NCALA Members’ Frequently Asked Questions

Members’ Frequently Asked Questions

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Regulation of Assisted Living Communities in North Carolina

Who regulates assisted living communities in North Carolina?

In NC, the Adult Care Licensure Section (ACLS) of the Division of Health Service Regulation (a division of the Department of Health and Human Services) regulates assisted living communities, which are called “Adult Care Homes” in the rules and regulations. ACLS is responsible for licensing of adult care homes (seven or more beds), issuing and renewing adult care home administrator certificates, among other responsibilities. ACLS performs initial and annual inspections of licensed adult care facilities, issues and renews adult care facility licenses, takes administrative actions against licensees or facilities as warranted based on non-compliance with state rules and statutes, and assists with complaint investigations as needed or requested by county departments of social services or complainants, among other functions. You can find their Web site and learn more about the ACLS here: https://www2.ncdhhs.gov/dhsr/acls/.

Administrator Certification

If a person has a North Carolina Nursing Home License, is the Adult Care Home Certification Required?

Yes, administrator certification is required for all persons who wish to operate an Adult Care Home. Current nursing home administrators ARE NOT exempt from the 120-hour classroom training, and are also still required to take the North Carolina State Rules Exam for Adult Care Homes. If you have further questions about this, contact DHSR at (919) 855-3765.

What are the CEU requirements for a certification to remain current?

Administrator certification is valid for two years and an administrator must receive 30 hours of DHSR-approved CEUs during that two-year period.

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Adult Care Home Training Requirements

Is it required that all personal care staff must be listed on the nurse aide registry or have completed this training?

Adult Care Home rules do not require that personal care staff complete the nurse aide-training program. If the employee has not, then it is the provider’s responsibility that the staff member complete an approved 80-Hour Training Program within the first six months of employment.

Providers are also required to check the DHSR Health Care Personnel Education and Credentialing Section to determine if any allegations of abuse or neglect have been reported against the applicant employee.

What are the continuing education requirements for a care coordinator and an aide in an Alzheimer’s Special Care Unit?

As with other special care unit staff, the care coordinator and aide must have 12 hours of continuing education annually. Six of those hours must be dementia-specific CEUs. The additional six hours must be in the area of medication administration for the care coordinator since that is a supervisory position. The same is true for the aide if the aide administers medication. Otherwise, the aide could take the remaining 6 hours of required CEUs in areas related to the care of older or disabled adults.

What are the training requirements for volunteers?

Volunteers who are performing personal care tasks that require training and/or competency validation per licensure rules must have the required training and/or competency validation. Volunteers working in this capacity are to be considered as staff by virtue of the personal care they are providing, regardless of the fact that they are not paid for their services. Such volunteers must meet all requirements in the licensure rules for the staff whose duties they are performing.

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Criminal Record Background Checks

Who do criminal background checks need to be performed on?

Criminal background checks have to be done for all employees who have direct, hands-on contact with residents. So, the exterminator, gardener, elevator mechanic, etc, do not have to be checked. A temporary CNA or RN must be checked by their temp agency (you may want to make sure that the temp agency is doing these checks and that it is in your contract with them).

Who must perform criminal background checks?

Senate Bill 41 requires that, for those prospective employees who have lived in North Carolina for less than five consecutive years, a national criminal records check must be obtained. For those prospective employees who have lived in North Carolina for more than five years, only a state criminal record check is required. In addition, the law requires that all contract agencies whose employees have direct contact with your residents must comply with this law.

The State Bureau of Investigation (SBI) is the state agency designated in the law to perform the national criminal record checks. As with the earlier law, state criminal record checks on prospective unlicensed employees who have direct access to your residents can either be sent to the SBI, or you may contract with a private provider to complete these checks for you.

In order to send requests for checks to the SBI, you must first contact them to obtain information on what they require from you to register for this process. You must obtain the SBI Access Agreement and sign it before the process is implemented.

You can call the SBI at (919) 662-4509, or send a request for information to the following address:
 
State Bureau of Investigation
Criminal Information and Identification Section
PO Box 29500
Raleigh, NC, 27626-0500

What is the effective date of the criminal record check law affecting adult care and family care homes?

This law, GS 131D-40 Criminal History Record Checks, applies to applicants for employment on or after January 1, 1997. Staff hired after, not prior to, that date are required to be checked since the law states that an offer of employment is conditional on consent to a criminal record check of the applicant. The law does not indicate that staff hired prior to the effective date of the law have to have a criminal record check.

Must an administrator who is also an owner of the facility have a criminal background check as required in GS 131D-40?

No, a criminal record check would not be necessary since the information provided by the check is strictly confidential to the hiring entity, which would be the administrator/owner, and intended to be used for hiring purposes only.

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Cost of Care

Is it possible for an adult care home to accept payments for room and board from a third party, in addition to the maximum rate established by the General Assembly, on behalf of State/County Special Assistance (SA) residents residing in the facility?

Yes, under the following conditions:

  1. The payment is made directly by the third party (family member, church, charity, etc) to the facility. Money paid directly to the facility to supplement the cost of room and board under the conditions below will not be counted as income and will not affect SA eligibility or the SA payment amount.
  2. The payments made by the third party are made voluntarily and result in one of the following:
    1. a private room is provided; or
    2. a private or semi-private room in a special care unit is provided.
  3. Accepting payments from a third party on behalf of a SA recipient, where the SA recipient resides in a regular semi-private room, is not permitted.
  4. Money given directly to the SA recipient, regardless of intent, is counted as income in determining SA eligibility and establishing SA payment amounts.

10A NCAC 13G .0704

May a facility require a hospitalized resident’s family to pay the personal care rate Medicaid pays the facility?

No. While the facility is not getting the Medicaid personal care payments during the resident’s hospitalization, neither is the resident receiving personal care services in the facility for which the Medicaid payments are intended. SA payment for room and board does continue during hospitalization for bed hold purposes.

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Discharge/Transfer

If a home changes ownership, may the new owners discharge the SA residents solely on the basis of being SA recipients?

No. This is not a grounds for discharge according to Rules 13F .0702 and 13G .0705. Failure to pay cannot be cited since these resident are being charged and have been paying the maximum amount allowed by law.

If a resident slaps a staff person or another resident, is this grounds for discharge?

This is not automatically grounds for discharge, particularly if it is a one-time occurrence and there is not serious injury and continuing threat to others in the home. Rules 13F .0702(d)(2) and 13G .0705(d)(2) state that there must be documentation of the incident and “the facility’s action taken to address the problem prior to pursuing discharge.”

Is a facility obligated to disregard a resident’s 14-day notice if the resident wishes to withdraw it?

The purpose of the 14-day notice is to allow the facility the opportunity to make any kind of arrangements necessary as a result of the resident leaving the facility. Once the notice has been given, the facility may arrange for the admission of another resident who will occupy the bed that is to be vacated. The facility is not under any obligation to disregard the notice if the resident decides not to leave, unless stated otherwise in the resident contract.

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Electronic Signatures

May facilities accept hospital forms or documents that have orders with electronic signatures of physicians?

Yes; however, there should be a statement on the form or document stating that an electronic signature was used.

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Food Service

Must a salt shaker be removed from a resident’s dining room table if the resident is on a no-added-salt diet?

No, not unless all residents at the table suffer from dementia or confusion and are on no-added-salt diets. Otherwise, if it is the practice of the home to have shakers on the tables rather than providing individual packets, the salt shakers should remain so that resident’s rights are not violated. The facility is responsible for preparing and serving the food to comply with the diet as ordered. If a resident is consistently non-compliant with the no-added-salt diet by adding salt to food at the table, the resident should be advised of the health threat involved and the resident’s MD consulted about the non-compliance.

Are facilities required to provide second servings of food at meal times upon request?

While rules do not address second helpings of food at meals, the provision of second helpings to residents on diets that are not calorie controlled is a “reasonable response,” as indicated in G.S. 131D-21(7), to this request. In addition, this is taking into account food preferences and customs of residents as required in 13F and 13G .0904. Also, GS 131D -21(1) is applicable.

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Furnishings

If a resident chooses to furnish their own rooms, are they mandated to have all of the required furnishings?

If a resident wishes to furnish his/her own room but does not want all of the required furnishings, the resident agreement or some piece of documentation on file would need to indicate that. This would not present a problem from a regulatory perspective, so long as there is evidence that this is in accordance with the resident’s wishes, and that any furnishings used or not used do not negatively impact, in any way, the health and safety of the resident.

Are resident dining room chairs allowed to have casters or rollers?

Your copy of “Rules for Adult Care Homes” may state in 13F.0306(d)(2): “…chairs that are sturdy, non-folding, without rollers, and designed to minimize tilting.” However, this rule has been revised effective July 1, 2005.

The updated rule, as of July 1, 2005, states:
13F.0306(d)(2): “…chairs that are sturdy, without rollers unless retractable or on front legs only, non-folding, and designed to minimize tilting.” [emphasis added]

Are molded plastic/resin chairs appropriate for use in facilities?

These chairs are not appropriate as interior furnishings from either a resident’s rights perspective or a safety perspective. Typically sold as lawn, deck, porch, or patio chairs, they are not intended as standard living room, dining room, or bedroom furniture and would not meet the requirement of “one comfortable chair” in the resident’s bedroom [13F .0306(b)(5) and 13G .0315(b)(5)]. However, a resident may have his/her own chair of this type as a personal furnishing if he/she so desires. As a safety issue, plastic/resin can crack and break and the rear legs of these chairs have been know to break when tilted back under weight. There is also the added risk of instability on hard services because of the tendency to slide.

May a resident be given a lock box to put where wanted in the resident’s room? May the lock box be placed in a lockable closet accessible with key by the administrator or SIC/AIC as requested by the resident?

Rules 13F and 13G .0906 (e) require lockable space within the facility and a key for the resident to have access to the space, but do not indicate whether the space has to be portable or stationary. A lock box may be used and kept in the resident’s room. The lock box may be placed within another lockable space, such as a closet, that only the administrator or SIC/AIC has access to, if requested by the resident.

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Healthcare and CPR

How is “quarterly” interpreted as used in Rule 13F and 13G .0903(c)?

These rules require a quarterly licensed health professional support review of applicable residents. Quarterly means every three months and does not mean strictly every 90 days. The wording was changed in the rule from every 90 days to quarterly to avoid a strict application of a specific number of days. If a review was done on March 1st, it would be expected that the next review would be performed sometime around the first of June, but not necessarily on the 90th day.

Does the use of insulin pumps require Licensed Health Professional Support?

Yes. The use of insulin pumps does require the licensed health professional support review according to 13F and 13G (a)(15) since it is medication administration through injection. A quarterly review by a registered nurse is required even if the resident completely manages the pump on his/her own. If staff are involved in any way with administering, managing, and/or monitoring the pump, the LHPS competency validation would be required according to 13F and 13G .0504, as well as the quarterly review.

When are bed rails considered a restraint?

If a resident is unable to get out of bed on his/her own because of physical incapacity, bed rails would not be considered a restraint. The same would hold true for a resident whose dementia is so severe that it has clearly impacted the resident’s capacity to get out of bed independently. However, if a resident with dementia is physically capable of controlling movements sufficiently to leave the bed, even if not likely to do so, the rails would be a restraint because of restriction of freedom of movement.

What does “on the premises” mean in Rules 13F and 13G .0507, which requires a CPR-trained staff person on the premises at all time?

Since CPR must be administered within a short period of time to be effective and prevent brain damage, premises must be interpreted to mean within the building or temporarily in the immediate area surrounding the building. While the CPR-trained staff could be in the yard area of the home from where he/she can be summoned quickly, this requirement may not be met by the staff person required to be within 500 feet of the home who, while on call, may not be able to be at the resident’s side within a matter of 2–3 minutes.

Is compliance with Rules 13F and 13G .0507 (Training on CPR) met if a staff person has had CPR training within the past 24 months, but the CPR certification has expired?

Yes. These rules require completion of CPR training within the last 24 months, not current certification. At this time, the American Red Cross offers a 1-year certification and the American Heart Association a 2-year certification. But as long as there is documentation that the training was completed through one of these programs or any of the other programs referenced in the rules within the last 24 months, the requirement is met.

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Medicare Drug Benefit—Medicare Part D

Will assisted living facilities be considered long-term care facilities under Medicare Part D?

No. The CMS definition of long-term care facility excludes assisted living.

If Medicaid covers assisted living as an alternative to nursing home placement, will those residents be treated the same as nursing home residents?

No. The Medicare Modernization Act makes no special provision for assisted living residents. AL residents will have to pay the same cost sharing as Medicare beneficiaries who reside in the community. This includes the co-pay of $1.00–$5.00 per prescription for low-income residents. Medicare Part D also makes no provision for payment for special pharmacy services for assisted living residents. This includes special packaging and delivery of medications.

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Medication-related Questions

Do Rules 13F .1010(a) and 13G .1010(a) restrict a resident’s choice of Pharmacy?

These rules do place some restriction on a resident’s choice of pharmacy if a pharmacist does not dispense medications in a way that enables the facility to administer medications according to its established medication administration policies and procedures. A facility having multiple systems of medication administration as a result of different pharmacies’ dispensing methods creates a greater chance of errors in medication administration. Since the facility is responsible for assuring safe administration and establishing policies and procedures to enable that, those policies and procedures can specify a system that requires medications to be dispensed in certain ways. Therefore, it is important that residents and responsible persons be made aware of the facility’s medication administration system and its impact on packaging of medications the facility is responsible for administering.

May a family member administer medications to a relative?

Medication in an adult care home is the responsibility of the facility unless there is a physician’s order for self-administration. If there is such an order, the family member may administer medications if the resident so desires. Only the resident with a self-administering order can give that authority to a family member.

What should happen if a resident or staff member refuses a vaccine required by law?

Residents and staff are to be notified of the immunization requirements according GS 131D-9 (pneumococcal vaccine for residents and flu vaccine for residents and employees). The law requires facilities to notify residents and employees of the immunization requirements and request that they be immunized, but they can refuse immunization after being fully informed of the health risks. If a person refuses immunization, the facility must document refusal by, at a minimum, a statement signed by the person refusing immunization stating that he/she was notified of the immunization requirement and fully informed of the health risks of not being immunized. This documentation should be maintained in the resident’s record or personnel file.

Are MARs and counting of medications required for residents who self-administer?

No, although it would be a good practice because it would provide a list of the medications that the resident is taking. If a MAR is maintained, it is also good practice to indicate self-administration on the form, especially if staff document when the resident takes his/her medication, or so staff will know why there is no documentation on the MAR, especially when a resident self-administers some medications but not all of them. The resident’s ability to self-administer should be evaluated on an ongoing basis.

What are the time frames for implementation of medication orders?

While such time frames are not specified in the rules, it is highly recommended that the facility’s policies and procedures address time lapses for starting administration of new orders such as emergency or stat orders, antibiotics, routine medication, and methods of legal borrowing of doses. The type of medication as well as the resident’s condition should be considered. For example, the facility’s policy for medications prescribed for acute problems, such as antibiotics, would require a more timely start of administration than for routine medications or those for chronic conditions. It is recommended that the facility get the assistance of a licensed health professional, such as a pharmacist, in determining an appropriate lapse time for starting new orders since it is the facility’s responsibility to assure the availability of medication in a time frame that would not put the residents’ health or safety at risk.

What is the facility’s responsibility for residents who refuse to follow physician orders or refuse to pay for medications?

Refusal to follow medication orders must be documented on the MAR as required by Rules 13F and 13G .1004(j)(7). In order to comply with Rules 13F and 13G .0902, the facility should notify the resident’s physician about refusals. The facility should advise the resident about the importance of following physician’s orders and what the health repercussions are of not following orders. The resident’s responsible person should also be informed. If the physician does not change the order and the resident continues to refuse, the facility should continue to document refusals and inform the resident that a discharge may be necessary because the facility is unable to meet the resident’s needs. Depending on the circumstances, i.e., how serious a health threat it is, the facility can do less than a 30-day discharge according to Part (b)(1) of the rule or a 30-day discharge according to Part (b)(6) of the rule. For refusal of payment (not lack of funds to pay), the facility must follow 30-day discharge procedures according to Part (b)(5) of the rule. The facility is still responsible for assuring medications are administered as ordered, as long the person is a resident of the facility, regardless of refusal or inability to pay.

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Record Retention Requirements

What are the record retention requirements for Adult Care Homes in NC?

10A NCAC 13F .0302: Design and Construction—The community shall have current sanitation and fire and building safety inspection reports maintained in the community and available for review.

10A NCAC 13F .0501: Personal Care Training and Competency—Documentation of the successful completion of the 80-hour training and competency evaluation program shall be maintained in the community and available for review. Documentation of the on-the-job training shall be maintained in the community and available for review.

10A NCAC 13F .0502: Personal Care Training Content and Instructors—The training provider shall maintain copies of the certificates and the skills evaluation checklists for a minimum of five years.

10A NCAC 13F .0503: Medication Administration Competency—A copy of the certificate (written exam) shall be maintained and available for review in the community.

10A NCAC 13F .1002: Medication Orders—Documentation of training attended by staff shall be maintained in the community.

10A NCAC 13F .1007: Medication Disposition—These records shall be maintained in the community for a minimum of one year.

10A NCAC 13F .1008: Controlled Substance—Records of controlled substances returned to the pharmacy or destroyed by the community shall be maintained by the community for a minimum of three years.

10A NCAC 13F .1202: Disposal of Resident Records—Shall be filed at the community for at least one year and then stored for at least two more years.

10A NCAC 13F .1213: Availability of Corrective Action and Survey Reports—Make available to residents and their families or responsible persons and to prospective residents and their families or responsible persons, upon request and within the community, corrective action reports by the county departments of social services and community survey reports by state licensure consultants that have been approved by the Adult Care Licensure Section of the Division of Health Service Regulation within the past 12 months.

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Release of Records

To whom can resident records be released?

Resident records can be released to the resident, guardian of the resident, or the resident’s power of attorney/healthcare power of attorney, provided the POA/HCPOA documentation authorizes such disclosure. Pursuant to Resident Right #6 (GS 131D-21), the resident may identify to whom he/she wants the records to be released. Additionally, most HIPPA forms allow the resident to name persons with whom he/she wants the records shared. If the resident is deceased, the personal representative of the estate (court-appointed administrator or executor of the will) is the person who is authorized to request records.

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Respite Care

Can respite care in adult care homes be used for day or partial-day stays in the facility, as well as overnight stays?

Respite care in adult care homes is intended for a short-term stay that does not exceed 30 days. A respite care period must be established by contract that specifies the date of admission and discharge as required in Rules 13F and 13G .0907. Subsequent respite care stays by the same resident must also be established by separate contracts and all the requirements of the respite rule would apply, i.e., admission, discharge dates, current FL-2, short-term assessment, verification of orders if not signed and dated within 7 days prior to admission, etc, for each separate respite stay period. The person is to be admitted as a respite resident, not a daily visitor, for a limited time period (30-day maximum) as specified in the contract, and provided care, services, and accommodations as any resident is entitled to receive according to law and rule. The respite resident must have a resident-designated bedroom and must be counted as a resident of the home for capacity, census, and staffing purposes. The rule does not allow for a contract to provide unlimited respite care throughout the year, whether it is on a daily or overnight basis. Each respite stay must be contracted and time-limited. How the respite period, as specified in the contract with an admission and discharge date, is used by the caregiver seeking respite, e.g., overnight stays or day/partial-day stays, depends on that caregiver.

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Staff-related Questions

Who is subject to being reported to the Health Care Personnel Registry?

Under General Statute 131E-256 Health Care Personnel Registry, the facility is obligated to report to the Health Care Personnel Registry allegations that appear to be related to the neglect or abuse of a resident, misappropriation of property, diversion of drugs, and fraud by healthcare personnel. Healthcare personnel in adult care homes are defined in this statute as “adult care personal care aide who is any person who either performs or directly supervises others who perform task functions in activities of daily living which are personal functions essential for the health and well being of residents …” Since the definition says “any person,” the person does not have to be an employee or payroll staff of the facility for the facility to report an allegation. Even if the person is employed from a staffing agency by a family member of the resident and this person is performing tasks as stated in the law, the facility is responsible for reporting any allegations specified in the law against this individual. The facility is responsible for the safety and protection of residents under its care and, therefore, is responsible for reporting according to the requirements of the law, regardless of the employment status of the individual authorized to provide or supervise personal care tasks.

What are the staff requirements for employees from staffing agencies?

Employees from staffing agencies must meet the appropriate qualifications in the rules for the position they are filling. The facility must have the appropriate documentation of staff qualifications (usually obtained from the employment agency) on file in the facility.

Must the names of staff on duty be posted in the facility?

No. GS 131D-4.3(a)(5) requires homes to post information on required staffing that indicates the number, not names, of direct care staff and supervisors that must be on each shift.

Is there a regulation in place that requires all AL staff to be CNA’s?

This will only become a requirement if and when the 1915 Waiver goes into effect. Right now there is no end in sight for that process, and it will be at least a year or so before this is a requirement. Providers should continue to hire based on existing practice, and if the person is not a CNA, then use the 80-hour training. Check the DHSR Health Care Personnel Education and Credentialing Section to see if the person has ever been listed as a CNA—the listing does not need to be current—but they must have a listing at some point in time and in good standing (no abuse and neglect!). If the person has ever been listed on the Registry, then the 80 hour training is not required. The employer MUST always do the LHPS competency validation on EVERYONE.

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