Mental Health Licensure and Certification Section

DHSR requires a facility to be licensed if the facility provides services to the mentally ill, developmentally disabled, or substance abusers for one or more minors or two or more adults. These services shall be day services offered to the same individual for a period of three hours or more for 24 hours or residential services provided for 24 consecutive hours or more. Facilities for individuals who are substance abusers include chemical dependency facilities.

When you have determined that the service you wish to provide does require a license, the following questions will help you pinpoint the service category that best fits your proposed program:

• Do you want to provide a day or residential service?
• Who do you want to work with?
• People with mental illness, intellectual/developmentally disabilities or substance use disorders?
• Adults or minors?
• How do you expect to be paid for the services you provide?

Once you have answered these questions, review the 31 specific services (PDF, 87 KB) that DHSR licenses to determine the best service category for your program. You can find more specific information about each service category under Rules and Resources. Review Subchapter G. Scroll through the document to find the service category number.

When an application for an initial is received, the MHLC team will vet to ensure the paper components requested to submit with the application are accounted for and current.

The application is then sent to DHSR construction. Construction will send a standard acknowledgment letter stating, "You may expect your review in approximately 18-10 weeks. However, if areas require a code interpretation, there could be a delay. (If the facility is a day program, this step is skipped).

When the applicant has successfully completed the physical plant review (no plant review by DHSR construction if a day treatment program), the application is sent to the L&T team for the program review. The L&T team will schedule a time to begin the program review process within 5-10 days after being assigned the application.

We provide the applicant six months to successfully complete the program review of the application process; however, we are ready to license much sooner. Please understand that the amount of time it takes to process an application for the program review weighs heavily if the licensee is prepared and has all the necessary material completed for the application process.

An interpretation the NC Department of Insurance determined in June of 1998. that any child under the age of six residing in a licensed Home (MHL, FCH or Child Care etc.) is considered non-ambulatory and, as such must be considered as part of the home's licensed census, as the child will require attention in addition to the care the licensed clients of the home will also require, this would also apply for an aged or disabled family member that needs assistance residing the home.

Based on the above, this will give the Licensed AFL a capacity of four, which will exceed the maximum capacity allowed per the .5600F service category; this will also change how the home is classified under the North Carolina State Building Code as there would be occupants in the home that require verbal and physical assistance to evacuate the home in the event of a fire or other emergency event, which would require the installation of a 13D Sprinkler System and have the home reclassified as a Licensed Small Residential Care Facility per DHSR construction.

The facility must lower their licensed census to two with a child or disabled family member in residence.

A qualified professional or an associate professional must meet one of the criteria outlined in the staff definitions in 10A NCAC 27G .0104. If an individual meets the criteria for a QP or an AP, then they can market themselves as such. There may be further requirements for a QP or AP position from individual agencies or organizations.

10A NCAC 27G .0104 STAFF DEFINITIONS
The following credentials and qualifications apply to staff described in this Subchapter:

DHSR does not assist with funding for facilities. Prospective providers should determine their funding source prior to applying for a mental health license with DHSR. If your plan includes being reimbursed with state dollars or Medicaid dollars, you will need to have a contract with an LME/MCO, and must contact the LME/MCO you wish to work with (generally the LME/MCO for your region) to find out the process for contracting with them.

Local Management Entity/Managed Care Organizations Directory

In order to be paid with Medicaid or state funds for providing a service, there may be additional staffing, training, or treatment requirements, for that particular service. These additional requirements are called "clinical coverage policies" for Medicaid funds, and "service definitions" for state funds. You may wish to research the service definition or clinical coverage policy that matches your service before you contact your LME/MCO.

DMH/DD/SAS web page with state funded service definitions

NC Medicaid web page that includes links to Clinical Coverage Policies for Medicaid Reimbursement.

Private Pay
If a prospective provider does not wish to take advantage of public dollars as a funding source (i.e. Medicaid, state, county funds), then the provider does not need to have a contract with the local LME/MCO and can just bill prospective clients.

Yes. Serving most clients without first obtaining a license is a violation of the law. Specifically, North Carolina General Statute 122C-28 states: “Operating a licensable facility without a license is a Class H felony, including a fine of one thousand dollars ($1,000) per day that the facility is in operation in violation of this Article.”

Yes. All staff must be trained and competent to provide services to the clients the facility serves.

Staff training should be provided by a person who is competent in the area in which staff need training. Training in medication administration, for example, must be conducted by a licensed registered nurse, pharmacist, or other legally qualified person as per 10A NCAC 27G .0209(c)(3). Training in client rights, including restrictive interventions, must be conducted by a person trained to train others. Your qualified professional may be a resource for assisting, developing or performing some of the required training. Your LME-MCO may also be a resource for training resources.

Yes, staff must be in place and the facility must be completely furnished and ready to open before an initial license is issued.

Mental Health Licensure requires the licensee to develop written policies and procedures. The Applicant’s policies and procedures manual must be submitted to the Licensure & Training Consultant at the first review. Policies and procedures manual helps align the missions and goals of the organization, the applicable laws and rules, and the processes by which the work is to be done. It serves as a consistent source for organizational policy, which are the overall regulations that govern the business, and the procedures that define how those policies will be implemented. Therefore, writing them well will help keep the organization on path and ensure that standard procedures are being conducted the same way by all staff.

Why Separate Policies and Procedures:
Policies reflect governing rules and are general in nature. Procedures indicate the specific implementation of a given policy. Policies adapt to changes in governmental statutes. Procedures, in addition to adapting to changes in policies, should also evolve with new tools and methods of treatment. This separation will ultimately serve to distinguish what is based on rules and what are the existing standards of practice.

Where to Begin:
You must begin by assembling all applicable North Carolina General Statute 122C and the 10A NCAC North Carolina Administrative Code (mental health licensure rules) for the type of license or designation sought. All applicable Rules become the foundation of your new policy and procedure manual. In the absence of all else, these things must be satisfied. The key to writing strong procedures and policies is to make the documents rigid enough to clearly indicate the rules of the organization, but flexible enough to be able to be followed easily and without significant deviation.

Rules:
The following rules are essential for all licensed mental health facilities to help formulate the required Operations and Management Policies, Guidelines and Procedures:

10A NCAC Chapter 13 N.C. Medical Care Commission
Subchapter O Health Care Personnel Registry
.0101 Definitions
.0102 Investigating and Reporting Health Care Personnel

10A NCAC Chapter 26 Mental Health, General
Subchapter C Designation of Facilities for the Custody and Treatment of Involuntary Clients

10A NCAC Chapter 27 Mental Health, Community Facilities and Services
Subchapter CProcedures and General Information
Subchapter DGeneral Rights
Subchapter ETreatment or Habilitation Rights
Subchapter F24-Hour Facilities
Subchapter GRules for Mental Health, Developmental Disabilities, and Substance Abuse Facilities and Services

There is no standard template. However, you will find information on our list of required materials.

Developing and maintaining a written emergency plan- specifically policies & procedures which prepare, train and require practice to ensure health, safety and welfare (shelter-in-place, lockdown and shelter-out), including maintaining (specific) information which will protect people served and staff during emergencies.

Developing and implementing plans, procedures and backup plans that include ways to globally communicate with people served and staff's families and community agencies before, during and after an emergency.

Special needs - a plan focused on people served and staff with special needs or chronic medical issues and requirements (such as transportation, food, etc.) before, during and after an emergency.

Recovery - A plan of action for recovery that includes the protection of information and assets to allow for a continuum of care for children and families.

Some counties use Emergency plans submitted through the NCDPS Risk Management Portal with the State of North Carolina. https://rmp.nc.gov/Portal/#

It depends on if the initial is a day or residential:

Residential

Sanitation and fire are required for all residential.

Day Program

Must submit the following

• Current local Fire Marshal's Inspection Report for the building.
• Current local Sanitation Inspection report if serving any food.

If a facility prepares food for sale or as part of a fee, it must have a permit, including sanitation inspections. The State considers food preparation to include the portioning of food.

If a facility serves commercially pre-packaged foods or foods that were individually packaged w/in a permitted restaurant w/o any extra handling, then no permit or inspection is needed. However, if the facility prepares or portions out the food in any way, then a permit & inspection are required.

• Examples:
  
  • Individual boxes of nuggets from a restaurant are handed to the end consumer (no permit/inspection) versus getting a platter of nuggets from a restaurant & giving a portion to each consumer (permit/inspection).
  • The individual sub is made & packaged at a restaurant and handed to the end consumer (no permit/inspection) VS Getting a sub from a restaurant & cutting it into portions to give to consumers (permit/inspection).
  • Handing a slice of pizza boxed at a restaurant to the end consumer (no permit/inspection) VS Getting a whole pizza & putting a slice on a plate for the consumer (permit/inspection).
  • Giving commercially packaged sliced apples to a consumer (no permit/inspection) VS Slicing an apple for them (permit/inspection).
  • Commercially packaged, pre-cooked item handed to a consumer for them to open & re-heat themselves (no permit/inspection) VS Opening & re-heating a commercially packaged, pre-cooked item for a consumer (permit/inspection).

Take the completed service categories section in the licensure application to your zoning, building and/or fire officials. Providers of day, outpatient and residential need zoning approval. Twenty-four hour residential services must present completed application to their LME-MCO to request a letter of support.

Yes. If you provide residential services for handicapped clients, you need to provide proper accommodations. Contact your local building official for information.

No. You need to review the physical plant requirements in 10A NCAC 27G Section .0300 to verify the facility meets the construction, space and other physical plant requirements for the clients to be served. You may, however, contact the DHSR Construction Section for specific questions.

To prepare for a more efficient review, please ensure that you follow these guidelines:

1. Make sure that your policy and procedures comply with the relevant rules and regulations.
2. Complete the policies and procedures worksheet.
3. When submitting information, ensure that staff records follow the format of the list of required materials worksheet.

Remember, the key to a more efficient review is organization and submitting the correct documentation.

Physical plant requirements are listed in the initial application packet. No DHSR construction fees are required for a day facility.

Application

• Take the completed application (pages 9-14) to your local zoning office and obtain zoning approval.
• Attach the zoning approval letter to the application.
• Preliminary program approval letter is required from the State Opioid Treatment Authority (SOTA) for all service category 3600 facilities.
• Submit all items listed in Requirements for Day Programs box on page 8, including approved:
  • Fire Marshal,
  • Sanitation and
  • Building Officials inspection reports as required.
• Include initial licensure fee upon submitting all items.
• Write a letter briefly describing the services to be offered by the facility.
• Develop written policies and procedures for your service but do not submit them with the application.
• Day Programs for children and adolescents cannot be 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.

24-hour residential applicants must contact the LME-MCO in the catchment area to verify/review if there is a need for the particular twenty-four hour residential service (see 10A NCAC 27G .0406). The LME-MCO will issue the letter of support which needs to be enclosed with the initial licensure application or a change application if changing service category.

All licenses expire at the end of the calendar year. A renewal application must be submitted through DHSR's online Enterprise System.

If there is a change of ownership to a new provider under the current Innovations Waiver, as long as the facility was licensed for five or six beds prior to 6/5/2011, the new owner can continue to be licensed for five or six beds and serve Innovation Waiver consumers in those beds.

The National Provider Identifier (NPI) is a Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Standard. The NPI is a unique identification number for covered health care providers. Covered health care providers and all health plans and health care clearinghouses must use the NPIs in the administrative and financial transactions adopted under HIPAA. If you have questions or need additional information regarding the NPI number, call the toll free number 1-800-465-3203 or visit the NPI website.

No, you do not. You do need to be approved as a DWI provider through the Division of Mental Health/Developmental Disabilities/Substance Abuse Services.

It is crucial to obtain approval from the Licensure and Training Team before making ANY changes to the current license, such as a service category, location change or change of ownership. If services are provided in a new facility or service category that has not been authorized, it will be considered unlicensed, which is a serious offense. It is important to note that any changes must be approved by the Licensure and Training Team. Refer to the Change application.

Sometimes, a provider may choose to transfer the ownership of their license to another provider. This process is known as "Change of Ownership" and requires the completion of a Change Application, followed by a review by the MHLC Section.

It is important to note that the license's ownership change is entirely separate from any business transaction between providers.

Until the license is officially transferred to the new prospective provider, the original owner/licensee remains responsible for their facility and consumers. Please review the Change Application packet.

Yes, however, all service categories must operate independently. If the services are run simultaneously, staff must not be utilized in different service categories at the same time, and the same room must not be used to deliver services concurrently. Facilities providing client activities must ensure space and supervision to guarantee client safety and welfare.