completed 4 January 2022

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