Fill - Free fillable North Carolina Department of Health and Human Services (North Carolina) PDF form

North Carolina Department of Health and Human Services

Division of Health Service Regulation

Mental Health Licensure & Certification Section

Mental Health Licensure and Certification Section

www.ncdhhs.gov/dhsr

Tel 919-855-3795 • Fax 919-715-8078

Location: Williams Building • 1800 Umstead Drive • Raleigh, NC 27603

Mailing Address: 1800 Umstead Drive • 2718 Mail Service Center • Raleigh, NC 27699-2718

An Equal Opportunity / Affirmative Action Employer

Initial

Licensure Application Packet

Form# DHHS/DHSR/MHL5001

Revised 08/01/2021

N.C. Department of Health and Human Services

Division of Health Service Regulation

Mental Health Licensure and Certification Section

1800 Umstead Drive ■ 2718 Mail Service Center ■ Raleigh, North Carolina 27699-2718

MHLC Initial Application Rev 08/01/2021 DHHS/DHSR-MHL/5001

Memorandum

To: M

ental Health, Developmental Disabilities, and Substance Abuse Facility Licensure Applicants

From: Mental Health Licensure and Certification Section

Re: Initial Licensure Application Packet

You may find helpful information regarding how to establish a mental health facility on our DHSR website.

The Facility Licensure Information link and The F and Q pages are great resources to review.

Enclosed you will find an Initial Licensure Application Packet. The packet includes the following:

• Licensure Application Process

• Initial Licensure Application

• Photographs sheet

• MH Licensure Policies and Procedures Worksheets

The

following rules are essential for all licensed mental health facilities to help formulate the required Operations and Management

Policies, Guidelines and Procedures (download for free at http://www.ncdhhs.gov/dhsr/mhlcs/rules.html).

• 10A NCAC Chapter 26 Mental Health, General

Subchapter C Other General Rules

• 10A NCAC Chapter 27 Mental Health, Community Facilities and Services

Subchapter C Procedures and General Information

Subchapter D General Rights

Subchapter E Treatment or Habilitation Rights

Subchapter F 24-Hour Facilities

Subchapter G Rules for Mental Health, Developmental Disabilities, and Substance Abuse Facilities and Services

Hard copies of these rules may be ordered from the Division of MH/DD/SAS:

• Phone: 984-236-5000

• E-mail: contactdmh@dhhs.nc.gov

• Mailing Address: 3001 Mail Service Center, Raleigh NC 27699-3001 (checks or money orders only made

payable to Division of Mental Health)

e following NC General Statutes are essential for all licensed mental health facilities. Below is not an all-inclusive list; a complete

list of NC General Statutes that govern licensed facilities are found at http://www.ncleg.net/gascripts/Statutes/StatutesTOC.pl

• NC GS 122C 6: Smoking Prohibited

• NC GS 122C 61: Treatment rights in 24-hour facilities

• NC GS 122C 62: Additional rights in 24-hour facilities

• NC GS 122C 63 Assurance for Continuity of Care for Individuals with Mental Retardation

• NC GS 122C 80 Criminal History; Record Check

• NC GS 131E 256 Health Care Personnel Registry

N.C. Department of Health and Human Services

Division of Health Service Regulation

Mental Health Licensure and Certification Section

2718 Mail Service Center ■ Raleigh, North Carolina 27699-2718

LICENSE APPLICATION PROCESS

An applicant is allowed six months from the date contact is made with applicant and a Licensure & Training team member to complete all requirements of

application review to obtain a license. After initial licensure, the facility must have the license renewed every year.

order to apply for a license from the Division of Health Service Regulation to operate a mental health facility as required

under General Statute 122C, you must do the following:

1. Complete the application

(a) 24-hour Residential Programs:

o Take the completed application (pages 9-14) to your local zoning office and obtain zoning compliance.

Attach the zoning compliance letter to the application.

• The

zoning compliance letter from your local zoning department must clearly identify:

o Facility address

o Zoning code (must be correct zoning code see below chart)

o Intended usage

Your application will not be processed if your zoning compliance information does not contain and verify the correct

zoning.

• Take the completed application (pages 9-14) to your area Local Management Entity-Managed Care Organization

(LME-MCO) office and obtain a Letter of Support as per 10A NCAC 27G .0406. Attach LME-MCO support letter to

the application. A Letter of Support is not required for services that have a Certificate of Need (CON) from DHSR,

which currently includes service category .3400 and ICF/IID facilities.

• Submit all items listed in the Requirements for 24-hour Residential Programs box on page 7.

• Include initial licensure fee upon submitting all items.

(b) Day Programs:

• Take the completed application (pages 9-14) to your local zoning office and obtain zoning approval. Attach the

zoning approval letter to the application.

• State Opioid Treatment Authority (SOTA) requires a preliminary program approval letter for all service category

3600 facilities.

• Submit all items listed in the Requirements for Day Programs box on page 8, including approved Fire Marshal,

Sanitation and Building Officials inspection reports as required.

• Include initial licensure fee upon submitting all items.

2. Write a letter briefly describing the services you will offer at the proposed facility.

3. Develop written policies and procedures for your service. Do not submit your organization’s P&P with the application,

as they will be reviewed later.

4. Make check payable to: NC Division of Health Service Regulation

5. Send application with the required information to: Division of Health Service Regulation

MH Licensure & Certification Section

1800 Umstead Drive

2718 Mail Service Center

Raleigh, NC 27699-2718

*Note: Before the construction of a new residential facility, you must submit blueprints and receive approval from the

DHSR Construction Section. For information, contact DHSR Construction at 919-855-3893.

N.C. Department of Health and Human Services

Division of Health Service Regulation

Mental Health Licensure and Certification Section

2718 Mail Service Center ■ Raleigh, North Carolina 27699-2718

Building Code Zoning Classifications - Requirements for Licensure Categories (revised 8-8-2013)

Program Code

10 NCAC 27G

Facility Type

Residential/

Institutional

24 hour

programs

Building

Classification

Code

.1100

Partial Hospitalization for individuals who are acutely mentally ill

Group B – Business Occupancy (Adults)

Group E – Educational or I4 (minors)

.1200

Psychosocial Rehab for individuals with Severe and Persistent Mental Illness

Group B – Business Occupancy

.1300

Residential Treatment for Children or Adolescents

Yes

Residential – Classification dependent on

number & ambulation status

.1400

Day Treatment for Children and Adolescents with Emotional or Behavioral

Disturbances

Group E – Educational Occupancy

or I-4

.1700

Residential Treatment Staff Secure for Children or Adolescents

Yes

Residential – Classification dependent on

number & ambulation status

.1800

Intensive Residential Treatment for Children or Adolescents

Yes

Institutional Occupancy

.1900

Psychiatric Residential Treatment for Children and Adolescents

Yes

Institutional Occupancy

.2100

Specialized Community Residential Centers for Individuals with Developmental

Disabilities

Yes

Residential or Institutional Occupancy

.2200

Before/After School and Summer Developmental Day Services for Children with or

at Risk for Developmental Delays, Developmental Disabilities, or Atypical

Development

Group E- Educational

or I-4

.2300

Adult Developmental and Vocational Program for Individuals with Developmental

Disabilities

Group B- Business Occupancy

.3100

Nonhospital Medical Detoxification for Individuals who are Substance Abusers

Yes

Institutional Occupancy

.3200

Social Setting Detoxification for Substance Abusers

Yes

Residential or Institutional Occupancy

.3300

Outpatient Detoxification for Substance Abuse

Group B – Business Occupancy

.3400

Residential Treatment/Rehabilitation for Individuals with Substance Abuse

Disorders

Yes

Residential or Institutional Occupancy

.3600

Outpatient Opioid Treatment

Group B- Business Occupancy

.3700

Day Treatment Facilities for Individuals with Substance Abuse Disorders

Group B- Business Occupancy

Group E – Educational or I4 (Minors)

.4100

Residential Recovery Programs for Individuals with Substance Abuse Disorders

and their Children

Yes

Typically Group R – Residential

.4300

Therapeutic Community

Yes

Typically Group R – Residential

.4400

Substance Abuse Intensive Outpatient Program (SAIOP)

Group B – Business Occupancy (Adults)

Group E – Educational or I4 (minors)

N.C. Department of Health and Human Services

Division of Health Service Regulation

Mental Health Licensure and Certification Section

2718 Mail Service Center ■ Raleigh, North Carolina 27699-2718

.4500

Substance Abuse Comprehensive Outpatient Treatment Program (SACOT)

Group B- Business Occupancy

.5000

Facility-Based Crisis Services for Individuals of All Disability Groups

Yes

Institutional Occupancy

.5100

Community Respite Services for Individuals of All Disability Groups

Yes

Typically Residential depending on the

number of residents

.5200

Residential Therapeutic (Habilitative) Camps for Children and Adolescents of All

Disability Groups

Yes

Wilderness Camp Settings

.5400

Day Activity For Individuals of All Disability Groups

Group B- Business Occupancy

Group E – Educational or I4 (Minors)

.5500

Sheltered Workshops For Individuals of All Disability Groups

Group B- Business Occupancy

.5600

Supervised Living For Individuals of All Disability Groups

Yes

Residential

.6000

Inpatient Hospital Treatment for Individuals who have Mental Illness or Substance

Abuse Disorders

Yes

Institutional Occupancy

Code

Program Type / Description

Day Program

Level II Clients

This program has been deleted

Level II clients (previously part of the .1300 program)

Level IV clients. Required to be a secured facility and Institutional – Unrestrained Occupancy (previously part of the .1500 program)

PRTF clients. May be staff secured or locked; still Institutional – Unrestrained Occupancy (previously part of the .1500 program)

Usually these are ICF/IID facilities and required to have a Certificate of Need (CON)

Institutional occupancy since providing medical treatment

Typically, not in a six-bed facility since requires CON

Program is for women and their children. Usually in apartment/motel situation but if less than six could be a home

Program is for adults and is usually in apartment/ motel situation but if less than six could be in a home

Requires Institutional Occupancy since requiring treatment

Typically, is a resident with another residential program. Could be part of a larger facility not residential

Support Services, not residential

Has six different programs. .5600A; .5600B; .5600C are limited to maximum of 6 clients. .5600F is limited to maximum of 3 clients in private residence.

Residential Camp

Any program not listed is not a licensed program by Mental Health

Programs typically licensed in Single-Family Dwellings and falling under G.S. 168 are: .1300, .1700, .2100, .5100 & .5600.

Division of Health Service Regulation

Mental Health Licensure and Certification Section

Policies and Procedures: Initial Licensure Survey

MHLC Initial Application Rev 08/01/2021 DHHS/DHSR-MHL/5001

License Fees: Initial License & Construction

All licensed facilities, residential and non-residential are required to pay an initial license and annual license renewal fee.

NC General Statute 122C-23:

• Prohibits the issuance of the license until the license fee is paid.

• Mandates that licenses must be renewed annually and will expire at the end of the calendar year.

Please submit the Licensure fee with the application. Do not submit the Construction fee. Our Construction section will

bill you for the applicable fee prior to conducting their site visit.

Initial Licensure Fee NC General Statute 131E-272: Following is a list of types of facilities with required fee, including the

base fee and the per bed fee.

Type of Facility

Number of Beds

Base Fee

Per Bed Fee

Non-residential Facilities

$265.00

N/A

Residential Facilities (Non-ICF/IID)

6 beds or less

$350.00

Residential Facilities (Non-ICF/IID)

7 beds or more

$525.00

$19.00

ICF/IID* Facilities

6 beds or less

$900.00

ICF/IID* Facilities

7 beds or more

$850.00

$19.00

*ICF/IID: Intermediate Care Facility for Individuals with Intellectual Disabilities, a specialized Medicaid facility requiring a Certificate

of Need from the DHSR Certificate of Need Section.

Construction Fees: In addition to the license fee, the DHSR Construction Section has a per project fee to review the

physical plant requirements for 24-hour residential facilities only. You will receive an invoice from the Construction

Section for the appropriate fee. Following is a list of fees:

Type of Facility

Number of Beds

Project Fee

Non-ICF/IID Facilities

1-3

$125.00

Non-ICF/IID Facilities

4-6

$225.00

Non-ICF/IID Facilities

7-9

$275.00

ICF/IID Facilities

1-6

$350.00

Other Residential

10 or more

$275.00 + $.15/sq. Ft. project space

Contact Information

For questions regarding any part of this process, please contact the appropriate section of the Division of Health Service

Regulation or visit our website https://.info.ncdhhs.gov/dhsr/

Mental Health Licensure and Certification Section

919-855-3795

Construction Section

919-855-3893

Division of Health Service Regulation

Mental Health Licensure and Certification Section

Policies and Procedures: Initial Licensure Survey

MHLC Initial Application Rev 08/01/2021 DHHS/DHSR-MHL/5001

License Application Requirements & Checklists

Incomplete applications will be returned to the sender, without processing, accompanied

by a letter explaining the incorrect or missing information. Please complete the

appropriate checklist prior to submitting your license application

Requirements for 24-hour Residential Programs—Existing Structures

Note: Before the construction of a new 24-hour residential facility, you must submit blueprints and receive approval from

the DHSR Construction Section. For additional information, contact DHSR Construction at 919-855-3893.

In addition to your cover letter, application, and fee, please submit the following:

1. A floor plan that specifies the following:

a) All levels, including basements and upstairs.

b) Identification of the use of all rooms/spaces.

c) Dimensions of all bedrooms, excluding any toilets, bathing areas and closets. Clarify double or single

occupancy.

d) Location of all doors and the dimensions of all exterior doors.

e) Location of all windows, including bedroom windows and sill height of bedroom windows above the finished

floor.

f) Location of all smoke detectors noting whether they are battery-operated, wired into the house current with

battery backup, and if they are interconnected

2. Exterior photos of each side of the building.

3. Interior photos of the kitchen, living areas, bedrooms, and any other rooms.

4. Directions from Raleigh or a map from the nearest major highway, street or intersection clearly show

the facility’s location.

5. Local Zoning Department approval for the proposed use.

6. Letter of support from LME/MCO. Not required for ICF-IID facilities or 10A NCAC 27G .3400.

7. Certificate of Need: Required for any new ICF/IID facilities or 10A NCAC 27G .3400.

8. Appointments for Fire & Sanitation Inspections.

24-Hour Residential Checklist

Item

Completed

Cover Letter

Completed Initial Licensure Application (form DHSR 5001)

Fee

Floor Plan Identifying all spaces in the facility

(all levels/floors, dimensions, doors, windows, smoke detectors, bathrooms, closets)

Pictures (Interior & Exterior)

6..

Directions to Facility

Zoning Approval (original)

Required for application to move forward

LME-MCO Support Letter if not ICF-IID or 10A NCAC 27G .3400.

Certificate of Need: If ICF-IID Facility or 10A NCAC 27G .3400

10.

Appointments for Fire & Sanitation Inspections.

Actual inspections are not needed when submitting the application but will be needed prior to DHSR Construction section

approval.

Division of Health Service Regulation

Mental Health Licensure and Certification Section

Policies and Procedures: Initial Licensure Survey

MHLC Initial Application Rev 08/01/2021 DHHS/DHSR-MHL/5001

Requirements for Day Programs

Note: Day Programs for children and adolescents cannot be located in a building classified as a Business Occupancy. These programs are required to

meet either Group E-Educational Occupancy or Group I-4 - Child Daycare Occupancy under the NCSBC.

addition to your cover letter, application, and fee, please submit the following:

1. A floor plan of the entire building or floor within the building of the space to be licensed that specifies

the following:

a. Identification and dimensions of rooms to be licensed.

b. Exits from the licensed space and building.

c. Toilet areas and other required support spaces.

2. Exterior photos of each side of the building. Interior photos of the proposed licensed space.

3. Directions from Raleigh or a map from the nearest major highway, street or intersection clearly show

the facility’s location.

4. Local Zoning Department approval or verification that the facility is classified under building/planning

for the intended use.

5. Current local Fire Marshal’s Inspection Report for the building.

6. Current local Sanitation Inspection report if serving any food.

7. A preliminary program approval letter is required from the State Opioid Treatment Authority (SOTA)

for all Service Category 3600 facilities.

8. New Construction/Renovation: the local Building Officials approval.

9. Existing Structure: If this is an existing Business Occupancy building (as classified under the North

Carolina state building code) and it is only a change of tenant use (for a program that is classified as a

‘Business Occupancy use’) approval from the local Building Official may not be required. Contact your

local Building Official and provide them with a copy of your application to verify if your program is

classified as a Business Occupancy and if they need to provide any type of documentation.

Day Program Checklist

Item

Completed

Cover Letter

Completed Initial Licensure Application (form DHSR 5001)

Fee

Floor Plan with dimensions

Pictures (Interior & Exterior)

Directions to Facility

Zoning Approval (original)

Required for application to move forward

Fire Inspection (clear copy or original)

Sanitation Inspection (clear copy or original) if serving food

10.

Preliminary Program approval from SOTA (service category 3600)

11.

Building Inspection (original) if applicable for new construction or renovation of

building

Division of Health Service Regulation

Mental Health Licensure and Certification Section

Policies and Procedures: Initial Licensure Survey

MHLC Initial Application Rev 08/01/2021 DHHS/DHSR-MHL/5001

INITIAL LICENSURE APPLICATION FOR MH/DD/SAS FACILITIES

Include First Name, Middle Initial & Last Name for every person listed in the application

Office use only: License Number: MHL#___________________________ FID# ___________________________________

1. FACILITY NAME: _____________________________________________________________________________

Name which the facility is advertised or presented to the public. This is the name that will be printed on your license. Refer

to this facility name in all inquiries.

2. FACILITY SITE ADDRESS: (NO P.O. BOXES)

Street Address: _________________________________________________________________________________

City: ___________________________________State: Zip Code: County:

Phone: _________________________________Email:__________________________________________________

* Must have an operable facility designated telephone that is clearly visible, accessible, on site and

available 24 hours.

3. FACIL

ITY CORRESPONDENCE MAILING ADDRESS:

Name of Contact Person: _________________________________________________________________________

Street Address: _________________________________________________________________________________

City: ___________________________________State: ____________________Zip Code: ______________________

Phone: _________________________________Email:__________________________________________________

4. NAME

OF FACILITY DIRECTOR:

(First, MI, Last)_________________________________________________________________________________________

5. SIGNA

TURE OF LICENSEE OR PERSON WITH SIGNATORY AUTHORITY: The undersigned, representing the governing

authority, submits information for the above-named facility and certifies the accuracy of this information in accordance with

10A NCAC 27G. ALL APPLICATIONS MUST HAVE AN ORIGINAL SIGNATURE

Name:

(First, MI, Last) _____________________________________________________________________________________________________________________________

Signature: ______

_________________________Title:___________________________ Date:__________________

OFFICIAL USE ONLY:

Licensure Categories:___________________________________ Check # _________________ Check Amount _______________

SOS

PPT

MFF

Staff Initials:

ACCESS

ACO

Remarks: ______________________________________________________________________________________

Fillable Form (signatures are not fillable)

Division of Health Service Regulation

Mental Health Licensure and Certification Section

Policies and Procedures: Initial Licensure Survey

MHLC Initial Application Rev 08/01/2021 DHHS/DHSR-MHL/5001

6. MANAGEMENT COMPANY: If the facility is managed by a company other than the licensee, provide the following information

about the Management Company:

Name of Company/Contact Person:

Street Address:

City: ___________________________________ State: ____________________Zip Code: _____________________

Phone: _________________________________Email:__________________________________________________

7. LOC

AL MANAGEMENT ENTITY/ MANAGED CARE ORGANIZATION (LME/MCO) (List name(s) of LME/MCOs with which the facility

has a contract):_________________________________________________________________

8. LEGAL IDENTITY OF OWNERSHIP/LICENSEE:

The full legal name of the individual, partnership, corporation or other legal entity, which owns the mental health facility business, is

required. Owner/Licensee means any person/business entity (Corp., LLC, etc.) that has legal or equitable title to or a majority

interest in the mental health facility. This entity is responsible for the financial and contractual obligations of the business and will

be recorded as the licensee on the license.

(a) Name of Owner/Corporation: __________________________________________________________________

Street Address:

City: ___________________________________ State: ____________________Zip Code: _____________________

Phone: _________________________________Email:__________________________________________________

(b) Federal Tax ID number of Owner/Licensee:

For Health Care Providers

The Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandated the adoption of a

standard unique identifier for health care providers. The National Plan and Provider Enumeration System (NPPES) collects identifying information

on health care providers and assigns each a unique National Provider Identifier (NPI). If you have questions or need additional information

regarding the NPI number, call the toll-free number 1-800-465-3203 or visit the website: https://medicaid.ncdhhs.gov/claims-and-billing/national-

provider-identifier

http://www.ncdhhs.gov/dma/NPI/index.htm

(d) Legal entity is:_____ For Profit ______ Not for Profit

(

e) Legal entity is: _____ Proprietorship

_____ Corporation _____ Limited Liability Company

_____ Partnership _____ Limited Liability Partnership

_____ Government Unit

(f) Name of CEO/President: :( First, MI, Last)

Title:

Street Address:

City: ___________________________________ State: ____________________Zip Code: _____________________

Phone: _________________________________Email:__________________________________________________

Fillable Form

Division of Health Service Regulation

Mental Health Licensure and Certification Section

Policies and Procedures: Initial Licensure Survey

MHLC Initial Application Rev 08/01/2021 DHHS/DHSR-MHL/5001

uilding Owner: If the above entity (partnership, corporation, etc.) does not own the building from which services are offered,

please provide the following information:

Name of Building Owner: ________________________________________________________________________

Street Address:

City: ___________________________________ State: ____________________Zip Code: _____________________

Phone: _______________________________Email:____________________________________________Lease expires:

________________________

9. OWNERS, PRINCIPLES, AFFILIATES, SHAREHOLDERS (Confidential Information for Official Use Only)

For-Profit Individuals or Companies

Complete the information below on all individuals who are owners, principles, affiliates or shareholders holding an interest of 5% or

more of the licensing entity listed on page 2. Attach additional pages if necessary. If you are the only owner, complete the

information below, listing the percentage interest as 100%.

Shareholder Name: ( First, MI, Last)

____________________________________________________________________________________________

Street Address: ________________________________________________________________________________

City: _____________________________________State:________________________ Zip Code: _______________

Phone: _______________________ Email: _________________________________________________________

Percentage interest in this facility: ____________Title: ________________________________________________

Shareholder Name: ( First, MI, Last)

____________________________________________________________________________________________

Street Address: ________________________________________________________________________________

City: _____________________________________State:________________________ Zip Code: _______________

Phone: _______________________ Email: _________________________________________________________

Percentage interest in this facility: ____________Title: ________________________________________________

Shareholder Name: ( First, MI, Last)

____________________________________________________________________________________________

Street Address: ________________________________________________________________________________

City: _____________________________________State:________________________ Zip Code: _______________

Phone: _______________________ Email: _________________________________________________________

Percentage interest in this facility: ____________Title: ________________________________________________

Non-Profit Companies and For-Profit Companies (If no individual holds an interest of 5% or more, please sign the statement below.)

There are no owners, principles, affiliates or shareholders who hold an interest of 5% or more of the licensing entity applying for or

renewing a license:

Signature________________________________ Title _______________________________ Date _____________

Fillable Form (excep

tion signatures)

Division of Health Service Regulation

Mental Health Licensure and Certification Section

Policies and Procedures: Initial Licensure Survey

MHLC Initial Application Rev 08/01/2021 DHHS/DHSR-MHL/5001

10. SERVICE CATEGORIES:

Services subject to licensure under GS 122C are shown in the table below and are found in the Rules for Mental Health,

Developmental Disabilities and Substance Abuse Facilities and Services. All applicants must complete the following table for all

services which are to be provided by the facility. If the service is not offered, leave the spaces blank.

Rule 10A NCAC 27G

Licensure Rules For Mental Health Facilities

Check

Service of

License

Beds Assigned by Age

0-17

18 & up

Total Beds

.1100 Partial hospitalizations for individuals who are acutely

mentally ill.

.1200 Psychosocial rehabilitation facilities for individuals

with severe and persistent mental illness

.1300 Residential treatment facilities for children or

adolescents—Level II (Max. of 12 clients)

.1400 Day treatment for children and adolescents with

emotional or behavioral disturbances

.1700 Residential treatment Staff Secure for Children or

Adolescents—Level III (Max of 12 clients)

.1800 Intensive residential treatment for children or

adolescents (Level IV)

.1900 PRTF – Psychiatric Residential Treatment Facility for

minors who are emotionally disturbed or who have a mental

illness.

.2100 Specialized community residential centers for

individuals with developmental disabilities. (Max. of 30

clients) (CON Required if ICF/IID)

.2200 Before/after school and summer developmental day

services for children with or at risk for developmental

delays, developmental disabilities, or atypical development

.2300 Adult Developmental and vocational programs for

individuals with developmental disabilities

.3100 Non-hospital medical detoxification for individuals

who are substance abusers

.3200 Social setting detoxification for substance abuse

.3300 Outpatient detoxification for substance abuse

.3400 Residential treatment/rehabilitation for individuals

with substance abuse disorders (CON Required)

.3600 Outpatient narcotic addiction treatment (preliminary

SOTA Authorization letter required)

.3700 Day treatment facilities for individuals with substance

abuse disorders

.4100 Therapeutic homes for individuals with substance

abuse disorders and their children (min. 3 clients)

.4300 A supervised therapeutic community for individuals

with substance abuse disorder

.4400 Substance Abuse Intensive Outpatient Program

.4500 Substance Abuse Comprehensive Outpatient

Treatment Program

illable Form

Division of Health Service Regulation

Mental Health Licensure and Certification Section

Policies and Procedures: Initial Licensure Survey

MHLC Initial Application Rev 08/01/2021 DHHS/DHSR-MHL/5001

Rule 10A NCAC 27G

Licensure Rules for Mental Health Facilities

Check

Service of

License

Beds Assigned by Age

0-17 18 & up Total Beds

.5000 facility based crisis service for individuals of all

disability groups

.5100 Community Respite services for individuals of all

disability groups

.5200 Residential therapeutic (habilitative) camps for

children and adolescents of all disability groups

.5400 Day activity for individuals of all disability groups

.5500 Sheltered workshops for individuals of all disability

groups

. 5600 supervised living for individuals of all disability groups –

NOTE: Only one category (A, B, C, D, E or F) can be checked for .5600 facilities

5600A Group homes for adults whose primary diagnosis is

mental illness (Max. of 6 clients)

5600B Group homes for minors whose primary diagnosis is

mental retardation or other developmental disabilities

(Max. of 6 clients) (CON required only if ICF/IID)

.5600C Group homes for adults whose primary diagnosis is

mental retardation or other developmental disabilities

(Max. of 6 clients) (CON required only if ICF/IID)

.5600D Group homes for minors with substance abuse

problems

.5600E Half-way houses for adults with substance abuse

problems

.5600F Alternative family living – providing service in own

private residence (Max. 3 clients)

11. DO YOU HAVE A CERTIFICATE OF NEED? Required for ICF/IID Facilities (program code .2100 or .5600C) and .3400 facilities

No Yes If yes, CON Number: ____________________ Date CON Received: _________________

12. Do you plan on serving clients requiring blood sugar checks? Yes No

*If yes and your staff will be conducting blood sugar checks, you must apply for a CLIA waiver before conducting blood sugar checks. Please contact DHSR’s Acute

& Home Care section’s CLIA branch for information on obtaining CLIA waiver: https://info.ncdhhs.gov/dhsr/ahc/clia/index.html

13. NUMBER OF CLIENTS FOR WHICH THE FACILITY IS GOING TO BE LICENSED:

Type

Specify Number to be Licensed

Ambulatory*

Non-Ambulatory, 1-3

Non-Ambulatory, 4 or more

Ambulatory: Is a person who can evacuate the facility without physical or verbal assistance during a fire or

other emergency.

14. NUMBER AND AGE(s) OF PEOPLE OTHER THAN CLIENTS RESIDING WITHIN THE FACILITY:

(Applicable only in categories where a private residence is allowable: .5600F & .5100 Private Home Respites)

____

______________________________________________________________________________________

Are any of the above people listed non-ambulatory? Yes No

illable Form

Division of Health Service Regulation

Mental Health Licensure and Certification Section

Policies and Procedures: Initial Licensure Survey

MHLC Initial Application Rev 08/01/2021 DHHS/DHSR-MHL/5001

PHYSICAL PLANT

Please fill in information for each inspection Department:

oning Department Official

Department Name: _____________________________________________________________________________

Street Address: ________________________________________________________________________________

City: _____________________________________State:________________________ Zip Code: _______________

Phone: _______________________ Email: _________________________________________________________

Local Building Official

Department Name: _____________________________________________________________________________

Street Address: ________________________________________________________________________________

City: _____________________________________State:________________________ Zip Code: _______________

Phone: _______________________ Email: _________________________________________________________

Local Fire Marshall

Department Name: _____________________________________________________________________________

Street Address: ________________________________________________________________________________

City: _____________________________________State:________________________ Zip Code: _______________

Phone: _______________________ Email: _________________________________________________________

Local Sanitation

Department Name: _____________________________________________________________________________

Street Address: ________________________________________________________________________________

City: _____________________________________State:________________________ Zip Code: _______________

Phone: _______________________ Email: _________________________________________________________

Building Information: Complete for 24-hour residential facilities only:

Has the building housed a licensed facility previously? Yes No

If Yes: Type of licensed facility: ________________________________________________________________

Previous License #: ______________________ Dates of Licensure: From: ____________ To: ______________

Does this building(s) contain facilities licensed for a different use other than the one an initial license is being sought

for? Yes

If yes, please clarify type of license _____________________________________________________________

Is the building a site constructed home or a manufactured/mobile home? _____________________________

NOTE: If it is a manufactured/mobile home, contact the DHSR Construction Section for licensure limitations on this type of structure)

If it is a manufactured/mobile home, was it built after 1976? Yes No

Fillable Form

Division of Health Service Regulation

Mental Health Licensure and Certification Section

Policies and Procedures: Initial Licensure Survey

MHLC Initial Application Rev 08/01/2021 DHHS/DHSR-MHL/5001

PHOTOGRAPHS

ame of Facility

: ______________________________________

County: ____________________________________________

Please attach/insert photos of your facility, as required, to this sheet and add other blank sheets as needed.

Please label each photograph as to the identity of the room within the facility. {If original photos are submitted on the

back of the photo, identify with the name and address of the facility (to help identify pictures should photos get separated)}.

Fillable Form

Division of Health Service Regulation

Mental Health Licensure and Certification Section

Policies and Procedures: Initial Licensure Survey

MHLC Initial Application Rev 08/01/2021 DHHS/DHSR-MHL/5001

Note

An applicant is allowed six months from the date contact is made with applicant and a Licensure & Training

team member to complete the program review of the application process.

• A person from the L&T team will contact you to begin the program review. Your six

months’ time frame begins from the initial contact with the L&T team member.

• Please note if you are a residential service, the application must be processed with

DHSR construction. DHSR construction time is separate from the MHLC timeframe.

• The amount of time it takes to complete an application process is driven by the

readiness of the applicant

• The L&T Team has a goal to get you licensed a lot sooner than 6 months, but you must

be ready for the Licensure & Team Program Review to do this.

A full list of the required materials that will be reviewed can be found on the DHSR website under the

forms and applications section. In addition, the policies and procedures worksheet that must

accompany your policies and procedures can be found under the forms and applications section.

Fill Online, Printable, Fillable, Blank North Carolina Department of Health and Human Services (North Carolina) Form

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Fillable North Carolina Department of Health and Human Services (North Carolina)

Fill Online, Printable, Fillable, Blank North Carolina Department of Health and Human Services (North Carolina) Form

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