State Assisted Living Policy: 1998. North Carolina



Assisted living residences NCAC Title 10 Chapter 42 Subchapter 42B, 42C and 42D; General statute 131D-2

General Approach

A one year moratorium on the construction of new assisted living residences was passed in 1997. The bill allows a waiver of the moratorium for counties with high occupancy rates.

Legislation passed the end of July 1995 established the umbrella term of "assisted living residences" for two types of long term residential care settings: (1) adult care homes, formerly called domiciliary homes, which must be licensed by the state; and (2) multi-unit assisted housing with services, a new housing category effective July 1, 1996, which must be registered with the state.

Multi-unit assisted housing models have to register with the Division of Facility Services and provide a disclosure statement to residents based on requirements established by the state. The statement describes the emergency response system, charges for services offered, limitations of tenancy and services, resident responsibilities, financial relationships between housing management and home care or hospice agencies, a listing of all home care or hospice agencies in the area, an appeal process and procedures for annual screening and referrals for service.


"Assisted living residence" means a group housing and services program for two or more adults, by whatever name it is called, which makes available, at a minimum, one meal per day and housekeeping services and provides personal care services directly or through a formal written agreement with one or more licensed home care agencies. Assisted living residences are to be distinguished from nursing homes subject to the provisions of G.S. 131E-102. Effective October 1, 1995 there are two types of assisted living residences: adult care homes and group homes for developmentally disabled adults.

"Adult care home" is an assisted living residence in which the housing management provides 24hour scheduled and unscheduled personal care services to two or more residents, either directly or, for scheduled needs, through formal written agreement with licensed home care or hospice agencies. There are three types of adult care homes.

  1. Adult care homes licensed for seven or more beds;

  2. Family care home,--an adult care home licensed for 2-6 beds; and

  3. Group home for developmentally disabled adults--an adult care home which is licensed for 2-9 beds for developmentally disabled adult residents.

"Multi-unit assisted housing with services" means "an assisted living residence in which hands on personal care services and nursing services which are arranged by housing management are provided by a licensed home care or hospice agency, through an individualized written care plan." Multi-unit assisted housing with service programs are required to register with the Division of Facility Services and to provide a disclosure statement.

Unit Requirements

Settings in which services are delivered may include self-contained apartment units or single or shared room units with private or common baths. Residential building codes apply to adult care homes serving six or fewer residents and institutional codes to adult care homes service more than six residents.

Adult homes may serve up to four residents per bedroom. Bedrooms must be 100 square feet, excluding vestibule and closet, for single rooms and 80 square feet per bed for multiple occupancy rooms. One bathroom must be provided for every five residents and a shower for every 10 residents.

Tenant Policy

Unless a physician determines otherwise, adult care homes may not care for people who are ventilator dependent, or require continuous licensed nursing care. Individuals whose physician certifies that placement is no longer appropriate, individuals whose health needs cannot be met in the specific adult care home as determined by the residence and people with such other medical and functional care needs as the Social Services Commission determines cannot be properly met cannot be served.

The disclosure statement for multi-unit assisted housing with services programs is required to be part of the rental agreement and covers the emergency response system, charges for services, limitations of tenancy, limitations of services, resident responsibilities, the financial and legal relationships between the housing management and home care or hospice agencies, a listing of all home care or hospice agencies in the area, an appeals procedure and procedures for initial and annual resident screening and referrals for services.

Unless the individual's physician determines otherwise, multi-unit assisted housing with services may not care for people who are ventilator dependent, have dermal ulcers stage III and IV, except stage III ulcers that are healing, take psychotropic medications without appropriate diagnosis and treatment plans, have nasogastric tubes or gastric tubes except when the individual is capable of independently feeding themself or is managed by a home care or hospice agency, individuals requiring continuous nursing care, and individuals who require maximum assistance with four or more ADLs and who meet the nursing home level of care criteria.


At a minimum residences must provide one meal a day and housekeeping services. Personal care may be provided directly or through contracts. Nursing services may be provided by the residence on a case by case exception basis approved by the Department of Health and Human Services. However, nursing services can be provided through licensed home care agencies. The Social Services Commission has the authority to limit nursing services provided by assisted living residences.


Personal care in adult care homes is reimbursed as a state plan service through Medicaid. The maximum State/County Special Assistance (SA) payment [this is an OSS payment that includes the federal SSI payment] for room and board is $893 a month plus a $31 personal needs allowance. The Medicaid payment varies with the needs of the residents. The basic payment is $8.07 a day which assumes each resident receives one hour of personal care a day. Homes receive higher payments for residents with extensive or total impairments in three specific ADLs: eating, toileting or both. The rate for residents who need extensive assistance or are totally dependent in eating is $16.00 per day, toileting $10.87 per day and for both eating and toileting, $18.80 per day. These three payment levels include the basic rate of $8.07 per day. Eligibility for the added payment is based on an assessment by the adult care home which is then verified by a county case manager.



Basic Rate



Eating and Toileting

Room and board





Personal care

24-hour $2.70










Medications must be administered in adult care homes by staff designated by the administrator who must assure the provision of appropriate training.


These requirements vary by the size of the facility and shift. Larger facilities (> 20) must have 0.4 aide hours per resident or eight hours per each 20 residents plus three hours for all other residents, whichever is greater, for the first and second shift. On the third shift, eight hours of aide duty is required per 50 or fewer residents. Residences of 12 or fewer residents must have one person on staff at all times and at least 12 hours must be spent providing personal care, health services, activities, medication management and other services needed by residents. Rules for homes serving 13-20 residents require at least one person on duty in the home to perform direct personal care and supervision. Food service and housekeeping functions must also be staff.


Administrators The administrator must verify that he earns 15 hours per year of continuing education credits related to the management of adult care homes and care of aged and disabled persons in accordance with procedures established by the Department of Health and Human Services. The requirement does not apply where the administrator is also a currently licensed nursing home administrator. The administrator must verify that he has worked in a licensed adult care home for at least 90 days (for an adult care home of 7+ beds) or 30 days (for family care homes) in an approved on the job training program or have appropriate education, training and experience.

Staff providing or directly supervising staff who provide basic personal care must successfully complete a 40 hour training program (for adult care homes 7+ and homes for developmentally disabled adults), or a 20 hour program (for family care homes), including a competency exam, approved by the department. This curriculum includes classroom training and supervised practical experience. The training and competency exam covers five areas: basic nursing skills; personal care skills; cognitive, behavioral and social care; basic restorative services; and residents' rights

Staff in any adult care home who perform certain health-related personal care tasks, as specified in rule, must successfully complete a 75 hour training program, including competency exam. This includes at least 30 hours of classroom instruction and at least 30 hours of supervised practical experience. The areas of competency include: observation and documentation; basic nursing skills, including special health related tasks; personal care skills; cognitive, behavioral and social care; basic restorative services; and residents' rights.

Staff with experience according to the rule may take the competency exam without undergoing training.


County Departments of Social Services monitor adult care homes at least every other month. State staff provide consultation, technical assistance and training to the county monitors. State staff also provide monitoring oversight and perform selected surveys of homes based on compliance history or lack of previous county monitoring.

Background Check

Administrators must provide written documentation about convictions of criminal offenses from the clerk of court in the county in which the conviction occurred, and about any driving offenses other than minor traffic violations. Criminal history record checks through the State Department of Justice are required for applicants for employment who do not have an occupational license.

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