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

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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 09/01/2021
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 Change Application Revised 09/01/2021 DHHS/DHSR-MHL/5002 Page 2 of 15
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 delay the application's processing 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 that must be submitted with the application. The Change of
Ownership fee is shown on the chart at the end of the instructions. In addition, 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 the increase in capacity, you must submit photos & a 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 the application.
• Requested Effective Date of Change: Enter the 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 the name printed on your most current license.
2. Current Facility Site Address: This address is the physical site location printed on the most current license.
3. Current Legal Identity of Ownership/Licensee: This is the name printed on your license as the licensee/owner. Please complete
the 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 is requested, the new licensee's representative 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 the name and contact information of the 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 09/01/2021 DHHS/DHSR-MHL/5002 Page 3 of 15
(c) Check if you are registered with the state as a 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 the sole owner, please fill in as percentage interest is 100%.
∗ If this is a non-profit entity, the signature and title and date are needed in the provided box.
∗ If proprietary ownership, complete the box as if a 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 the service category. If a change in the service category, complete "from" and
"to" entries. Check the category that describes the service/s your facility will provide. For example, enter the number of beds for
residential facilities under either the Children category or Adult category. An increase of beds above 6 may require invoicing by
DHSR for an 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 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 the required information to:
N.C. 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 09/01/2021 DHHS/DHSR-MHL/5002 Page 4 of 15
Change Application Checklist
letter explaining the incorrect or missing information. Please complete the correct checklist
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 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. The location of all smoke detectors noting whether they are battery-operated, wired into the house
current with battery backup, and 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.
• 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 the 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 a location change is in a different county than 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 09/01/2021 DHHS/DHSR-MHL/5002 Page 5 of 15
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 a
ddition 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 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 Official's 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 the 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 the 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 09/01/2021 DHHS/DHSR-MHL/5002 Page 6 of 15
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. An 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. CURREN
T 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 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 THE ABOVE ADDRESS AND MUST HAVE AN ORIGINAL SIGNATURE
Licensure Categories: ____________________________ Check # _______________________________ Check Amount:_________________
SOS:________ ACCESS:_________ PPT:________ ACO:____________
Remarks:_______________________________________________________________________________________________ Staff Initials: ______
Fillable Form (Signatures are not fillable)
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 09/01/2021 DHHS/DHSR-MHL/5002 Page 7 of 15
REQUESTED CHANGES
Requested Effective Date of Change: ____________________
∗ Please note, this is the requested date of the change. There is no guarantee that the change will be
completed by this date.
In application pages 7 – 11, please complete ONLY those changes being requested.
1. REQUES
TED 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. REQUES
TED 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. REQUES
TED NAME OF FACILITY DIRECTOR :
( First, MI, Last)__________________________________________________________________
5. SIGNAT
URE 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)_______________________________________________________________________________
Signat
ure: _______________________________Title: ___________________________ Date: _________________
6
. REQUESTED MANAGEMENT COMPANY: If a 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:__________________________________________________
Fillable Form (Signatures are not fillable)
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 09/01/2021 DHHS/DHSR-MHL/5002 Page 8 of 15
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 an individual, partnership, corporation or other legal entity that 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: _______________________________________________________
(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: __________________________________________________________________________________
Fillable Form (Signatures are not fillable)
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 09/01/2021 DHHS/DHSR-MHL/5002 Page 9 of 15
9. OWNE
RS, 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 the 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
Fillable Form (Signatures are not fillable)
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 09/01/2021 DHHS/DHSR-MHL/5002 Page 10 of 15
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 a
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
Fillable Form (Signatures are not fillable)
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 09/01/2021 DHHS/DHSR-MHL/5002 Page 11 of 15
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 Y
OU 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. NUMB
ER 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. NUM
BER AND AGE
(s) OF PEOPLE OTHER THAN CLIENTS RESIDING WITHIN THE FACILITY:
(Applicable only in categories where the private residence is allowable: .5600 F & .5100 Private Home Respite)
__________________________________________________________________________________________
Are any of the above people non-ambulatory? Yes No
Fillable Form (Signatures are not fillable)
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 09/01/2021 DHHS/DHSR-MHL/5002 Page 12 of 15
CONSTRUCTION: PHYSICAL PLANT
Please fill in EACH inspection Department information if a 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
Fillable Form (Signatures are not fillable)
Page 13 of 15
Building Code Zoning Classifications - Requirements for Licensure Categories (revised 7/7/2015)
Program Code
10 NCAC 27G
Facility Type
24-hour
programs
Building
Classification
Code
.1100
Partial Hospitalization for individuals who are acutely mentally ill
No
Group B – Business Occupancy (Adults)
Group E – Educational or I-4 (Minors)
a
.1200
Psychosocial Rehab for individuals with Severe and Persistent Mental Illness
No
Group B – Business Occupancy
a
.1300
Residential Treatment for Children or Adolescents
Yes
Residential – Classification dependent on
number & ambulation status
b
.1400
Day Treatment for Children and Adolescents with Emotional or Behavioral
Disturbances
No
Group E – Educational Occupancy
or I-4
a
.1700
Residential Treatment Staff Secure for Children or Adolescents
Yes
Residential – Classification dependent on
number & ambulation status
d
.1800
Intensive Residential Treatment for Children or Adolescents
Yes
Institutional Occupancy
e
.1900
Psychiatric Residential Treatment for Children and Adolescents
Yes
Institutional Occupancy
f
.2100
Specialized Community Residential Centers for Individuals with
Developmental Disabilities
Yes
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
No
Group E- Educational
or I-4
a
.2300
Adult Developmental and Vocational Program for Individuals with
Developmental Disabilities
No
Group B- Business Occupancy
a
.3100
Nonhospital Medical Detoxification for Individuals who are Substance
Abusers
Yes
Institutional Occupancy
h
.3200
Social Setting Detoxification for Substance Abusers
Yes
Residential or Institutional Occupancy
m
.3300
Outpatient Detoxification for Substance Abuse
No
Group B – Business Occupancy
a
.3400
Residential Treatment/Rehabilitation for Individuals with Substance Abuse
Disorders
Yes
Residential or Institutional Occupancy
i
.3600
Outpatient Opioid Treatment
No
Group B- Business Occupancy
a
.3700
Day Treatment Facilities for Individuals with Substance Abuse Disorders
No
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
Yes
Typically Group R – Residential
j
.4300
Therapeutic Community
Yes
Typically Group R – Residential
k
.4400
Substance Abuse Intensive Outpatient Program (SAIOP)
No
Group B – Business Occupancy (Adults)
Group E – Educational or I4 (minors)
a
.4500
Substance Abuse Comprehensive Outpatient Treatment Program (SACOT)
No
Group B- Business Occupancy
a
.5000
Facility-Based Crisis Services for Individuals of All Disability Groups
Yes
Institutional Occupancy
l
.5100
Community Respite Services for Individuals of All Disability Groups
Yes
Typically, Residential depending on the
number of residents
m
.5200
Residential Therapeutic (Habilitative) Camps for Children and Adolescents
of All Disability Groups
Yes
Wilderness Camp Settings
p
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
.5400
Day Activity for Individuals of All Disability Groups
No
Group B- Business Occupancy
Group E – Educational or I4 (Minors)
a
.5500
Sheltered Workshops for Individuals of All Disability Groups
No
Group B- Business Occupancy
a
.5600
Supervised Living for Individuals of All Disability Groups
Yes
Residential
o
.6000
Inpatient Hospital Treatment for Individuals who have Mental Illness or
Substance Abuse Disorders
Yes
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 it requires CON
j
The 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, it is with another residential program. However, it 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.
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
An appli
cant is allowed six months from the date contact is made with the applicant and a Licensure & Training team member
to complete the program review of the application process.
• A pers
on 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 that 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.
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Completed 21 February 2022

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