NC DHSR AHCLCS: Home Care and Hopsice Licensure Survey Checklist

Home Care and Hospice Licensure Survey Checklist

In order to assist in preparation for initial licensure survey and to ensure compliance with the North Carolina rules governing the licensure of home care agencies, you are advised to have the following items ready for review at the time of the initial survey.

Home Care and Hospice Licensure Survey Checklist (PDF, 305 KB)

Administrative Policies and Procedures - to include the following at a minimum:
- Evidence that the applicant has previously owned or operated a home care agency {10A NCAC 13J .0903(a)}
- Evidence that the applicant has taken a DHSR approved home care training course {10A NCAC 13J .0903(a)}
- Agency organization chart {10A NCAC 13J .1001(a)(8)}
- Evidence of premise for operation {10A NCAC 13J .0903(b)(c))}
- Geographic service area {10A NCAC 13J .1001(g)}
- Agency director job description {10A NCAC 13J .1001(b,d,e)} and
  Companion sitter agency director job description {10A NCAC 13J .1503 1(a,b)}
- Service supervisor job description {10A NCAC 13J .1001(c,d)}
- Job description for other categories {10A NCAC 13J .1003(d)}
- Annual projected budget {10A NCAC 13J .1002(a)}
- Infection control policies {10A NCAC 13J .1003(a)} including:
  - Communicable disease control
  - Blood borne pathogen policy contents
  - TB test policy and contents
  - Hepatitis B immunization/declination policy
  - Exposure control plan or policy
  - Post-exposure follow-up plan/policy
- Annual program evaluation policy {10A NCAC 13J .1004(a-e)}
- Quarterly client record review policy {10A NCAC 13J .1004(d)}
Client Care Policies
- Scope of services policy {10A NCAC 13J .1100}
- Service policies per service category {10A NCAC 13J .1102, 10A NCAC 13J .1103, 10A NCAC 13J .1104, 10A NCAC 13J .1105, 10A NCAC 13J .1106, 10A NCAC 13J .1107, 10A NCAC 13J .1108, 10A NCAC 13J .1109}
- Coordination and referral policy {10A NCAC 13J .1001(a)(11) & 10A NCAC 13J .1101(a)(8)}
- Quarterly supervision of In-Home Aides (IHAs) {10A NCAC 13J .1110 (i)}
- Admissions/acceptance policy {10A NCAC 13J .1101}
- Discharge policy {10A NCAC 13J .1402 (2)(d)}
- Client's rights and responsibilities policy {10A NCAC 13J .1007(a-d)} and No Smoking Policy (GS131E-143)
- Agency complaint policy with state hot line number(s) {10A NCAC 13J .1007(d)}
  Health Care Personnel Registry (HCPR) reporting policy
- Plan of care policy and contents {10A NCAC 13J .1202 (a-b)}
- Quarterly plan of care review policy {10A NCAC 13J .1202 (a)}
- Client record storage and retention policy {10A NCAC 13J .1401(c)(f)}
- Client record content policy {10A NCAC 13J .1402}
- Orders (medication, treatment, and/or in-home aide) policy {10A NCAC 13J .1302}
- Companion, sitter, respite policies (where applicable)
Personnel policies and procedures
- Competency verification, skills validation/checklist policy {10A NCAC 13J .1003(e) and 10A NCAC 13J .1110(a-b)}
- Personnel records policy and content {10A NCAC 13J .1003(d)(e)(f)}
- Annual performance evaulation policy {10A NCAC 13J .1003(e)}
- In-service training policy {10A NCAC 13J .1003(c)}
- Orientation policy {10A NCAC 13J .1003(c)}
- Criminal background investigation policy (State Bureau of Investigation - SBI) policy {10A NCAC 13J .0906(a)}

Home Care and Hospice Licensure Survey Checklist (PDF, 305 KB)

NC Division of Health Service Regulation

Acute and Home Care Licensure and Certification Section

Home Care and Hospice Licensure Survey Checklist