SECTION .0500 ‑ CERTIFICATION INFORMATION

10A NCAC 06S .0501       PROCEDURE

(a)  All individuals, groups or organizations operating or wishing to operate an adult day health program as defined by G.S. 131D‑6 shall apply for a certificate to the county department of social services in the county where the program is to be operated.

(b)  A social worker shall provide technical assistance and shall conduct a study of the program using the Division of Aging and Adult Services form DAAS-6205, as set forth in 10A NCAC 06R .0601(b).

(c)  The county department of social services shall submit the initial certification package to the Division of Aging and Adult Services. The materials and forms to be included in the package are:

(1)           program policies;

(2)           organizational diagram;

(3)           job descriptions;

(4)           Form 732a-ADS (Daily Rate Sheet) or the equivalent, as set forth in 10A NCAC 06R .0601(c)(4), showing planned expenditures and resources available to carry out the program of service for a 12 month period;

(5)           a floor plan of the facility showing measurements, restrooms and planned use of space;

(6)           Form DOA‑1498 (Fire Inspection Report) or the equivalent, as determined by the local fire inspector, completed and signed by the local fire inspector, indicating approval of the facility, no more than 30 days prior to submission with the certification package;

(7)           Form DOA‑1499 (Building Inspection Report for Adult Day Care Centers), DOA-1499a (Building Inspection Form for Adult Day Care Homes), or the equivalent, as determined by the local building inspector, completed and signed by the local building inspector, or fire inspector or fire marshal, if a building inspector is not available, indicating approval of the facility, no more than 30 days prior to submission with the certification package;

(8)           Form DENR‑4054 (Inspection of Adult Day Service Facility), or the equivalent, as determined by a local registered environmental health specialist, completed and signed by a local registered environmental health specialist, indicating approval of the facility, no more than 30 days prior to the submission with the certification package;

(9)           written notice and the effective date if a variance of local zoning ordinances has been made in order for property to be utilized for an adult day health program;

(10)         a copy of the articles of incorporation, bylaws and names and addresses of board members for adult day health programs sponsored by a non‑profit corporation;

(11)         the name and mailing address of the owner of an adult day health program;

(12)         a written medical statement from a physician, nurse practitioner, or a physician's assistant, completed within the 12 months prior to submission of the certification package, for each proposed staff member certifying absence of a health condition that would pose a risk to others and that the employee can perform the duties assigned to him or her on the job;

(13)         verification of standard first aid and cardio-pulmonary resuscitation (CPR) certification for each proposed staff member who is physically able and who will provide direct participant care as defined in 10A NCAC 06R .0201. The requirements of 10A NCAC 06R .0504(d) shall be applicable to this Rule.

(14)         evidence of the completion of a Statewide criminal history records search for the past five years for the adult day health program owner and each proposed staff member who provides direct participant care, conducted by an agency approved by the North Carolina Administrative Office of the Courts; and

(15)         DAAS‑6205 (Adult Day Health Certification Report). This form must be submitted by the county department of social services with a copy to the program.

(d)  No more than 90 days prior to the end of the current period of certification, the county department of social services shall submit to the Division of Aging and Adult Service the following forms and materials that make up a certification package for the renewal of a certification.

(1)           Form DOA‑1498 (Fire Inspection Report) or the equivalent, as determined by the local fire inspector, completed and signed by the local fire inspector, indicating approval of the facility, no more than 12 months prior to submission with the certification package;

(2)           Form DOA‑1499 (Building Inspection Report for Adult Day Care Centers), DOA-1499a (Building Inspection Form for Adult Day Care Homes), or the equivalent, as determined by the local building inspector, when structural building modifications have been made during the previous 12 months, completed and signed by the local building inspector, or fire inspector or fire marshal, if a building inspector is not available, indicating approval of the facility, within 30 days following completion of the structural building modifications;

(3)           Form DENR-4054 (Sanitation Evaluation Report) or the equivalent, as determined by a local registered environmental health specialist, completed and signed by a local registered environmental health specialist, indicating approval of the facility, no more than 12 months prior to submission with the certification package;

(4)           a written medical statement from a physician, nurse practitioner, or physician's assistant for each staff member hired subsequent to the previous certification or recertification expiration date, certifying absence of a health condition that would pose a risk to others and that the employee can perform the duties normally assigned on the job;

(5)           an updated copy of the program polices, organizational diagram, job descriptions, names and addresses of board members if applicable, and a floor plan showing measurements, restrooms, and planned use of space, if any changes have been made since the previous certification package was submitted;

(6)           Form 732a-ADS (Daily Rate Sheet) or the equivalent showing planned expenditures and resources available to carry out the program of service for a 12 month period;

(7)           verification of standard first aid and cardio-pulmonary resuscitation certification (CPR) for each proposed staff member who is physically able and who will provide direct participant care;

(8)           evidence of the completion of a Statewide criminal history record that complies with Subparagraph (c)(14) of this Rule; and

(9)           DAAS‑6205 (Adult Day Health Certification Report). This form must be submitted with the certification package by the county department of social services to the Division of Aging and Adult Services at least 30 days in advance of the expiration date of the certificate, with a copy to the program.

(e)  If during the study of the program it does not appear that all standards can be met, the county department shall send written notice to the applicant, stating the reasons the standards are not met, and shall give the applicant an opportunity to withdraw the application or remedy the defect by the deadline provided by the local department of social services.

(f)  Following review of the certification package, a pre‑certification visit for certification shall be made by staff of Division of Aging and Adult Services.

(g)  Within 14 business days, the Division of Aging and Adult Services shall provide written notification to the applicant and the county department of social services and local departments of health of the action taken after a review of the certification package and visit.

History Note:        Authority G.S. 131D‑6; 143B-153(2a); 143B‑153(6); 42 USC 3032c;

Eff. May 1, 1992;

Amended Eff. July 1, 2000; March 1, 1993;

Readopted Eff. November 1, 2019.