Mental Health Licensure and Certification Section
1
Polic
y and Procedure list 10/14/2021
Mental Health Licensure Policies and
Procedures Worksheets
Use of form:
Mental Health Licensure requires the licensee to develop written policies and procedures. Therefore, policies and procedures must
be submitted to the Licensure and Training Consultant at the first review.
Instructions:
1. Use the policy worksheet to identify the page number you address each point for ease in reference and review.
2. Policy and procedure manuals must include a table of contents with page numbers
3. This worksheet must be completed and submitted with Policies and Procedures
Policies should be dated and the pages numbered. This worksheet is not a substitution for the rules. The licensee is responsible for
complying with all applicable rules and statutes. Therefore, the information below is only a snapshot of the actual rules and is not a
substitute for obtaining a licensure rule book.
Fillable Form
Mental Health Licensure and Certification Section
2
Po
licy and Procedure list 10/14/2021
Name Facility
__________________________
Address Facility (Street, City, State, Zip Code)
Date
______________
Name of LTC
Program Code
Policy / Procedure Checklist
SUBCHAPTER G. RULES FOR MENTAL HEALTH, DEVELOPMENTAL DISABILITIES, AND SUBSTANCE ABUSE FACILITIES AND SERVICES
Policy Page Number
Must be Entered
Yes
No
Comments
who will perform the assessment; and
time frames for completing an assessment.
persons authorized to document;
how to transport records;
safeguard of records
record accessibility to authorized users and
assurance of confidentiality of records.
Fillable Form
Mental Health Licensure and Certification Section
3
Polic
y and Procedure list 10/14/2021
Policy Page Number
Must be Entered
Yes
NO
Comments
Individuals presenting problem or need;
will provide services to address the needs of the
individual;
QUALITY IMPROVEMENT and QUALITY ASSURANCE
committee;
QUALITY IMPROVEMENT and QUALITY ASSURANCE
improvement plan;
methods for monitoring client care
qualified supervision for all staff
strategies for improving client care;
staff credentialing/privileging
review of all fatalities
Fillable Form
Mental Health Licensure and Certification Section
4
Po
licy and Procedure list 10/14/2021
Policy Page
Number Must be
Entered
Yes
NO
Comments
special client activity areas; (one area is your Fire/Disaster Plan:
What you plan to do if there is a fire or disaster and how you will
execute the plan).
requirements for maintaining client confidentiality.
training and continuing education.
grievances
identifying,
reporting,
investigating and,
controlling infectious and communicable diseases of staff
Fillable Form
Mental Health Licensure and Certification Section
5
Po
licy and Procedure list 10/14/2021
Policy Page Number
Must be Entered
Yes
No
Comments
supervision plan upon hiring each associate professional
Policy Page Number
Must be Entered
Yes
No
Comments
supervision upon hire of each paraprofessional.
Policy Page Number
Must be Entered
Yes
No
Comments
partnership with the client or legally responsible person or both,
within 30 days of admission for clients who are expected to
client outcome(s) that are anticipated to be achieved by
the provision of the service and a projected date of
achievement;
strategies;
staff responsible;
a schedule for review of the plan at least annually in
consultation with the client or legally responsible person
or both;
the basis for evaluation or assessment of outcome
achievement; and
written consent or agreement by the client or
responsible party, or a written statement by the provider
Fillable Form
Mental Health Licensure and Certification Section
6
P
olicy and Procedure list 10/14/2021
Page Number Must be
Entered
Yes
No
Comments
dispensing without a Pharmacist, except for emergency use.
Comments
Pharmacist must have an original label with expiration dates
Client name;
M.D. name;
dispensed date;
administration directions; clear directions for self-admin
name, strength, quantity & expiration date of the drug;
Comments
administered to each client must be kept current. Medications
administered shall be recorded immediately after administration.
The MAR is to include the following:
client's name;
name, strength, and quantity of the drug;
instructions for administering the drug;
date and time the drug is administered; and
Mental Health Licensure and Certification Section
7
Po
licy and Procedure list 10/14/2021
Policy Page Number Must be
Entered
Yes
NO
Comments
licensed persons or by unlicensed persons trained by a registered
nurse, Pharmacist or other legally qualified person and privileged
and kept with the MAR file followed by an appointment or
Comments
drug supply shall be disposed of promptly unless it is reasonably
expected that the patient or resident shall return to the facility. In
such a case, the remaining drug supply shall not be held for more
Comments
in a securely locked cabinet in a clean, well-lighted,
ventilated room between 59º and 86º F.;
in a refrigerator, if required, between 36º and 46º F. If the
refrigerator is used for food items, medications shall be
kept in a separate, locked compartment or container;
separately for each client;
separately for external and internal use;
securely if approved by a physician for a client to self-
Comments
intervention is indicated.
Mental Health Licensure and Certification Section
8
P
olicy and Procedure list 10/14/2021
Policy Page Number
Must be Entered
YES
NO
Comments
SUBCHAPTER D. GENERAL RIGHTS
Policy Page Number
Must be Entered
YES
NO
Comments
If a facility uses Seclusion, Restraints and Isolation Time Out this section MUST be in the facility's policy and procedure manual
exploitation of clients are reported to the County Department of
a serious risk.
within the facility.
prohibited from restricting a client's rights.
permission for giving written permission for 24hr restrictive
planned use of a restrictive intervention.
Fillable Form
Mental Health Licensure and Certification Section
9
P
olicy and Procedure list 10/14/2021
Policy Page Number Must
be Entered
Yes
NO
Comments
debriefing and planning with the client and legally responsible person.
This process should be conducted based on the cognitive functioning of
Policy Page Number Must
be Entered
Comments
unwarranted suspension or expulsion from the facility.
expulsion or other discharge not mutually agreed upon and shall
establish documentation requirements that include:
Timeframe for resuming services after suspension.
the specific time and conditions for resuming services
following suspension;
efforts by the staff of the facility to identify an alternative
s
ervice to meet the client's needs and designation of suc
h
s
ervice; and
Policy Page Number Must
be Entered
Comments
or their living area may occur, and if permitted, the procedures for
person's area may occur.
(A) scope of search;
(B) reason for search;
(C) procedures followed in the search;
(D) a description of any property seized; and
Mental Health Licensure and Certification Section
10
Po
licy and Procedure list 10/14/2021
Policy Page Number
Must be Entered
YES
NO
Comments
Policy Page Number
Must be Entered
Comments
and violation penalties; disclosure rules for confidential info;
procedure for obtaining a copy of treatment plan; grievance
procedure (including contact person); suspension/expulsion and
be informed of the purpose, goal & reinforcement structure of a
behavior management system; potential restrictions; notification
provisions regarding use; notice that the legally responsible person
after use of restrictive interventions; a competent adult may
designate an individual to receive information after restrictive
interventions and notification provisions regarding restriction of
Policy Page Number
Must be Entered
Comments
Mental Health Licensure and Certification Section
11
P
olicy and Procedure list 10/14/2021
Policy Page Number
Must be Entered
YES
NO
Comments
participate in appropriate and generally acceptable social
interactions and activities with other clients and non
client
acceptable social interactions and activities with other clients and
non
client members of the community.
Policy Page Number
Must be Entered
Comments
governance and the development of client self
governance groups
Policy Page Number
Must be Entered
Comments
and alternative treatments.
what the procedure is to withdraw consent:
The timeframe of consents (no more than six months)
written consents for;
Planned interventions
Antabuse and Depo-Provera
with termination.
Fillable Form
Mental Health Licensure and Certification Section
12
Polic
y and Procedure list 10/14/2021
Policy Page Number
Must be Entered
YES
NO
Comments
secure a violent and aggressive client and
ensure if force necessary written 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
SUBCHAPTER E. TREATMENT OR HABILITATION RIGHTS
NCAC 27E Treatment of Habilitation Rights must be reflected in the
Policy Page Number Must
be Entered
actions to ensure dignity and respect during and after the
intervention. Including using the intervention as a last resort; and
Yes
No
Comments
Mental Health Licensure and Certification Section
13
P
olicy and Procedure list 10/14/2021
Policy Page Number Must
be Entered
YES
NO
Comments
painful body contact; substances which create painful bodily
r
eactions; electric shock; insulin shock; unpleasant-tastin
g
f
oodstuffs; application of noxious substances (noise, bad smells,
splashing with water); physically painful procedures to reduce
interventions deemed unacceptable.
Policy Page Number Must
be Entered
Comments
indicated as a method of therapeutic treatment.
indicated and the authorization for the use of such treatment for a
specific client can only be made by a physician or a licensed Ph.D.
who has been formally trained and privileged in the use of a
procedure.
Policy Page Number Must
be Entered
Comments
emergency situations, in order to terminate a behavior or
action in which a client is in imminent danger of abuse or
injury to self or other persons or when property damage is
occurring that poses an imminent risk of danger of injury or
harm to self or others; or
as a planned measure of therapeutic treatment (NOTE: NO
PRTF shall NOT have planned restrictive intervention's
§
Mental Health Licensure and Certification Section
14
P
olicy and Procedure list 10/14/2021
Policy Page Number Must
be Entered
Yes
NO
Comments
be included in the client's treatment/habilitation plan whenever it is used:
More than four times or
More than 40 hours in a calendar month
in a single episode in which the original order is renewed for up to a total
of 24 hours in accordance with the limit specified in Item in your policy
as a measure of therapeutic treatment designed to reduce dangerous,
aggressive, self-injurious or undesirable behaviors to a level that will allow
valid for no more than six months and that the decision to continue the
specific intervention shall be based on clear and recent behavioral
evidence that the intervention is having a positive impact and continues
retaliation by staff or for the convenience of staff or due to inadequacy of
staffing.
abuse.
facility.
physical restraint. The data collected and analyzed shall reflect for each
incident:
the type of procedure used, and the length of time employed;
alternatives considered or employed; and
effectiveness, determine trends and take corrective action where
necessary. In addition, the facility shall make the data available to the
Mental Health Licensure and Certification Section
15
Policy and Procedure list 10/14/2021
Policy Page Number
Must be Entered
Yes
NO
Comments
employees who may authorize and implement restrictive
regarding the use of restrictive interventions.
restrictive interventions are used.
when restrictive interventions are used.
and psychological well-being and assessing the possible
documentation physical disabilities
a room used for seclusion
if using Isolation: criteria
whenever a restrictive intervention is utilized, documentation
shall be made in the client record to include
how emergency use of restrictive interventions shall be
or physical restraint.
health or safety.
use of seclusion, physical restraint or isolation time-out.
Mental Health Licensure and Certification Section
16
P
olicy and Procedure list 10/14/2021
Policy Page Number
Must be Entered
Yes
NO
Comments
when and how others will be notified.
restrictive interventions.
Policy Page Number
Must be Entered
Comments
The necessity for the protective device
Facility employee using device has been trained and demonstrate
d
c
ompetence in the use for a device
Observation and interventions documented in a client record
contract with an area program, the utilization of protective devices
in the treatment/habilitation plan shall be subject to review by the
Comments
additional safeguards in a facility that utilizes restrictive
Intervention Advisory Committee.
details how client information is disseminated and reasoning for
document the specific training and orientation given to the
Mental Health Licensure and Certification Section
17
Po
licy and Procedure list 10/14/2021
Treatment Rights in 24-hour Facilities
Policy Page Number Must be
Entered
NCGS 122C-61: Treatment rights in 24-hour facilities
YES
NO
Comments
1. The client will have the right to receive necessary
treatment for and prevention of physical ailments based
upon the client's condition and projected length of stay.
2. Clients have the right during treatment or habilitation
(no later than the time of discharge) to an individualized
written discharge plan containing recommendations for
further services designed to enable the client to live as
normally as possible.
Policy Page Number Must be
Entered
NCGS 122C-62: Additional rights in 24-hour facilities
Comments
3. Adult Clients have the right to:
Make and receive confidential phone calls
Receive visitors between 8:00 am and 9:00 pm for at
least 6 hours daily; 2 hours shall be after 6:00 pm.
Visiting shall not take precedence over therapies.
Communicate & meet under appropriate
supervision with individuals of their own choice.
Make visits outside of the facility unless issues are
related to commitment proceedings or court orders.
Be out of doors daily and have access to facilities &
equipment for physical exercise several times a
week.
Keep and use personal clothing and possessions.
Participate in religious worship.
Retain a driver's license unless otherwise prohibited.
Have access to individual storage space for private
use.
Mental Health Licensure and Certification Section
18
Policy and Procedure list 10/14/2021
Policy Page Number Must be
Entered
Rule Continued
Yes
NO
Comments
4. Minor Clients have the right to:
Make and receive phone calls.
Under appropriate supervision, receive visitor's
b/n 8:00 am and 9:00 pm for at least 6 hours
daily; 2 hours shall be after 6:00 pm. Visiting
shall not take precedence over therapies.
Send and receive mail and have access to
writing materials, postage, staff assistance.
Receive special education and vocational
training.
Be out of doors daily and participate in play,
recreation, and physical exercise regularly in
accordance with client needs.
Keep and use personal clothing and possessions
under appropriate supervision.
Participate in religious worship.
Have access to individual storage space for
personal belongings.
Have access to and spend a reasonable sum of
own money.
Retain a driver's license unless otherwise
prohibited.
Mental Health Licensure and Certification Section
19
Policy and Procedure list 10/14/2021
Subchapter 27F Specific Rules for 24-Hour Facilities
SUBCHAPTER 27F - 24-HOUR FACILITIES
Policy Page Number
Must be Entered
10A NCAC 27F .0101 Scope
Yes
No
Comments
1. Article 3, Chapter 122C of the General Statutes provides
specific rights for each client who receives mental
health, developmental disability or substance abuse
service. This subchapter delineates the rules regarding
those rights for clients in a 24-hour facility.
Policy Page Number
Must be Entered
10A NCAC 27F .0102. LIVING ENVIRONMENT
Yes
No
Comments
2. Efforts to make a quiet atmosphere for uninterrupted
sleep, privacy areas.
3. The client may suitably decorate the room when
appropriate.
Policy Page Number
Must be Entered
10A NCAC 27F .0103 Health, Hygiene and Grooming
Yes
No
Comments
4. Clients will have the right to dignity, privacy and humane
care in healthy hygiene
and grooming.
5. The client will have access to shower/tub daily or more
often as needed, access to a barber or beautician, access
to linens and towels and other toiletries.
6. Adequate toilets, lavatory and bath facilities equipped
for a client with mobility impairment will be available.
7. Ct bathtubs, showers and toilets will be private.
Mental Health Licensure and Certification Section
20
Policy and Procedure list 10/14/2021
Policy Page Number
Must be Entered
10A NCAC 27F .0104 Storage and Protection of Clothing
and Possessions
Yes
No
Comments
8. Staff will make every effort to protect clients' personal
clothing and possessions from loss or damage.
Policy Page Number
Must be Entered
10A NCAC 27F .0105 Client's Personal Funds
Yes
No
Comments
9. Each client will be encouraged to maintain funds in a
personal account.
10. Funds managed by staff will: assure client right to
deposit and withdraw money; regulate the receipt and
distribution, and deposits of funds; provide adequate
financial records on all transactions; assure client funds
are kept separate; allow a deduction from accounts for
payment of treatment/habilitation services when
authorized; issue receipts for deposits and withdrawals
provide quarterly client statements.
11. Authorization by the client is required before a
deduction can be made from an account for any amount
owed for damages done by the client to the facility, to
an employee of the facility, a visitor or another Client.
SUBCHAPTER 13O HEALTHCARE PERSONNEL REGISTRY
Policy Page Number Must
be Entered
10A NCAC 13O .0102 Investigating and Reporting Health Care
Personnel Registry
Yes
No
Comments
1. The reporting by health care facilities to the
Department of all allegations against health care
personnel as defined in G.S. 131E-256 (a)(1),
including injuries of unknown source, shall be done
within 24 hours of the health care facility becoming
aware of the allegation. The results of the health
care facility's investigation shall be submitted to the
Department in accordance with G.S. 131E-256(g).