Frequently Asked Questions

14-Day Notice

Is a facility obligated to disregard a resident's 14-day notice if the resident wishes to withdraw it?
The purpose of the 14-day notice is to allow the facility the opportunity to make any kind of arrangements necessary as a result of the resident leaving the facility. Once the notice has been given the facility may arrange for the admission of another resident who will occupy the bed to be vacated. The facility is not under an obligation to disregard the notice if the resident decides not to leave unless stated otherwise in the resident contract.

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Continuing Education

What are the continuing education requirements for a care coordinator and an aide in an Alzheimer's Special Care Unit?
As with other special care unit staff, the care coordinator and aide would have to have 12 hours of continuing education annually. Six of those hours would have to be dementia specific. The additional six hours would have to be in the area of medication administration for the care coordinator since that is a supervisory position. The same is true for the aide if the aide administers medication. Other wise, the aide could take the remaining six hours of required continuing education in areas related to the care of older or disabled adults.

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Criminal Record Check

What is the effective date of the criminal record check law affecting adult care and family care homes?
This law, G.S. 131D-40 Criminal History Record Checks, applies to applicants for employment on or after January 1, 1997. Staff hired after, not prior to, that date are required to have been checked since the law states that an offer of employment is conditioned on consent to a criminal record check of the applicant. The law does not indicate that staff hired prior to the effective date of the law have to have a criminal record check.

Does the administrator who is also owner of the facility have to have the criminal background check as required in G.S. 131D-40?
No, the criminal record check would not be necessary since the information provided by the check is strictly confidential to the hiring entity, which would be the administrator/owner, and intended to be used for hiring purposes only.

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If a home changes ownership, may the new owners discharge the Special Assistance (SA) residents solely on the basis of being SA recipients?
No. This is not a grounds for discharge according to rule 10A NCAC 13F .0702 and 10A NCAC 13G .0705. Failure to pay cannot be cited since these resident are being charged and have been paying the maximum amount allowed by law.

If a resident slaps a staff person or another resident, is this ground for discharge?
This is not automatically a ground for discharge, particularly if a one-time occurrence and there is not serious injury and continuing threat to others in the home. Rules 10A NCAC 13F .0702(d)(2) and 10A NCAC 13G .0705(d)(2) state that there must be documentation of the incident and "the facility's action taken to address the problem prior to pursuing discharge."

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Electronic Signatures

May facilities accept hospital forms or documents that have orders with electronic signatures of physicians?
Yes, however there should be a statement on the form or document stating that an electronic signature was used.

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Food Service

Must a salt shaker be removed from a resident's dining room table if the resident is on a no-added-salt (NAS) diet?
No, not unless all residents at the table suffer from dementia or confusion and are on no-added-salt diets. Otherwise, if it is the practice of the home to have shakers on the tables rather than providing individual packets, the salt shakers should remain so that resident rights are not violated. The facility is responsible for preparing and serving the food to comply with the diet as ordered. If a resident is consistently non-compliant with the NAS diet by adding salt to food at the table, the resident should be advised of the health threat involved and the resident's physician consulted about the non-compliance.

Are facilities required to provide for second servings of food at meal times upon request?
While rules do not address second helpings of food at meals, the provision of second helpings to residents on diets that are not calorie controlled is a "reasonable response", as indicated in G.S. 131D-21(7), to this request. In addition, this is taking into account food preferences and customs of residents as required in 10A NCAC 13F .0904 and 10A NCAC 13G .0904. G.S. 131D–21(1) is also applicable.

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Are molded plastic/resin chairs appropriate for use in facilities?
These chairs are not appropriate as interior furnishing from a resident’s rights perspective or a safety perspective. Typically sold as lawn, deck, porch or patio chairs, they are not intended as standard living room, dining room or bedroom furniture and would not meet the requirement of "one comfortable chair" in the resident’s bedroom [10A NCAC 13F .0306(b)(5) and 10A NCAC 13G .0315(b)(5)]. However, a resident may have his/her own chair of this type as a personal furnishing if he/she so desires. As a safety issue, plastic/resin can crack and break and the rear legs of these chairs have been known to break when tilted back under weight. There is also the added risk of instability on hard services because of the tendency to slide.

May a resident be given a lock box to put where wanted in the resident’s room?
Can the lock box be placed in a lockable closet accessible with key by the administrator or supervisor in charge/administrator in charge (SIC/AIC) as requested by the resident? Rules 10A NCAC 13F .0906(e) and 10A NCAC 13G .0906(e) require lockable space within the facility and a key for the resident to have access to the space but do not indicate whether the space has to be portable or stationary. A lock box may be used and kept in the resident’s room. The lock box may be placed within another lockable space, such as a closet that only the administrator or SIC/AIC has access to if requested by the resident.

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Health Care and CPR

How is "quarterly" interpreted as used in rule 10A NCAC 13F .0903(c) and 10A NCAC 13G .0903(c)?
These rules require a quarterly licensed health professional support review of applicable residents. Quarterly means every three months and does not mean strictly every 90 days. The wording was changed in the rule from every 90 days to quarterly to avoid a strict application of a specific number of days. If a review was done on March 1st, it would be expected that the next review would be performed sometime around the first of June, but not necessarily on the 90th day.

Does the use of insulin pumps require Licensed Health Professional Support (LHPS)?
Yes. The use of insulin pumps does require the licensed health professional support review according to 10A NCAC 13F .0903(a)(15) and 10A NCAC 13G .0903(a)(15) since it is medication administration through injection. A quarterly review by a registered nurse is required even if the resident completely manages the pump on his/her own. If staff are involved in any way with administering, managing and/or monitoring the pump, the LHPS competency validation would be required according to 10A NCAC 13F .0504 and 10A NCAC 13G .0504 as well as the quarterly review.

When are bed rails considered a restraint?
If a resident is unable to get out of bed on his/her own bed because of physical incapacity, bed rails would not be considered a restraint. The same would hold true for a resident whose dementia is so severe that it has clearly impacted the resident’s capacity to get out of bed independently. However, if a resident with dementia is physically capable of controlling movements sufficiently to leave the bed, even if not likely to do so, the rails would be a restraint because of restriction of freedom of movement.

What does "on the premises" mean in rules 10A NCAC 13F .0507 and 10A NCAC 13G .0507 requiring a Cardiopulmonary Resusitation (CPR)- trained staff person on the premises at all time?
Since CPR must be administered within a short period of time to be effective and prevent brain damage, premises must be interpreted to mean within the building or temporarily in the immediate area surrounding the building. While the CPR- trained staff could be in the yard area of the home from where he/she can be summoned quickly, this requirement may not be met by the staff person required to be within 500 feet of the home who, while on call, may not be able to be at the resident’s side within a matter of two-three minutes.

Is compliance with rules 10A NCAC 13F .0507 and 10A NCAC 13G .0507 (Training on CPR) met if a staff person has had CPR training within the past 24 months but the CPR certification has expired?
Yes. These rules require completion of CPR training within the last 24 months not current certification. At this time, the American Red Cross offers a one-year certification and the American Heart Association a two-year certification. But as long as there is documentation that the training was completed through one of these programs or any of the other programs referenced in the rules within the last 24 months, the requirement is met.

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How should a facility respond to medication refusals by residents?
This is not a "one-answer-fits-all" question. A specific response depends on such factors as the medication refused and the resident's current physical and/or mental condition. What is clear is that rule 10A NCAC 13F .1211 and rule 10A NCAC 13G .1211 require development of written policies and procedures of medication administration in compliance with applicable rules, including when medications are not administered such as refusals. Development of medication policies and procedures are to be in conjunction with a licensed health professional who is authorized to administer or dispense medications. For a facility with a special care unit, policies and procedures for methods of behavior management regarding appropriate medication administration are to be developed (10A NCAC 13F .1305).

Policies and procedures for medication administration ensure systems are in place for the health and safety of residents. Policies such as those for refusals guide staff and help ensure physician notification. It is not possible for a facility's policy and procedure to address every scenario/situation/issue; therefore, the resident's physician or prescribing physician should be contacted if there are any questions or direction needed when a medication is not administered. Issues of refusals by residents with cognitive impairment such as dementia or Alzheimer's should also include the involvement and direction of the resident's family/significant other/responsible party or legal representative. The facility's policy of physician notification and involvement of other parties does not take precedence over the facility's responsibility of ensuring a resident's health care needs are met.

Do rules 10A NCAC 13F .1010(a) and 10A NCAC 13G .1010(a) restrict a resident's choice of pharmacy?
These rules do place some restriction on a resident’s choice of pharmacy if a pharmacist does not dispense medications in a way that enables the facility to administer medications according to its established medication administration policies and procedures. A facility having multiple systems of medication administration as a result of different pharmacies’ dispensing methods creates a greater chance of errors in medication administration. Since the facility is responsible for assuring safe administration and establishing policies and procedures to enable that, those policies and procedures can specify a system that requires medications to be dispensed in certain ways. Therefore, it is important that residents and responsible persons be made aware of the facility’s medication administration system and its impact on packaging of medications the facility is responsible for administering.

May a family member administer medications to a relative?
Medication in an adult care home is the responsibility of the facility unless there is a physician's order for self-administration. If there is such an order, the family member may administer medications if the resident so desires. Only the resident with a self-administering order can give that authority to a family member.

What should happen if a resident or staff refuses a vaccine required by law?
Residents and staff are to be notified of the immunization requirements according G.S. 131D-9 (pneumococcal vaccine for residents and flu vaccine for residents and employees). The law requires facilities to notify residents and employees of the immunization requirements and request that they be immunized, but they can refuse immunization after being fully informed of the health risks. If a person refuses immunization, the facility must document refusal by, at a minimum, a statement signed by the person refusing immunization stating that he/she was notified of the immunization requirement and fully informed of the health risks of not being immunized. This documentation should be maintained in the resident record or personnel file.

Are medication administration record's (MAR) and counting of medications required for residents who self-administer?
No, although it would be good practice because there would be a list of the medications that the resident is taking. If an MAR is maintained, it is also good practice to indicate self-administration on the form, especially if staff document when the resident takes his/her medication, or so staff will know why there is no documentation on the MAR, especially when a resident self-administers some medications but not all of them. The resident’s ability to self-administer should be evaluated on an ongoing basis.

What are time frames for implementation of medication orders?
While such time frames are not specified in rule, it is highly recommended that the facility’s policies and procedures address time lapse for starting administration of new orders such as emergency or stat orders, antibiotics, routine medication and methods of legal borrowing of doses. The type of medication as well as the resident’s condition should be considered. For example, the facility’s policy for medications prescribed for acute problems such as antibiotics would require a more timely start of administration than for routine medications or those for chronic conditions. It is recommended that the facility get the assistance of a licensed health professional, such as a pharmacist, in determining an appropriate lapse time for starting new orders since it is the facility’s responsibility to assure the availability of medication in a time frame that would not put the residents’ health or safety at risk.

What is the facility's responsibility for residents who refuse to follow physician orders or refuse to pay for medications?
Refusal to follow medication orders must be documented on the MAR as required by rules 10A NCAC 13F .1004(j)(7) and 10A NCAC 13G .1004(j)(7). In order to comply with rules 10A NCAC 13F .0902 and 10A NCAC 13G .0902, the facility should notify the resident's physician about refusals. The facility should advise the resident about the importance of following physician orders and what the health repercussions are of not following orders. The resident's responsible person should also be informed. If the physician does not change the order and the resident continues to refuse, the facility should continue to document refusals and inform the resident that a discharge may be necessary because the facility is unable to meet the resident’s needs. Depending on the circumstances, i.e., how serious a health threat it is, the facility can do less than a 30-day discharge according to Part (b)(1) of rule or a 30-day discharge according to Part (b)(6) of rule. For refusal of payment (not lack of funds to pay), the facility must follow 30-day discharge procedures according to Part (b) (5) of the rule. The facility is still responsible for assuring medications are administered as ordered as long the person is a resident of the facility regardless of refusal or inability to pay.

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Payment for Bed Hold

May a facility require a hospitalized resident's family to pay the personal care rate Medicaid pays the facility?
No. While the facility is not getting the Medicaid personal care payments during the resident's hospitalization, neither is the resident receiving personal care services in the facility for which the Medicaid payments are intended. Special Assistance payment for room and board does continue during hospitalization for bed hold purposes.

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Release of Records

To whom can resident records be released?
Resident records can be released to the resident, guardian of the resident or the resident’s power of attorney/health care power of attorney (POA/HCPOA) provided the POA/HCPOA documentation authorizes such disclosure. Pursuant to Resident Right #6 (G.S. 131D-21) the resident may identify to whom he/she wants the records to be released. Additionally, most HIPPA forms allow the resident to name persons with whom he/she wants the records shared. If the resident is deceased, the personal representative of the estate (court appointed administrator or executor of the will) is the person who is authorized to request records.

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Respite Care

Can respite care in adult care homes be used for day or partial-day stays in the facility as well as overnight stays?
Respite care in adult care homes is intended for a short-term stay that does not exceed 30 days. A respite care period must be established by contract that specifies the date of admission and discharge as required in rules 10A NCAC 13F .0907 and 10A NCAC 13G .0907. Subsequent respite care stays by the same resident must also be established by separate contracts and all the requirements of the respite rule would apply, i.e., admission, discharge dates, current FL-2, short-term assessment, verification of orders if not signed and dated within seven days prior to admission, etc. for each separate respite stay period. The person is to be admitted as a respite resident, not a daily visitor, for a limited time period (30-day maximum) as specified in the contract and provided care, services and accommodations as any resident is entitled to receive according to law and rule. The respite resident must have a resident designated bedroom and be counted as a resident for the home for capacity, census and staffing purposes. The rule does not allow for a contract to provide unlimited respite care throughout the year, whether it is on a daily or overnight basis. Each respite stay must be contracted and time limited. How the respite period, as specified in the contract with an admission and discharge date, is used by the caregiver seeking respite, i.e., overnight stays or day/partial-day stays, depends on that caregiver.

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Who is subject to be reported to the Health Care Personnel Registry?
Under G.S. 131E–256 Health Care Personnel Registry, the facility is obligated to report to the Health Care Personnel Registry allegations which appear to be related to the neglect or abuse of a resident, misappropriation of property, diversion of drugs and fraud by health care personnel. Health care personnel in adult care homes is defined in this statute as an "adult care personal care aide who is any person who either performs or directly supervises others who perform task functions in activities of daily living which are personal functions essential for the health and well being of residents…" Since the definition says "any person", the person does not have to be an employee or payroll staff of the facility for the facility to report an allegation. Even if the person is employed from a staffing agency by a family member of the resident and this person is performing tasks as stated in the law, the facility is responsible for reporting any allegations specified in the law against this individual. The facility is responsible for the safety and protection of residents under its care and, therefore, is responsible for reporting according to the requirements of the law regardless of the employment status of the individual authorized to provide or supervise personal care tasks.

What are the training requirements for volunteers?
Volunteers who are performing personal care tasks that require training and/or competency validation per licensure rules must have the required training and/or competency validation. Volunteers working in this capacity are to be considered as staff by virtue of the personal care they are providing regardless of the fact that they are not paid for their services. Such volunteers must meet all requirements in licensure rule for staff whose duties they are performing.

What are the staff requirements for employees from staffing agencies?
Employees from staffing agencies must meet the appropriate qualifications in rule for the position they are filling. The facility must have the appropriate documentation of staff qualification from the employment agency on file in the facility.

Do names of staff on duty have to be posted in the facility?
No. G.S. 131D-4.3(a)(5) requires homes to post information on required staffing that indicates the number, not names, of direct care staff and supervisors that must be on each shift.

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