An Overview of Adult Care Home Regulation in North Carolina

Adult Care Home Defined

Senate Bill 502, ratified by the 1995 General assembly, established new terminology and definitions for what were formerly called "domiciliary homes" in North Carolina. Adult care homes are now defined in G.S. 131D-2.1 as follows:

"Adult Care Home" is an assisted living residence in which the housing management provides 24-hour 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. Some licensed adult care homes provide supervision to people with cognitive impairments whose decisions, if made independently, may jeopardize the safety or well-being of themselves or others and therefore require supervision. Medication in an adult care home may be administered by designated, trained staff. Adult care homes that provide care to two to six unrelated residents are commonly called family care homes. Adult care homes and family care homes are subject to licensure by the Division of Health Service Regulation.

People not to be cared for in adult care homes are specified in G.S. 131D-2.2 as follows:

Except when a physician certifies that appropriate care can be provided on a temporary basis to meet the resident's needs and prevent unnecessary relocation, adult care homes shall not care for individuals with any of the following conditions or care needs:

  1. Ventilator dependency;
  2. Individuals requiring continuous licensed nursing care;
  3. Individuals whose physician certifies that placement is no longer appropriate;
  4. Individuals whose health needs cannot be met in the specific adult care home as determined by the residence; and
  5. Such other medical and functional care needs as the Social Services Commission determines cannot be properly met in an adult care home.

These statutory changes were the result of recommendations of the N.C. Department of Human Resources Steering Team for Domiciliary Care which met for a year and a half, beginning in August of 1993. Five different sub-teams studied and made reports on issues related to funding mental health coordination, research needs, housing models, and legislation and rules.


1945 -First law enacted requiring licensure of "all boarding homes and rest homes" under rules adopted by the Social Service Commission.

1973 -Department of Human Resources created and authorized to inspect and license homes for the aged and infirm. The department designated the Division of Health Service Regulation as the licensing agency. Local county departments of social services continued to perform monthly monitoring oversight.

1977 -Statutory name change of facilities to domiciliary care homes and first major revision of licensure rules.

1984 -Second major rule revision.

1987 -Significant rule revision and law enacted revising administrative penalties for violations.

1990 -Staffing rule revised to allow staffing to census.

1991 -Policy development role assigned to DHSR from DSS.

1993 -N.C. Department of Human Resources Steering Team for Domiciliary Care and its sub-teams begins meeting to address problems facing the domiciliary care program.

1995 -Ratification of Senate Bill 502 (assisted living and adult care home definitions) and Senate Bill 864 (requiring staff training, case management, resident assessment, and changes in the way homes are reimbursed through introduction of Medicaid reimbursement for personal care services). Final report of DHR Steering team published.

1996 -Temporary rules addressing staff training, resident assessment and care plans and licensed health professional support became effective (Jan. 1).

1997 - Adult care bed moratorium set for one year by law; G.S. 131D-34 (penalty law) amended and G.S. 131D-2.7 (licensure law) amended with regards to provisional license and license revocation.

1998 - Adult care bed moratorium extended for one year and staffing ratio on third shift changed from 1/50 to 1/30 (effective Jan. 1, 1999).

1999 - The Department of Health and Human Services introduced proposed changes in adult care home regulation known as the Long-Term Care Safety Initiative which became the basis for new legislation requiring competency evaluation for staff administering medications, behavioral intervention training, supervisory staff, due process and appeals rights for discharge, compliance history review as a basis for issuing and renewing licenses, special care unit rules and disclosure requirements, time limited provisional licenses, time limits for investigation of complaints, tighter medication administration and resident assessment rules, and rulemaking authority under the N.C. Medical Care Commission. Additional legislation required certification of adult care home administrators, except family care home administrators.

2000 - Immunization of adult care home residents against pneumococcal disease and residents and employees against influenza virus (G.S. 131D-9); reporting of deaths of adult care home residents (G.S. 131D-34.1); temporary rules for respite care in adult care homes; extension of moratorium on new adult care home beds through Sept. 30, 2001; licensing of developmentally disabled adults group homes under G.S. 131D-2.3 ceases with licensing as mental health group homes (supervised living) under G.S. 122C.

2001 – Legislation bringing adult care homes of seven or more beds under Certificate of Need law and regulations.

Sources of Oversight

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

  1. The Division of Health Service Regulation (DHSR) - Develops and implements policies and procedures governing the licensing and enforcement of rules and conducts facility surveys on an annual basis.
  2. The Division of Social Services (DSS) - Administers Special Assistance program, protective services, civil rights programs, case management services, and resident assessment prior to admission.
  3. County departments of social services (97) monitor facilities at least quarterly for compliance with rules, investigate complaints, and provide case management services to eligible residents and resident assessment services prior to admission.
  4. The Division of Mental Health/Developmental Disabilities/Substance Abuse Services (DMH/DD/SAS). Administers case management and treatment services CAP-MR/DD, and other residents requiring treatment and habilitation services.
  5. Area Mental Health Programs - Provide services to clients placed from state mental institutions and from the community if they are included in area program service plans.
  6. The Division of Medical Assistance (DMA). -Administers the Medicaid program which includes reimbursement for personal care and enhanced care case management services for adult care home residents.
  7. The Division of Aging and Adult Services (DAAS) - Oversees the state's Long Term Care Ombudsman program which involves the following:
    1. Long Term Care Ombudsmen - Resolve resident rights complaints.
    2. Community Advisory Committees - Observe and report to the Division of Aging general conditions of homes on quarterly visits and assist residents in resolving grievances.
  8. Local Building Inspectors and Fire Departments - Conduct safety inspections annually.
  9. Local Health Departments - Conduct sanitation inspections annually and more often to follow up corrective action.
  10. Home Health Agencies (PDF, 67 KB) and Hospice (PDF, 71 KB) - Provide service to individual residents upon physician orders and provider/family arrangement and often report observations to regulatory agencies.
  11. OSHA (Occupational Health and Safety Administration) - Inspects for compliance with its regulations which include those governing infection control.


North Carolina has supplemented support to indigent residents in adult care homes through State/County Special Assistance (SA) which is an entitlement with payments being made directly to residents. The rate is set by the General Assembly. The maximum monthly SA rate, as of October 1, 2001, is $1,091/month to cover room and board.

In 1995, the General Assembly authorized the use of Medicaid funding for personal care services for SA/Medicaid-eligible residents of adult care home. On August 1, 1995, the state, through its Medicaid program, began reimbursing adult care homes for one hour of basic personal care assistance to SA/Medicaid-eligible residents.

On January 1, 1996, Medicaid began covering enhanced personal care services for residents. Currently, enhanced care payments cover residents who need extensive or total assistance with eating, toileting, ambulation/locomotion or any combination of the three. Residents receiving enhanced personal care services are also eligible for adult care home case management services provided by a case manager through the county department of social services or the area mental health program. Case managers verify the need for enhanced care and assure that health care service needs are being met.

Area mental health programs can provide wrap-around services for adult care home residents with mental conditions, depending on funding provided for these services. Wrap-around services include those supports documented as a need in the resident’s care plan and, if properly addressed, would develop greater independence and improve the quality of life for people in adult care home with diagnoses of mental retardation, developmental disabilities, and/or mental illness.

Penalties and Enforcement

Administrative Penalties
Statutory authority for imposing administrative penalties is found in G.S. 131D-34. The statute also directs the secretary of DHHR to establish a penalty review committee of nine members to review all Type A violations and any Type A or Type B violations which have not been corrected within the time frame specified in the plan of correction.

There are two basic types of violations as specified in G.S. 131D-34:

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 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, DHSR has several other enforcement remedies available in state law for both adult care homes and nursing homes as follows:

  1. A 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.
  2. 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.
  3. 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. Unfortunately, in the situations in which the division has needed to use this option, we could not afford to have the court take up to 20 days to act.
  4. 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.
  5. 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, in compliance with G.S. 150B-3, which encourages the state to settle disputes through informal means, gives 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.

Building Requirements

In addition to applicable building code requirements, adult care homes must meet requirements of the adult care home licensure rules which address arrangement and size of rooms, lighting, water and air temperature, entrances and exits, and service and fire safety equipment. Annual sanitation and fire and building safety inspection reports by the appropriate authorities are required. Fire safety requirements address fire extinguisher specifications, smoke and heat detectors, fire alarm system, meeting fire safety requirements of city ordinance or county building inspectors, written fire and disaster plans, and fire rehearsals (at least four a year on each shift). Sprinkler systems have not been required by licensure rules.