Ensuring Quality Care
in Nursing Homes in North Carolina

Please note that Continuing Care Retirement Communities (CCRCs) are another type of housing that has nursing home beds. 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.

What is a Continuing Care Retirement Community?

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 a nursing home to legally exist, the agency must apply for a Certificate of Need from the Department of Health and Human Services (Division of Health Services Regulation), and be approved.

The Health Planning Unit of DHSR determines how many facility beds will be designated either private pay, Medicare, or Medicaid. In other words, the government will agree to reimburse a facility with either Medicare or Medicaid funds for services to an eligible resident if he or she is assigned to a "Medicare" or "Medicaid" bed. If a resident is admitted to a "private pay" bed, he or she is responsible for payment of services without using Medicare or Medicaid funds. The Certificate of Need section determines how many beds of each type a facility may offer.

Certificate of Need Section

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 (both nursing homes and adult care homes). Their purpose is to insure compliance with state licensure regulations for safety standards. They work with local building inspectors to make sure licensure regulations, fire protection codes, and building codes are met.

When all reviews are completed and approved, the Construction Section recommends licensure to the Nursing Home Licensure and Certification Section, which then 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. In other words, at this time, the Nursing Home Licensure and Certification Section determines if the agency, group, or individual applying for licensure is able to deliver resident services in accordance with current rules and procedures.

After a facility is licensed to operate, construction inspections of some types of facilities are made, as time permits, to verify continued compliance with construction and safety standards. Inspections are made when indicated by complaints, requests by other agencies, and/or a facility's request.

This section also determines if a nursing home qualifies for Medicare/Medicaid reimbursement. As a part of this determination, the Construction Section has engineers, paid with federal funds, that survey nursing homes wishing to qualify for Medicare/Medicaid certification. The inspections are done initially and thereafter annually (unannounced) for safety and building compliance.

It is helpful to note several things here. First, licensure is a state process. Certification is a federal process. The requirements may be different. Licensure must be approved before a facility can apply for certification. The Construction Section handles the building and safety regulations portion of the process for both types of approval - licensure and certification. The Licensure and Certification Section waits for a positive recommendation from the Construction Section before it begins the health and care portion of the licensure and/or certification process. The Licensure and Certification Section makes the final determination as to whether or not a facility meets all the requirements.

Please also note the importance of Medicare/Medicaid certification. If a nursing home is not certified for Medicare/Medicaid, that means all the beds will be assigned as "private pay" beds (see Certificate of Need section above). Only those persons who could afford to pay for care out of their own pocket would be accepted. If the facility is certified for Medicare/Medicaid, then the facility will be told how many beds they may offer, what types of beds they may offer, and how many beds of each type they may offer. This makes a difference for a person seeking admission because the method of payment he or she will use will determine if there is an available bed for them.

Construction Section

Additionally, the Division of Medical Assistance determines eligibility for individuals to receive Medicaid reimbursement for nursing home care. This is different from eligibility for a facility to be able to receive reimbursement for Medicare/Medicaid. When a facility receives certification for Medicare/Medicaid, they may then accept residents who pay for their care with either Medicare or Medicaid.

Division of Medical Assistance

Nursing Home Licensure and Certification Section

This section is primarily responsible for conducting annual and follow up inspections in nursing homes.

Nursing Home Complaints Investigation
This section has two functions:

• complaint intake, and
• complaint investigations.

The Complaint Intake Unit is generally staffed with two nurses who respond to calls between the hours of 8:00am and 5:00pm. During Holidays and between hours there is an automated answering machine available to the public. The section provides a toll-free number for citizen complaints at 800-624-3004. Complaints are primarily taken by phone, however, letters and in-office visits are also accepted.

• Division of Health Services Regulation
  Develops and implements policies, administrative rules, and procedures governing the licensing and enforcement of compliance for nursing homes, and conducts facility surveys (monitoring) when indicated.

  

  Division of Health Services Regulation

  

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

  

  Division of Social Services

  

• County Departments of Social Services
  Each county Department houses an Adult Protective Services Unit that responds to complaints of abuse, neglect, and exploitation of older or disabled adults in nursing homes.

  

  County Departments of Social Services

  

• 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.

  

  CAP-MR/DD
  Division of Mental Health/DD/SAS
  Thomas S.

  

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

• Division of Medical Assistance (DMA)
  Administers and establishes the eligibility requirements for the state Medicaid programs.

  

  Division of Medical Assistance

  

• 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.
  

  Division of Aging and Adult Services
  Locate an Ombudsman in Your Area
  More About the Ombudsman Program

  

• Local Building Inspectors and Fire Departments
  Conduct safety inspections annually.

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

• Home Health Agencies and Hospice
  Provide service to individual residents upon physician orders and provider/family arrangement.

• 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 and cover approximately ten percent of nursing homes statewide.

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. A daily fine of up to $200 is levied for each day the violation is not corrected.

• 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 an 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 which is normally not imposed unless it is believed that continued admissions would place a threat to the safety and welfare of residents.

• Temporary Management
  The General Assembly passed a law in 1993 which enables DHSR, 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.

• 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. 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 imminent life-threatening conditions exist in a facility.