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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
Change
Licensure Application Packet
Form# DHHS/DHSR/MHL5002
Revised 05/05/2020
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 Change Application Revised 05/05/2020 DHHS/DHSR-MHL/5002 Page 2 of 14
Instructions for Completing a Change Licensure Application
Overview
1. These instructions are provided to assist you in completing a change application.
2. Failure to provide all requested information will result in delaying the processing of the application. If the information
does not pertain to your facility mark N/A in the area.
3. Change requests must be submitted at least 30 days prior to the anticipated change.
4. A change in the ownership of a license has an associated fee which must be submitted with the application. The
Change of Ownership fee is shown on chart at end of instructions. Construction related fees will be invoiced to you at
a later date (change of capacity, change of location).
Type of Licensure Application
1. Facility MHL#: Enter Facility Mental Health License number.
2. Check the appropriate box/boxes for the action you are requesting. If the action is not listed, fill in the blank beside
“Other”.
• Change of Location: See Change of Location Checklists (pages 4 & 5).
• Change of Capacity: If increase in capacity you must submit photos & floor plan. Capacity increases over 6 beds
require a per bed fee of $19.00 for beds over 6.
• Change of Service Category: New letter of support needed from the LME
• Change of Facility Name: Complete this application.
• Change of Licensee/Ownership: Complete this application. Signatures are required for the current licensee/owner
and the prospective new licensee/owner (or designees) in #4 and #5 in the change application. A fee is assessed
for a change of ownership which must accompany application.
• Requested Effective Date of Change: Enter date when you are requesting that the change be effective. This may
be related to other changes that are occurring with your business.
Current Information
1. Current Facility Name: Enter name printed on your most current license.
2. Current Facility Site Address: This address is the physical site location as printed on most current license.
3. Current Legal Identity of Ownership/Licensee: This is the name printed on your license as the licensee/owner. Please
complete address & phone information.
4. Signature of Current Licensee: Current licensee or designated authority for licensee must sign and date here. For a
change in ownership request, see above italicized directions for Change of Licensee/Ownership.
5. Signature of Requested New Licensee: If a change of ownership being requested, the representative of the new
licensee must sign here. Please note: there is a change of ownership fee (see “change of ownership fee” table below).
Requested Changes
On the Requested Changes page, please complete only those changes you are requesting.
1. Facility Name: Enter the name of the facility that will be printed on your license.
2. Facility Site Address: Enter the new physical location of your facility.
o Note: If you are changing locations, please make sure the building code classification for the new address
is in compliance with the program(s) to be licensed.
3. Facility Correspondence Mailing Address: This address will be where you will receive all mail for the facility. Indicate
the name to address correspondence.
4. Name of Facility Director: This will be the person who is responsible for managing the facility.
5. Name of Contact Person: This could be you or the person responsible for managing the facility. This person can
answer daily process and licensure questions about the facility.
6. Management Company: Enter this information if the facility will be managed by a company other than the licensee.
7. Local Management Entity/Manage Care Organization (LME/MCO): Enter the names of LME/MCOs with which the
facility has a contract.
8. Legal Identity of Ownership/Licensee: This is the name that will be printed on the license as licensee/owner.
(a) Enter name and contact information of new owner.
(b) Federal Tax ID# - if applicable.
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 Change Application Revised 05/05/2020 DHHS/DHSR-MHL/5002 Page 3 of 14
(c) Check if you are registered with the state as profit or non-profit.
(d) Type of entity under which the business is operated. All entities should be registered with the state except
proprietorship and private partnership.
(e) Supply information for CEO or President.
(f) If you lease the building, complete the data on the person from whom you lease/rent.
9. Owners, Partners, Affiliates, Shareholders (Confidential Information for Official Use Only):
∗ If the ownership has investors or shareholders in the business, fill in the information requested. If ownership is
a corporation/company having only 1 person who is sole owner, please fill in as percentage interest is 100%.
∗ If this is a non- profit entity, Signature and title and date needed in box.
∗ If proprietary ownership, complete the box as if shareholder
10. Extensions in Ownership: Enter information about Affiliates who directly or indirectly control the owner of this facility.
11. Service Categories: Note the change or additions to service category. If change in service category complete “from”
and “to” entries. Check the category that describes the service/s your facility will provide. For residential facilities, enter
the number of beds under either the Children category or Adult category. Increase of beds above 6 may require
invoicing by DHSR for additional fee.
12. Certificate of Need: Note if you have a certificate of need for a required service category, and the CON # and date.
13. Number of Clients: Note the number of clients you will serve and the disability category or categories that you will
serve.
14. Number of Others Living in the Facility: Complete only if requesting service category .5600F or .5100-Private Home
Respite. Include the number and ages of anyone that lives in the facility that is not a client.
15. Ambulatory/ Non-Ambulatory Beds: Complete only if you are requesting a change of Ambulatory Beds to Non-
Ambulatory Beds.
Construction Fees: 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
Change of Ownership Fees
The Operations and Capital Improvements Appropriations Act of 2006 instituted a fee for all residential and non-residential
facilities.
Following is a list of types of facilities that require a change of ownership fee, including the base fee and the per bed fee.
Type of Facility
Number of Beds
Base Fee
Per Bed Fee
Non-residential Facilities
0
$215.00
N/A
Residential Facilities
(Non-ICF/IID)
6 beds or less
$305.00
$0
Residential Facilities
(Non-ICF/IID)
7 beds or more
$475.00
$17.50
ICF/IID Facilities
6 beds or less
$845.00
$0
ICF/IID Facilities
7 beds or more
$800.00
$17.50
Make check payable to: Send Application with required information to:
NC Division of Health Service Regulation Division of Health Service Regulation
MH Licensure & Certification Section
1800 Umstead Drive
2718 Mail Service Center
Raleigh, NC 27699-2718
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 Change Application Revised 05/05/2020 DHHS/DHSR-MHL/5002 Page 4 of 14
Change Application Checklist
a letter explaining the incorrect or missing information. Please complete the correct
checklist below if you are requesting a change of location prior to submitting your
Requirements for 24-hour Residential Programs—Existing Structures
Note: Before 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 and application 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 the dimensions of 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
showing the location of the facility.
5. Local Zoning Department approval for the proposed use.
• 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
6. Letter of support from LME/MCO (Only required when changing Counties)
7. Appointments for Fire & Sanitation Inspections.
Change of Location Checklist: Residential
Item
Completed
1
Completed Change Licensure Application (form DHSR 5002)
2
Floor Plan Identifying all spaces in facility
(all levels/floors, dimensions, doors, windows, smoke detectors, bathrooms, closets)
3
Pictures (Interior & Exterior)
4
Directions to Facility
5
Zoning Approval (original – within 1 year of application date)
Required for application to move forward
6
LME-MCO Support Letter
*Only needed if location change is in a different county then the facility is currently located.
7
Appointments for Fire & Sanitation Inspections.
Actual inspections are not needed when submitting the application but will be needed prior to DHSR Construction
section approval.
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 Change Application Revised 05/05/2020 DHHS/DHSR-MHL/5002 Page 5 of 14
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.
In addi
tion to your cover letter and application 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
showing the location of the facility.
4. Local Zoning Department approval or verification the facility is classified under building/plannin
g
for 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.
Change of Location Checklist: Day Program
Item
Completed
1
Completed Change Licensure Application (form DHSR 5002)
2
Floor Plan Identifying all spaces in facility
(all levels/floors, dimensions, doors, windows, smoke detectors, bathrooms, closets)
3
Pictures (Interior & Exterior)
4
Directions to Facility
5
Zoning Approval (original – within 1 year of application date)
Required for application to move forward
6
Fire & Sanitation Inspections.
(Sanitation inspection only needed if facility will be serving food)
Note: If you are changing locations, please make sure the building code classification for the new
address is in compliance with the programs being licensed (see Building Code Classifications page
below).
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 Change Application Revised 05/05/2020 DHHS/DHSR-MHL/5002 Page 6 of 14
CHANGE LICENSE APPLICATION FOR MH/DD/SAS FACILITIES
TYPE OF CHANGE: FACILITY MHL#: ____________________
Facility Name
Capacity*
Licensee/ Ownership**
Service Category and Code
Ambulatory Bed(s) to Non-Ambulatory Bed(s)
Adding a Mental Health Service to a Mental Health Hospital MHH#: ____________________________
Location* Within the Same County Into a Different County
Shareholders
Other; Please Specify: __________________________________________________________________________
Note: *Change of Location & Change of Capacity require a Construction Fee. You will be invoiced for these fees. Do not send money
for Construction Section when submitting this application. Increase in Capacity over 6 beds requires a licensure fee.
**Change in Ownership requires a license fee to accompany this application
CURRENT LICENSE INFORMATION (complete requested change(s) on following pages)
1. CURRE
NT FACILITY NAME: __________________________________________________________
2. CURRENT FACILITY SITE ADDRESS: (NO P.O. BOXES)
Street Address: ________________________________________________________________________
City: ___________________________________State: Zip Code: County:
Phone: ________________________Email:__________________________________________________
3. CURRE
NT LEGAL IDENTITY OF OWNERSHIP/LICENSEE:
Name of Owner: ____________________________________________________________________
Street Address: _________________________________________________________________________
City: ___________________________________ State: ____________________Zip Code: _____________
Phone: _________________________________ Email: ________________________________________
4. SIGNATURE OF CURRENT LICENSEE: 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.
Name: _________________________________________Title: ___________________________________
Signature: ________________________________________Date: _________________________________
Name: ___________________________________________Title: _________________________________
Signature: ________________________________________Date: _________________________________
5. SIGNATURE OF REQUESTED NEW LICENSEE (if applicable): 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.
Name: ___________________________________________Title: __________________________________
Signature: ________________________________________Date: __________________________________
.
ALL APPLICATIONS MUST BE MAILED TO ABOVE ADDRESS AND MUST HAVE AN ORIGINAL SIGNATURE
OFFICIAL USE ONLY: DHSR Form 5002
Licensure Categories: ________________________________________________________________________________________
Licensure Recommendation: ____________________________________ DHSR Consultant: _______________________________
Remarks: __________________________________________________________________________________________________
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 Change Application Revised 05/05/2020 DHHS/DHSR-MHL/5002 Page 7 of 14
REQUESTED CHANGES
Requested Effective Date of Change: ____________________
∗ Please note, this is requested date of change, there is no guarantee the change will be
completed by this date.
In application pages 7 – 11, please complete ONLY those changes being requested.
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. NEW REQUESTED FACILITY SITE ADDRESS: (NO P.O. BOXES) (Please note you cannot move to the
new location until you have received your new license for this location.)
Street Address: ___________________________________________________________________________
City: ___________________________________State: Zip Code: County:
Phone: _________________________________Email:____________________________________________
*must be installed and operable prior to licensing; cannot be a cell phone.
3. FACILITY CORRESPONDENCE MAILING ADDRESS:
Name of Contact Person: ________________________________________________________
Street Address: _______________________________________________________________
City: ___________________________________ State: ____________________Zip Code: ____________
Phone: _________________________________Email:___________________________________
Email Address (to which all correspondence will be sent)
4. NAME OF FACILITY DIRECTOR :
( First, MI, Last)________________________________________________________________
5. SIGNATURE 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.
Name:
(First, MI,Last)_______________________________________________________________________
Signature: _______________________________Title: ___________________________ Date: ___________
6
. MANAGEMENT COMPANY: If 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:_________________________________________
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 Change Application Revised 05/05/2020 DHHS/DHSR-MHL/5002 Page 8 of 14
7. LOCAL 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:
Full legal name of 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 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: _________________________________________________
(c) NATIONAL PROVIDER IDENTIFIER (NPI): _________________________________________________
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: 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:__________________________________________
Building 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: __________________________________________________________________________
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 Change Application Revised 05/05/2020 DHHS/DHSR-MHL/5002 Page 9 of 14
9. OWNERS, PARTNERS, AFFILIATES, SHAREHOLDERS (Confidential Information for Official Use Only):
Complete the information below on all individuals, proprietorship or entities who are owners, partners, affiliates or shareholders holding
an interest of 5% or more of the applicant entity. Attach additional pages if necessary. We ask that you voluntarily provide your social
security number with the understanding that it will be used only as an identification number for internal record keeping and data
processing. If you are the only owner, complete the information below, listing the percentage interest as 100%. Documentation
verifying all parties agree to change should be submitted in application.
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
licensee applying for or renewing a license:
_____________________________ ____________________________________ _________
Signature Title Date
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 Change Application Revised 05/05/2020 DHHS/DHSR-MHL/5002 Page 10 of 14
10. SERVICE CATEGORIES:
Services subject to licensure under G.S. 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 (initial and renewal)
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.
Changing from __________ to ____________ Adding _____________ Deleting _____________
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 hospitalization 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
.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)
.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
.5000 Facility based crisis service for individuals of all
disability groups
.5100 Community respite services for individuals of all disability
groups
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 Change Application Revised 05/05/2020 DHHS/DHSR-MHL/5002 Page 11 of 14
Rule 10A NCAC 27G Licensure Rules for Mental
Health Facilities
Check
Service of
License
Beds Assigned by Age
0-17
18 & up
Total Beds
.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 (CON required for ICF/IID facility)
Only One from the “.5600” categories can be chosen.
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)
.5600C Group homes for adults whose primary
diagnosis is mental retardation or other developmental
disabilities
(Max. of 6 clients)
.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 the following service categories: .2100, .3400, & .5600 (only when
ICF/IID facility)
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 BEDS:
Type
Current License
Requested Change
Ambulatory*
Non-Ambulatory, 1-3
Non-Ambulatory, 4 or more
*Ambulatory: a person who can evacuate the building 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 private residence is allowable: .5600 F & .5100 Private Home Respite)
Are any of the above people non-ambulatory? Yes No
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 Change Application Revised 05/05/2020 DHHS/DHSR-MHL/5002 Page 12 of 14
CONSTRUCTION: PHYSICAL PLANT
Please fill in EACH inspection Department information if change of location:
Zoning 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
No
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
Page 13 of 14
Building Classifications and Service
NOTE: Day Programs for children and adolescents cannot be 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.
Program
Code
10 NCAC 27G
Facility Type/Service Category
Day/24-
Hour/
Periodic
Building
Classification
Code
.1100
Partial Hospitalization for individuals who are acutely mentally ill
Day
Group B – Business Occupancy (Adults)
Group E – Educational or I-4 (Minors)
a
.1200
Psychosocial Rehab for individuals with Severe and Persistent
Mental Illness
Day
Group B – Business Occupancy
a
.1300
Residential Treatment for Children or Adolescents
24- Hour
Residential – Classification dependent on number & ambulation
status
b
.1400
Day Treatment for Children and Adolescents with Emotional or
Behavioral Disturbances
Day
Group E – Educational Occupancy
or I-4
a
.1700
Residential Treatment Staff Secure for Children or Adolescents
24- Hour
Residential – Classification dependent on number & ambulation
status
d
.1800
Intensive Residential Treatment for Children or Adolescents
24- Hour
Institutional Occupancy
e
.1900
Psychiatric Residential Treatment for Children and Adolescents
24- Hour
Institutional Occupancy
f
.2100
Specialized Community Residential Centers for Individuals with
Developmental Disabilities
24- Hour
Residential or Institutional Occupancy
g
.2200
Before/After School and Summer Developmental Day Services
for Children with or at Risk for Developmental Delays,
Developmental Disabilities, or Atypical Development
Day
Group E- Educational
or I-4
a
.2300
Adult Developmental and Vocational Program for Individuals with
Developmental Disabilities
Day
Group B- Business Occupancy
a
.3100
Nonhospital Medical Detoxification for Individuals who are
Substance Abusers
24- Hour
Institutional Occupancy
h
.3200
Social Setting Detoxification for Substance Abusers
24- Hour
Residential or Institutional Occupancy
m
.3300
Outpatient Detoxification for Substance Abuse
Periodic
Group B – Business Occupancy
a
.3400
Residential Treatment/Rehabilitation for Individuals with
Substance Abuse Disorders
24- Hour
Residential or Institutional Occupancy
i
.3600
Outpatient Opioid Treatment
Periodic
Group B- Business Occupancy
a
.3700
Day Treatment Facilities for Individuals with Substance Abuse
Disorders
Day
Group B- Business Occupancy
Group E – Educational or I-4 (Minors)
a
.4100
Residential Recovery Programs for Individuals with Substance
Abuse Disorders and their Children
24- Hour
Typically Group R – Residential
j
.4300
Therapeutic Community
24- Hour
Typically Group R – Residential
k
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
MHLC Change Application Revised 05/05/2020 DHHS/DHSR-MHL/5002 Page 14 of 14
Program
Code
10 NCAC 27G
Facility Type/Service Category
Day/24-
Hour/
Periodic
Building
Classification
Code
.4400
Substance Abuse Intensive Outpatient Program (SAIOP)
Periodic
Group B – Business Occupancy (Adults)
Group E – Educational or I4 (minors)
a
.4500
Substance Abuse Comprehensive Outpatient Treatment
Program (SACOT)
Periodic
Group B- Business Occupancy
a
.5000
Facility Based Crisis Services for Individuals of All Disability
Groups
24- Hour
Institutional Occupancy
l
.5100
Community Respite Services for Individuals of All Disability
Groups
24- Hour
Typically, Residential depending on number of residents
m
.5200
Residential Therapeutic (Habilitative) Camps for Children and
Adolescents of All Disability Groups
24- Hour
Wilderness Camp Settings
p
.5400
Day Activity for Individuals of All Disability Groups
Day
Group B- Business Occupancy
Group E – Educational or I4 (Minors)
a
.5500
Sheltered Workshops for Individuals of All Disability Groups
Day
Group B- Business Occupancy
a
.5600
Supervised Living for Individuals of All Disability Groups
24- Hour
Residential
o
.6000
Inpatient Hospital Treatment for Individuals who have Mental
Illness or Substance Abuse Disorders
24- Hour
Institutional Occupancy
l
Code
Program Type / Description
a
Day Program
b
Level II Clients
c
This program has been deleted
d
Level II clients (previously part of the .1300 program)
e
Level IV clients. Required to be a secured facility and Institutional – Unrestrained Occupancy (previously part of the .1500 program)
f
PRTF clients. May be staff secured or locked; still Institutional – Unrestrained Occupancy (previously part of the .1500 program)
g
Usually these are ICF/IID facilities and required to have a Certificate of Need (CON)
h
Institutional Occupancy since providing medical treatment
i
Typically, not in a six-bed facility since requires CON
j
Program is for women and their children. Usually in apartment/motel situation but if less than six could be a home
k
Program is for adults and is usually in apartment/ motel situation but if less than six could be in a home
l
Requires Institutional Occupancy since requiring treatment
m
Typically, is with another residential program. Could be part of a larger facility that is not residential.
n
Support Services, not residential
o
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.
p
Residential Camp
q
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
1
Policy and Procedure list 3/30/20
MH Licensure Policies and Procedures
Worksheets
Use of form:
Mental Health Licensure requires the licensee to develop written policies and procedures. Policies and procedures must
be submitted to the Licensure and Training Consultant at the first review. All subchapters and rules are hyperlinked for
convenience in worksheet.
Instructions:
1. Use the policy worksheet to identify the page number on which you address each point for ease in reference and
review.
2. Policy and procedure manuals must include table of contents with page numbers or below worksheet.
3. The Yes, No, NA and I (incomplete) columns are for internal use.
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. The information below is only a snapshot of the actual rules
and is not a substitute for obtaining a licensure rule book.
Division of Health Service Regulation
Mental Health Licensure and Certification Section
Policies and Procedures: Initial Licensure Survey
2
Policy and Procedure list 3/30/20
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
10A NCAC 27G .201 Governing Body
Yes
No
NA
(I)
1. Delegation of Management Authority (Chain of command).
2. Admission Criteria for admission into facility.
3. Admission Assessments including:
• who will perform the assessment; and
• time frames for completing assessment.
4. Criteria for discharging client from facility
5. Client record management, including:
• persons authorized to document;
• how to transport records;
• safeguard of records
• record accessibility to authorized users and
•
assurance of confidentiality of records.
Division of Health Service Regulation
Mental Health Licensure and Certification Section
Policies and Procedures: Initial Licensure Survey
3
Policy and Procedure list 3/30/20
Policy Page
Number Must be
Entered
Rule
Yes
NO
N/A
(I)
6. Screenings and assessments, which shall include:
• Individuals presenting problem or need;
• will provide services to address the needs of the individual;
•
disposition of clients.
7. Quality assurance and Quality improvement activities, including:
• 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
;
• st
aff credentialing/privilegin
g
• review of all fatalities
•
adoption of standards practice.
8. Incident Reporting
9. Voluntary Non-Compensated client work
10. Fee assessment and collection
11. Medical Emergency Plan
12. Authorization for and follow up of lab tests.
Division of Health Service Regulation
Mental Health Licensure and Certification Section
Policies and Procedures: Initial Licensure Survey
4
Policy and Procedure list 3/30/20
Policy Page
Number Must be
Entered
Rule
Yes
NO
N/A
(I)
13. Transportation including the accessibility of emergency information for a client when
transporting.
14. Safety precautions and requirements for facility areas including 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 are going to execute).
15. Volunteers: services of volunteers, including supervision and requirements for maintaining
client confidentiality.
16. Areas in which staff, including nonprofessional staff, receive training and continuing education.
17. Client grievance policy and procedures for review of client grievances
18. Minutes of the governing body shall be permanently maintained.
19. Policies and procedures for;
• identifying,
• reporting,
• investigating and,
• controlling infectious and communicable diseases of staff and client.
Division of Health Service Regulation
Mental Health Licensure and Certification Section
Policies and Procedures: Initial Licensure Survey
5
Policy and Procedure list 3/30/20
NOTES
Division of Health Service Regulation
Mental Health Licensure and Certification Section
Policies and Procedures: Initial Licensure Survey
6
Policy and Procedure list 3/30/20
Policy Page
Number Must be
Entered
10A NCAC 27G .0203 Competencies of Qualified and Associate Professionals
Yes
No
NA
(I)
1. Policy on implementing and creating the individualized supervision plan upon hiring each
associate professional
Policy Page
Number Must be
Entered
10A NCAC 27G .0204 COMPETENCIES AND SUPERVISION OF PARAPROFESSIONALS
Yes
No
NA
(I)
2. Policy on implementing and creating of the individualized supervision upon hire of each
paraprofessional.
Policy Page
Number Must be
Entered
10A NCAC 27G .0205. ASSESSMENT AND TREATMENT/HABILITATION OR SERVICE PLAN
Yes
No
NA
(I)
3. The plan shall be developed based on the assessment, and in partnership with the client or
legally responsible person or both, within 30 days of admission for clients who are expected to
receive services beyond 30 days.
4. The plan shall include:
• client outcome(s) that are anticipated to be achieved by provision of the service and a
p
rojected date of achievement;
• strategies;
• staff responsible;
• a schedule for review of the plan at least annually in consultation with the client o
r
le
gally responsible person or both;
• 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 stating why such consent could not be obtained.
Division of Health Service Regulation
Mental Health Licensure and Certification Section
Policies and Procedures: Initial Licensure Survey
7
Policy and Procedure list 3/30/20
10A NCAC 27G .0209. MEDICATION REQUIREMENTS
Page Number
Must be Entered
Medication Dispensing
Yes
No
NA
(I)
1. Medications dispensed only by written MD order.
2. Dispensing of medications only by Licensed person.
3. How take-home Methadone given to client by RN only.
4. Policy on how Facilities shall not keep prescription drugs for dispensing without a Pharmacist,
except for emergency use.
Medication packaging and labeling
5. Policy on Non-Prescribed drug containers not dispensed by a Pharmacist must have original label
with expiration dates visible.
6. Policy on Prescription medications must be dispensed in tamper resistant packaging.
7. Policy on the label of prescription meds must include:
• Client name;
• MD name
;
• d
ispensed date;
• administration directions;
• name, strength, quantity & expiration date of drug;
•
name & address of pharmacy; name of Pharmacist.
Medication administration
8. How prescription or non-prescription drugs shall be administered.
9. A Medication Administration Record (MAR) of all drugs 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
• name or initials of person administering the drug.
Division of Health Service Regulation
Mental Health Licensure and Certification Section
Policies and Procedures: Initial Licensure Survey
8
Policy and Procedure list 3/30/20
Policy Page
Number Must be
Entered
Rule
Yes
NO
N/A
(I)
10. Medications, including injections, shall be administered only by licensed persons, or by
unlicensed persons trained by a registered nurse, pharmacist or other legally qualified person
and privileged to prepare and administer medications.
11. Client requests for medication changes or checks shall be recorded and kept with the MAR file
followed up by appointment or consultation with a physician.
Medication Disposal
12. Upon discharge of a patient or resident, the remainder of his or her drug supply shall be disposed
of promptly unless it is reasonably expected that the patient or resident shall return to the
fac
ility and in such case, the remaining drug supply shall not be held for more than 30 calend
ar
days after the date of discharge.
Medication Storage
13. Medications shall be stored:
• 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.
o 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;
•
in a secure manner if approved by a physician for a client to self-medicate.
Policy Page
Number Must be
Entered
Medication review
1. 6-month drug review by a Psychiatrist or Pharmacist required if taking Psychotropic medications
2. Findings from drug review recorded in client record with corrective action plan.
3. Staff is responsible for informing MD of review results if medical intervention is indicated.
Division of Health Service Regulation
Mental Health Licensure and Certification Section
Policies and Procedures: Initial Licensure Survey
9
Policy and Procedure list 3/30/20
Policy Page
Number Must be
Entered
Medication Errors
YES
NO
N/A
(I)
4. Policy on significant adverse drug reactions and how reported immediately to a physician or
pharmacist.
SUBCHAPTER D. GENERAL RIGHTS
Policy Page
Number Must be
Entered
10A NCAC 27D .0101. POLICY ON RIGHTS RESTRICTIONS AND INTERVENTIONS
YES
NO
N/A
(I)
If facility uses Seclusion, Restraints and Isolation Time Out this section MUST be in facility’s policy and procedure manual
1. How ALL instances of alleged or suspected abuse, neglect or exploitation of clients are reported
to the County Department of Social Services.
2. What safeguards are used when medications are known to present serious risk.
3. Identify restrictive intervention (RI) that is prohibited from use within the facility.
4. If a 24-hour facility, the circumstances under which staff are prohibited from restricting the
rights of a client.
5. Identify allowed restrictive intervention(s) in your facility.
6. Staff (position) responsible for informing client of restrictive interventions.
7. Due process procedure for a client who refuses the use of restrictive interventions.
8. Identify staff person (position) responsible for giving written permission for giving written
permission for 24hr restrictive interventions.
9. Identify staff person (position) who is responsible for review client of restrictive interventions.
10. Process for appeal for the resolution of any disagreement over the planned use of a restrictive
intervention.
Division of Health Service Regulation
Mental Health Licensure and Certification Section
Policies and Procedures: Initial Licensure Survey
10
Policy and Procedure list 3/30/20
Policy Page
Number Must be
Entered
Rule Continued
Yes
NO
N/A
(I)
11. Following the use of restrictive intervention, the staff shall conduct a debriefing and
planning with the client and legally responsible person. This process should be conducted
based on the cognitive functioning of the client.
Policy Page
Number Must be
Entered
10A NCAC 27D .0102. SUSPENSION AND EXPULSION POLICY
12. Policy documenting each client shall be free from threat or fear of unwarranted suspension or
expulsion from the facility.
13. The policy shall address the criteria to be used for suspension, 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 staff of the facility to identify an alternative service to meet the client's needs and
designation of such service; and
• the discharge plan, if any.
Policy Page
Number Must be
Entered
10A NCAC 27D .0103. SEARCH AND SEIZURE POLICY
14. Policy that specifies the conditions under which searches of the client or his/her living area
may occur, and if permitted, the procedures for seizure of the client's belongings, or
property in the possession of the client.
15. Each client is free from unwarranted invasion of privacy.
16. Specifications on the conditions under which searches of the client or person’s area may occur.
17. Where and how to document a search and seizure.
(A) scope of search;
(B) reason for search;
(C) procedures followed in the search;
(D) a description of any property seized; and
(E) an account of the disposition of seized property.
Division of Health Service Regulation
Mental Health Licensure and Certification Section
Policies and Procedures: Initial Licensure Survey
11
Policy and Procedure list 3/30/20
NOTES
Division of Health Service Regulation
Mental Health Licensure and Certification Section
Policies and Procedures: Initial Licensure Survey
12
Policy and Procedure list 3/30/20
Policy Page
Number Must be
Entered
10A NCAC 27D .0104. PERIODIC INTERNAL REVIEW
YES
NO
N/A
(I)
18. Procedure on conducting a review at least every 3 years to check for compliance with
applicable laws.
19. The governing body will keep and maintain the three most recent written reports of the findings
of reviews.
Policy Page
Number Must be
Entered
10A NCAC 27D .0201. INFORMING CLIENTS
20. Written client rights shall be made available to each client and or legal representative.
21. Each client shall be informed of his right to contact the Disability Rights of North Carolina.
22. Documentation kept in client record that client rights have been explained.
23. Within 72 hours or three visits, client will be informed of rules and violation penalties; disclosure
rules for confidential info; procedure for obtaining a copy of treatment plan; grievance
procedure (including contact person); suspension/expulsion and search and seizure.
24. In facilities using Restrictive Interventions: timeframe client will 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 a
restrictive interventions; a competent adult may designate an individual to receive information
after restrictive interventions and notification provisions regarding restriction of rights.
Policy Page
Number Must be
Entered
10A NCAC 27D .0202. INFORMING STAFF
25. Policy on informing staff of client rights.
26. Documentation of receipt of information by each staff
Division of Health Service Regulation
Mental Health Licensure and Certification Section
Policies and Procedures: Initial Licensure Survey
13
Policy and Procedure list 3/30/20
Policy Page
Number Must be
Entered
10A NCAC 27D .0301. SOCIAL INTEGRATION
YES
NO
N/A
(I)
27. Each client in a day/night or 24-hour facility is encouraged to participate in appropriate and
generally acceptable social interactions and activities with other clients and non
‑
client members
of the community.
28. Clients shall not be prohibited from appropriate and generally acceptable social interactions and
activities with other clients and non
‑
client members of the community.
Policy Page
Number Must be
Entered
10A NCAC 27D .0302. CLIENT SELF‑GOVERNANCE
29. A day/night or 24
‑
hour facility, allows client input into facility governance and the development
of client self
‑
governance groups
Policy Page
Number Must be
Entered
10A NCAC 27D .0303. INFORMED CONSENT
30. Clients will be informed about the alleged benefits potential risks and alternative treatments.
31. Clients will be about the length of time the consent is valid and what the procedure is to
withdraw consent:
• The timeframe of consents (no more than six months)
• written consents for;
Planned interventions
Antabuse and Depo-Perovera
32. Clients have a right to refuse treatment and not be threaten with termination.
Division of Health Service Regulation
Mental Health Licensure and Certification Section
Policies and Procedures: Initial Licensure Survey
14
Policy and Procedure list 3/30/20
Policy Page
Number Must be
Entered
10A NCAC 27D .0304. PROTECTION FROM HARM, ABUSE, NEGLECT OR EXPLOITATION
YES
NO
N/A
(I)
33. Staff shall protect clients from harm, abuse, neglect and exploitation in accordance with G.S.
122C-66.
34. Staff shall not subject a client to any sort of abuse or neglect.
35. Goods or services shall not be sold to or purchased from a client.
36. Staff shall use only that degree of force necessary to repel or 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
the degree of aggressiveness displayed by the client.
37. Any violation by a staff of this rule is grounds for dismissal.
SUBCHAPTER E. TREATMENT OR HABILITATION RIGHTS
SECTION 10A NCAC 27E. PROTECTIONS REGARDING INTERVENTIONS PROCEDURES
If the facility uses Seclusion, Restraints and Isolation Time Out below 10A NCAC 27E Treatment
of Habilitation Rights must be reflected in the facility’s policy and procedure manual.
Policy Page
Number Must be
Entered
10A NCAC 27E .0101. LEAST RESTRICTIVE ALTERNATIVE
1. Facilities shall provide services using the least restrictive, most appropriate while ensuring a safe
and respectful environment.
2. The use of restrictive intervention’s shall be accompanied by actions to insure dignity and
respect during the after the intervention. Including using the intervention as a last resort; and
employing the intervention by people trained in its use.
Division of Health Service Regulation
Mental Health Licensure and Certification Section
Policies and Procedures: Initial Licensure Survey
15
Policy and Procedure list 3/30/20
Policy Page
Number Must be
Entered
10A NCAC 27E .0102. PROHIBITED PROCEDURES
YES
NO
N/A
(I)
3. The following procedures are prohibited: corporal punishment; painful body contact; substances
which create painful bodily reactions; electric shock; insulin shock; unpleasant tasting foodstuffs;
application of noxious substances (noise, bad smells, splashing with water); physically painful
procedures to reduce behavior
4. The governing body may determine to prohibit use of any interventions deemed unacceptable.
Policy Page
Number Must be
Entered
10A NCAC 27E .0103. GENERAL POLICIES REGARDING INTERVENTION PROCEDURES
5. Procedures only employed when clinically or medically indicated as a method of therapeutic
treatment.
6. The determination that a procedure is clinically/medically indicated and the authorization for use
of such treatment for a specific client can only be made by a physician or a licensed PHD who has
been formally trained and privileged in the use of a procedure.
Policy Page
Number Must be
Entered
10A NCAC 27E .0104. SECLUSION, PHYSICAL RESTRAINT AND ISOLATION TIME-OUT AND PROTECTIVE
DEVICES USED FOR BEHAVIORAL CONTROL
7. Written policy delineates use of restrictive interventions.
8. The use of restrictive interventions shall be limited to:
• 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 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 § 483.356 - Protection of residents.)
Division of Health Service Regulation
Mental Health Licensure and Certification Section
Policies and Procedures: Initial Licensure Survey
16
Policy and Procedure list 3/30/20
Policy Page
Number Must be
Entered
Rule Continued
Yes
NO
N/A
(I)
9. Restrictive interventions are considered a planned intervention and must 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 which will allow the use of less restrictive
treatment or habilitation procedures.
10. The planned intervention has consent or approval and shall be considered 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 to b
e
needed
11. How restrictive interventions will not be used as coercion, punishment or retaliation by staff or
for the convenience of staff or due to inadequacy of staffing.
12. Restrictive intervention’s will not be used in a manner that causes harm or abuse.
13. Define and outline the permissible use of restrictive interventions within a facility.
14. The facility shall collect and analyze data on the use of seclusion and 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
•
the effectiveness of the procedure or alternative employed.
15. The facility shall analyze the data on at least a quarterly basis to monitor effectiveness,
determine trends and take corrective action where necessary. The facility shall make the data
available to the Secretary upon request.
Division of Health Service Regulation
Mental Health Licensure and Certification Section
Policies and Procedures: Initial Licensure Survey
17
Policy and Procedure list 3/30/20
Policy Page
Number Must be
Entered
Rule Continued
Yes
NO
N/A
(I)
16. Identifying, training, assessing competence of facility employees who may authorize and
implement restrictive interventions.
17. The duties and responsibilities of responsible professionals regarding the use of restrictive
interventions.
18. The person responsible (position) for documentation when restrictive interventions are used.
19. The person responsible (position) for the notification of others when restrictive interventions are
used.
20. The person responsible (position) for checking the client's physical and psychological well-being
and assessing the possible consequences of the use of a restrictive intervention.
21. Procedures with the use of Restrictive Interventions:
• documentation physical disabilities
• 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 limited.
22. Precautions and actions are employed when a client is in seclusion or physical restraint.
23. Discontinuing immediately at any indication of risk to the client's health or safety.
24. Standing orders or PRN orders shall not be used to authorize the use of seclusion, physical
restraint or isolation timeout.
Division of Health Service Regulation
Mental Health Licensure and Certification Section
Policies and Procedures: Initial Licensure Survey
18
Policy and Procedure list 3/30/20
Policy Page
Number Must be
Entered
Rule Continued
Yes
NO
N/A
(I)
25. When any restrictive intervention is utilized for a client, who, when and how others will be
notified.
26. How the facility will conduct reviews and reports on any and all use of restrictive interventions.
Division of Health Service Regulation
Mental Health Licensure and Certification Section
Policies and Procedures: Initial Licensure Survey
19
Policy and Procedure list 3/30/20
NOTES
Division of Health Service Regulation
Mental Health Licensure and Certification Section
Policies and Procedures: Initial Licensure Survey
20
Policy and Procedure list 3/30/20
Policy Page
Number Must be
Entered
10A NCAC 27E .0105. PROTECTIVE DEVICES
27. Procedure ensuring when a protective device is utilized for a client
• The necessity for the protective device
• Facility employee using device has been trained and demonstrated competence in the
use for device
• Observation and interventions documented in client record
•
Protocol on maintenance and cleaning of the devices
28. Procedure documenting if facility is operated by or under contract with an area program, the
utilization of protective devices in the treatment/habilitation plan shall be subject to review by
the Client Rights Committee.
10A NCAC 27E .0106. INTERVENTION ADVISORY COMMITTEES
29. Intervention Advisory Committee shall be established to provide additional safeguards in a
facility that utilizes restrictive interventions as planned interventions
30. Document who is required in the membership of your Intervention Advisory Committee.
31. A procedure that governs the Intervention Advisory Committee and details how client
information is disseminated and reasoning for disseminating.
32. A procedure regarding the Intervention Advisory Committee will document the specific training
and orientation given to the Committee.
NOTES
____________________________________________________________________________________________________________________ ______
___________________________________________________________________________________________________________________________
Division of Health Service Regulation
Mental Health Licensure and Certification Section
Policies and Procedures: Initial Licensure Survey
21
Policy and Procedure list 3/30/20
Treatment Rights in 24-hour Facilities
Policy Page
Number Must
be Entered
NCGS 122C-61: Treatment rights in 24-hour facilities
YES
NO
N/A
(I)
1. 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 to have as soon as practical during treatment but not later than the time of
discharge, an individualized written discharge plan containing recommendation 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
3. Adult Clients have the right to:
• Make and receive confidential phone calls
• Receive visitor’s between 8:00 a.m. and 9:00 p.m. for at least 6 hours daily, 2 hours shall
be after 6:00pm. Visiting shall not take precedence over therapies.
• Communicate & meet under appropriate supervision with individuals of own choice.
• Make visits outside of the facility unless issues related to commitment proceedings or
court order.
• 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.
Division of Health Service Regulation
Mental Health Licensure and Certification Section
Policies and Procedures: Initial Licensure Survey
22
Policy and Procedure list 3/30/20
Policy Page
Number Must
be Entered
Rule Continued
Yes
NO
N/A
(I)
4. Minor Clients have the right to:
• Make and receive phone calls.
• Under appropriate supervision, receive visitor’s b/n 8:00 a.m. and 9:00 p.m. for at least 6
hours daily, 2 hours shall be after 6:00pm. 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 on a regu
lar
b
asis 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.
NOTES
____________________________________________________________________________________________________________________ ______
____________________________________________________________________________________________________________________ ______
Division of Health Service Regulation
Mental Health Licensure and Certification Section
Policies and Procedures: Initial Licensure Survey
23
Policy and Procedure list3/30/20
S
ubchapter 27F Specific Rules for 24-Hour Facilities
SUBCHAPTER 27F - 24-HOUR FACILITIES
Policy Page
Number Must
be Entered
10A NCAC 27F .0101 Scope
1. Article 3, Chapter 122C of the General Statues provides specific rights for each client who receives a
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
2. Efforts to make a quiet atmosphere for uninterrupted sleep, privacy areas.
3. Client may suitably decorate room, when appropriate.
Policy Page
Number Must
be Entered
10A NCAC 27F .0103 Health, Hygiene and Grooming
4. Clients will have the right to dignity, privacy and humane care in healthy hygiene
and grooming.
5. Client’s 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 use by a client with a mobility impairment
will be available.
7. Ct bathtubs, showers and toilets will be private.
Division of Health Service Regulation
Mental Health Licensure and Certification Section
Policies and Procedures: Initial Licensure Survey
24
Policy and Procedure list 3/30/20
Policy Page
Number Must
be Entered
10A NCAC 27F .0104 Storage and Protection of Clothing and Possessions
8. Staff will make every effort to protect client personal clothing and possessions from loss or damage.
Policy Page
Number Must
be Entered
10A NCAC 27F .0105 Client’s Personal Funds
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 deduction from accounts for payment of treatment/habilitation
services when authorized; issue receipts for deposits and withdrawals provide client quarterly
statements.
11. Authorization by client 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
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).
Division of Health Service Regulation
Mental Health Licensure and Certification Section
Policies and Procedures: Initial Licensure Survey
25
Policy and Procedure list 3/30/20
NOTES
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