Ensuring Quality Care
in Assisted Living Facilities in North Carolina


Ensuring the quality of care in assisted living facilities is important to everyone.


To help ensure that quality of resident care is consistent from one facility to another, the legislature gave the Department of Health and Human Services (DHHS) the authority and responsibility to:

  • license facilities
  • define rules and procedures for facilities
  • monitor facilities to ensure that the rules and procedures are being followed
  • ensure that any problem areas were corrected.

The Department (DHHS) chose the Division of Health Services Regulation to handle oversight and regulation of all of the responsibilities listed above for adult care homes in North Carolina.


Division of Facility Services
courtesy Division of Health Service Regulation


Please note that assisted living facilities include Multi-Unit Housing with Services and Continuing Care Retirement Communities. These two types of facilities are handled in a slightly different manner from adult care homes.

Assisted living housing, called Multi-Unit Housing with Services, is not required to be licensed; however, this type of housing is required to register with the NC Division of Health Service Regulation and to provide a disclosure statement describing services offered, charges for services, financial/legal relationship with home care agencies, and other important information for consumers.


Continuing Care Retirement Communities (CCRCs) are another type of housing that is considered assisted living. They may offer either nursing home or adult care home levels of service and may provide both. Use the link below to find out more about them and how they are regulated.


Older Man
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Division of Health Service Regulation

The Division of Health Service Regulation is divided into to several sections/branches to handle the oversight and regulation of adult care homes. Some of them are:


Certificate of Need Section

"The North Carolina Certificate of Need Law prohibits health care providers from acquiring, replacing, or adding to their facilities and equipment, except in specified circumstances, without the prior approval of the Department of Health and Human Services. The law restricts unnecessary increases in health care costs and limits unnecessary health services and facilities based on geographic, demographic and economic considerations. The fundamental premise of the CON Law is that increasing health care costs may be controlled by governmental restrictions on the unnecessary duplication of medical facilities." So, in order for an adult care home to legally exist, the agency must apply for a Certificate of Need from the Department of Health and Human Services (Division of Health Service Regulation), and be approved. This section will tell the applicant how many adult care home beds they may offer.


Construction Section

Architects and engineers, funded by state appropriations, review plans and specifications, both for new and existing buildings, for facilities applying to be licensed by the Division. They perform an on-site inspection in conjunction with local building inspectors and fire code inspectors as well. Their purpose is to insure compliance with state licensure regulations for safety standards.

When all reviews are completed and approved, the section recommends licensure to the Adult Care Home Licensure Section, which at that time assesses the program aspects of licensure that relate to delivery of resident services in order to issue a new or revised license to the applicant. Licensure is a two part process. The Construction Section evaluates for building safety and codes and then makes a recommendation to the Adult Care Home Licensure Section which then makes a separate evaluation to assess the applicant's ability to deliver resident services in accordance with current rules and procedures. (Read more about this process in the next section.)

After a facility is licensed to operate, construction inspections are made, as time permits, to verify continued compliance with construction and safety standards. Adult care homes are generally scheduled for bi-annual inspections for compliance with construction and safety standards. Other inspections are made when indicated by complaints, requests by other agencies, and/or a facility's request.


Adult Care Licensure Section

This section is responsible for licensing and regulating assisted living facilities called adult care homes, the registration of assisted living facilities called multi-unit housing with services, and the certification of administrators.

When the Construction Section makes a favorable recommendation for licensure to the Adult Care Home Licensure Section, the second part of the process begins. This section determines if the agency, group, or individual applying for licensure is able to deliver resident services in accordance with current rules and procedures. A Registered Nurse, a pharmacist, a dietician, and a local Adult Home Specialist (Department of Social Services) work together to conduct the evaluation. If they find that the applicant is able to deliver both a safe environment and quality care, the applicant is then licensed to provide services.

Adult care homes are governed by state rules and regulations, not federal. There is no certification process for Medicare/Medicaid reimbursement for adult care homes. What this means is that residents are responsible for paying for care versus having Medicare or Medicaid pay for care, as may be the case in nursing homes. However, since 1996, adult care homes may apply to the Division of Medical Assistance to enroll, versus being certified, as a Medicaid provider. The Division of Medical Assistance offers a program called State/County Special Assistance to pay for some personal care services for eligible individuals paid for with Medicaid dollars. (This same program may also be used to help some eligible individuals pay for total care in an adult care home, though reimbursement is made directly to the individual.) If an adult care home is enrolled as a Medicaid provider, some residents may be eligible to have some personal care paid for by Medicaid. For eligibility questions related to Medicaid or state/county special assistance, contact your local county Department of Social Services. They are also the contact agency for complaints and concerns.

There are two types of adult care homes:

  • family care homes for two to six residents
  • adult care homes for seven or more residents


The North Carolina legislature specifically authorized county Departments of Social Service to supervise adult care homes under rules made by the Medical Care Commission.

The Division of Health Service Regulation:

  • works with the county Departments of Social Services to ensure the bi-monthly monitoring of facilities is completed
  • performs inspections of homes when needed or requested
  • may levy penalties against homes out of compliance with the regulations
  • provides oversight for the Adult Home Specialist's annual assessment and monitoring plan




General Types of Oversight

The following agencies/organizations/programs have some degree of oversight of adult care homes, with direct or indirect regulatory authority.

  • Division of Health Service Regulation
    Develops and implements policies, administrative rules, and procedures governing the licensing and enforcement of compliance for adult care homes, and conducts facility surveys (monitoring) when indicated. also acts as a consultant to the local Departments of Social Services and provides technical assistance, training, and oversight of the local DSS Adult Home Specialists.

  • Division of Social Services (DSS)
    Administers the Special Assistance for Disabled Adults program, Adult Protective Services, civil rights programs, and case management services.

  • County Departments of Social Services
    Monitor adult care homes for compliance with rules, investigate complaints, and provide case management services to eligible residents. Each county Department also houses an Adult Protective Services Unit that responds to complaints of abuse, neglect, and exploitation of older or disabled adults in adult care homes.

  • Division of Mental Health/Developmental
    Disabilities/Substance Abuse Services (DMH/DD/SAS)

    Administers case management and treatment services for Thomas S., CAP-MR/DD, and other residents requiring treatment and habilitation services.

  • Area Mental Health Programs
    Provide services to clients - as requested - by families, physicians, or facilities.

  • Division of Aging and Adult Services (DAAS)
    Oversees the state’s Long-Term Care Ombudsman program which involves the following:

    • NC Long-Term Care Ombudsmen
      Advocate on behalf of nursing home residents and provide a variety of services and assistance to nursing home residents, families, and providers. Complaint resolution is one of the services provided. They are particularly well informed about Residents' Rights issues.

      • Community Advisory Committees
        Observe and report to the ombudsmen the general conditions of homes observed during quarterly unannounced facility visits and may assist residents in resolving grievances.
  • Local Building Inspectors and Fire Departments
    Conduct safety inspections annually.

  • Local Health Departments
    Conduct sanitation inspections annually, and more often to follow up corrective action.

  • Home Health Agencies and Hospice
    Provide service to individual residents upon physician orders and provider/family arrangement and often report observations to regulatory agencies.

  • Occupational Health and Safety Administration (OSHA)
    Inspects for compliance with its regulations which include those governing infection control. In long-term care facilities, the emphasis is on employee safety and hazards. Typical issues would be surfaces where an employee could trip, slip, or fall; ergonomics; bloodborne pathogens; tuberculosis; etc. They provide education and training on safety and hazard issues to facility staff to help ensure the safety of all. Inspections are random.




The Oversight Process

Facilities that violate licensure rules or the certification standards can be subject to sanctions, including fines. Facilities vary according to the type of care they are licensed to provide. Some adult care homes provide care for those with Alzheimer's and/or dementia. They may be in a Special Care Unit or service may be offered in a locked unit.


Be sure to inquire about the type of service for which the home is licensed. This will impact what agency goes in to monitor service and safety and how often they go in to ensure the quality of care. Pay special attention if the person needing care has Alzheimer's disease or related dementia. Read about Special Care Units and locked units before deciding whether or not to choose the facility. Ask questions about oversight, staff training, and activities provided.

In addition to the licensure and certification requirements, adult care homes must also honor the Residents' Bill of Rights. These rights are designed to promote and protect the well-being of residents.


For regulatory complaints within adult care homes, there are Adult Home Specialists within each county Department of Social Services available to look into complaints and concerns. They also provide annual assessments with oversight by the Division of Health Service Regulation under rules set by the Medical Care Commission.


The Construction Section of the Division of Health Services Regulation generally schedules bi-annual inspections for compliance with construction and safety standards. Other inspections are made when indicated by complaints, requests by other agencies, and/or a facility's request.

The Long-Term Care Ombudsman Program advocates on behalf of adult care home residents and provides a variety of services and assistance to residents, families, and providers. Complaint resolution is one of the services ombudsmen provide. The Ombudsmen are available to assist residents and families whenever they are needed. The Community Advisory Committee members visit adult care homes at least quarterly and work to resolve problems when identified. They are particularly well informed about Residents' Rights issues.


Fire Departments conduct safety inspections annually.

Health Departments conduct sanitation inspections annually.

Adult Home Specialist,
Department of Social Services
Annual Assessment
Bi-monthly Monitoring**
Construction Section,
Division of Health Service Regulation
Bi-annual & By Request
Fire Department Annually
Local Health Department Annually
Abuse, Neglect, Exploitation
Department of Social Services
Regional Long-Term Care Ombudsmen As Needed
Community Advisory Committees, Ombudsmen Program Quarterly
Mental Health As Requested
Home Health and Hospice As Requested

* Visits are minimums.
**The annual assessment follows guidelines developed by the Division of Health Services Regulation, with key health and safety indicators. The Adult Home Specialist decides which issues need additional review and develops an overview monitoring plan geared toward correcting any problem areas. The bi-monthly monitoring by the Adult Home Specialist is designed to ensure that the monitoring plan is being carried out successfully. The Specialist has the authority to cite a facility for violations and to recommend an appropriate penalty. The Penalty Review Committee (see below) then reviews the violations and specifies an appropriate penalty to the Division of Health Service Regulation for implementation.




Penalties and Enforcement

The North Carolina legislature authorizes the Secretary of the Department of Health and Human Resources to establish a Penalty Review Committee of nine members to review all violations.

There are two basic types of violations:

Type A
Violations are those that create substantial risk that death or serious physical harm will occur or where such harm has occurred. Penalty amounts for this type can range from $250 to $5,000 for homes licensed for nine or fewer beds and $500 to $10,000 for adult care homes of ten or more beds. Uncorrected Type A violations are subject to a daily penalty of up to $500.00 a day if not corrected within the time frame specified in the plan of correction.

Type B
Violations are those that present a direct relationship to the health, safety, or welfare of residents, but not substantial risk of death or serious physical harm. No monetary fines are imposed unless violations are not corrected within the time frame specified on the plan of correction. There is a daily fine of up to $200 for each day the violation is not corrected.


Other Means of Enforcement
In addition to civil money penalties, the Division of Health Service Regulation has several other enforcement remedies available in state law as follows:

  • Provisional License
    Reduction from a full to a provisional license can occur when the provider fails to substantially comply with applicable laws and rules and there is reasonable expectation that the home will comply in a reasonable amount of time and remain in compliance.

  • Suspension of Admissions
    Suspension of new admissions may also be imposed when the provider fails to substantially comply with applicable laws and rules. This is a more severe penalty than a provisional license and is normally not imposed unless it is felt that continued admissions would place a threat on the safety and welfare of residents.

  • Temporary Management
    The General Assembly passed a law in 1993 which enables , in lieu of using revocation or summary suspension action, to ask the courts to appoint a temporary manager to operate a facility where conditions exist that create a substantial risk of death or serious physical harm to residents. Unfortunately, in situations where this option is needed, action needs to be taken immediately - the situation could not afford to have the court take up to 20 days to act.

  • Revocation
    Revocation of a license can occur when a provider fails to substantially comply with applicable laws and rules and there is no reasonable expectation for the facility to come into compliance within a reasonable amount of time or remain in compliance even if it comes into compliance. Obviously, this is the most severe action short of summarily suspending a license.

  • Summary Suspension of a License
    A license can be summarily suspended and residents relocated (closing the home and moving the residents) without prior due process in the event that there are imminent life-threatening conditions in a facility.


The Division of Health Service Regulation encourages all involved to settle disputes through informal means. They give providers an opportunity to informally dispute actions taken against them and to provide additional information that may not have been available to the surveyors at the time of the monitoring visit.

Following all informal appeals, the Administrative Procedures Act governs through use of a contested case process (except for summary suspension of a license which is implemented without prior due process). If a provider is dissatisfied with the decision at the administrative level, the provider can appeal to superior court.

The NC Division of Health Service Regulations also posts penalties for Adult Care Homes that they monitor.




Facility Compliance

Check with your Ombudsman and/or the NC Division of Health Service Regulation for information on recent citations and complaints for a facility being considered. Find out information about how well a facility abides by federal, state, and local regulations by seeing if the facility has been brought before the North Carolina Division of Health Services Regulations Penalty Review Committee. This nine-member committee reviews administrative penalties charged against adult care homes and to makes recommendations regarding penalties to the Division of Health Service Regulation. This information is now available online and a link is provided below to the Adult Care Licensure Section.




Abuse, Neglect, and Exploitation

Any suspicion of the occurrence of Elder Abuse must be reported, according to North Carolina law.

Complaints of immediate life-threatening conditions as well as abuse, neglect and misappropriation in adult care homes are referred to Adult Protective Services within each county Department of Social Service.
Person Available to Help

You may make a confidential and anonymous report if you wish. Remember, the resident being abused needs your help.

You Can Make the Difference!



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