Informal Dispute Resolution Procedures

The Adult Care Licensure Section (ACLS) is the government entity responsible for regulating and licensing adult care homes in North Carolina. The purpose of Informal Dispute Resolution (IDR) is to provide adult care licensees an opportunity to dispute deficiencies cited during a state inspection.

IDR Request Deadline: IDR requests must be submitted in writing within the 15 working days afforded the facility to submit a Plan of Correction, as indicated in the official Statement of Deficiencies (SOD) letter. The postmark date of the IDR request must be on or before the IDR request deadline. If the licensee exceeds this time frame, the IDR Coordinator will deny the request for IDR.

IDR requests must be submitted in writing to the Division of Health Service Regulation, Adult Care Licensure Section, at the following address:

IDR Coordinator, ACLS
2708 Mail Service Center
Raleigh, NC 27699-2708

For Construction Surveys: Submit requests directly to the Division of Health Service Regulation, Construction Section Chief at 2705 Mail Service Center, Raleigh, NC 27699-2705.

IDR Request Letters: In accordance with G.S. § 131D-2.11(a2), each adult care home shall be offered an opportunity, at the facility's request, to informally resolve disputed findings from state inspections. Facilities may also contest the severity of noncompliance that resulted in a violation determination. To be given such an opportunity, facilities are required to send a written request for IDR clearly identifying the specific deficiencies being disputed. An explanation of why those deficiencies are being disputed (or why the severity of noncompliance is being disputed) along with any supporting documentation must be sent and postmarked by the IDR request deadline. The facility must submit two hard copies of the IDR request letter and any supplemental information.

Submission of Additional Written Material: The facility may submit additional written information for review. The material must be included with the IDR request letter or submitted separately on or before the IDR request deadline. The facility must submit two hard copies and highlight or clearly identify the information that is pertinent to the disputed deficiency or findings. Any material that does not meet these requirements will not be reviewed. The IDR may be held without submission of additional written material. The submission of documentation at the IDR meeting is not allowed, however, the information can be presented verbally. Any written material pertaining to the performance of a surveyor(s) shall be submitted to ACLS management and not included in the IDR process.

Scheduling IDRs: Upon receipt of a written request for IDR, the IDR Coordinator will determine if the request meets the requirements outlined in the IDR policies and procedures. If the request is postmarked past the 15-day deadline, the IDR Coordinator will notify the licensee that the request has been denied. However, any information submitted by the licensee will still be forwarded to the survey team for their review and action.

If the IDR request is approved, the IDR Coordinator will schedule the IDR meeting and notify the licensee in writing. The request letter and any supporting documentation will first be shared with the survey team to determine what effect the information may have on the cited deficiency or finding. If the issue involves complex medical conditions, the team leader may request review and dialogue with the Division's medical director. The survey team's decision should be communicated in writing to the IDR Coordinator within 10 days of receipt of the information. If the survey team, in conjunction with the Supervisor, decides to amend the SOD report, the IDR Coordinator will be notified of the specific changes and provided a copy of the amended report. The IDR Coordinator will then notify the licensee in writing of the survey team's decision and ask the licensee to confirm whether or not the facility wants to proceed with the IDR. If the facility wishes to proceed, the IDR Coordinator will communicate the status of the IDR meeting to the survey team leader, supervisor, IDR panel, and management via email.

IDR Meeting Format: IDR meetings are typically scheduled for a one-hour timeframe unless the number of deficiencies being disputed cannot reasonably be reviewed and discussed within one hour. The IDR may be rescheduled at the request of the licensee one time only. The IDR may be conducted as a face-to-face meeting or a conference call per the licensee's request.

Desk Reviews: When there are no violations contested and no enforcement action (Standard Deficiencies), the IDR shall be conducted as an in-office desk review. After the survey team review is completed, the IDR panel will meet privately in person or by phone. Desk reviews will be scheduled at the convenience of the panel and does not include oral presentations. The desk review and final decision should be completed and communicated to the licensee in writing within 30 days of the initial IDR request.

IDR Notification and Attendance: The IDR Coordinator ensures that the IDR panel members, survey team leader, regional supervisor, branch manager, county department of social services supervisor, and state long-term care ombudsman are notified of the facility's IDR request as well as the date, time, location, and format of the IDR meeting.

Face to Face and Conference Call Meetings: Attorneys and their employees are not allowed to attend the IDR meeting. The following individuals may attend and are responsible for protecting the confidentiality of resident information:

  1. Facility representatives and staff;
  2. Survey team members, ACLS observers and/or ACLS management staff;
  3. State and regional long-term care ombudsmen; and
  4. Resident, the resident's legal guardian and/or medical power of attorney. [Note: These individuals can only stay during the discussion of information pertinent to the specific resident. They must be identified prior to the start of the IDR meeting and have signed and verified authorization forms on hand.]

Facility representatives and staff, ombudsmen, the resident, and the resident's legal guardian or medical power of attorney may provide verbal information pertinent to the deficiencies being disputed and respond to questions from the IDR panel members. With the exception of facility representatives and staff, oral statements will be limited to five minutes.

The facility representatives or staff will first present information to the panel. Survey team members may request to address the IDR panel to clarify information or to seek clarification of the information presented by the facility. The panel may ask questions of the facility and/or survey team. Facility staff cannot ask direct questions to surveyors. All participants in the IDR process are expected to keep their demeanor professional, respectful and non-confrontational when presenting information which may be contradictory to information provided by others. ACLS observers and management will not participate in the discussion. However, section management may intervene if the interaction or behavior of the participants is inappropriate and disruptive to the meeting. It is expected that the IDR Coordinator will direct and facilitate the meeting and intervene as necessary to maintain the rules of conduct as well as the focus of the presentations and interactions. The IDR meeting can be terminated if resolution of inappropriate behavior cannot be attained in a timely manner.

IDR Panel: The panel consists of two ACLS survey staff (not involved in the disputed survey) and an adult care home provider representative recommended by NCALA and/or NCALTCF and approved by ACLS. The IDR Coordinator will provide a copy of the IDR request packet to each panel member for review at least two weeks prior to the scheduled IDR meeting. The packet will include the IDR request letter, SOD report, and any additional information submitted by the facility. Only those deficiencies identified in the facility's request will be reviewed in IDR. The panel members will not discuss the report or details of the report with survey team members, facility staff or any others before or following the IDR meeting. The panel members will have reviewed the IDR packet prior to the IDR meeting.

IDR Results: After the IDR meeting, panel members will convene privately to review and discuss the information provided. The IDR panel will decide that a deficiency or finding is to be upheld or deleted, that a deficiency is to be upheld with deletion of a finding(s), or that the severity of the violation should be lowered. The panel shall not decide to move a deficiency or suggest that a deficiency or finding is to be rewritten. The IDR panel will then provide their final decision in writing to the IDR Coordinator.

Upon receipt, the IDR Coordinator will forward the panel's decision to the Section Chief for review and approval. At his or her discretion, the Section Chief may override the decision of the IDR panel. The IDR Coordinator will inform the licensee of the final IDR results in writing within 10 working days of the IDR meeting. A copy of the letter will be sent to the survey team leader, regional supervisor, branch manager, county department of social services supervisor, and state long-term care ombudsman.

Actions Generated by IDR: When the IDR panel decides that a deficiency or finding should not have been cited and the Section Chief approves the decision, the following actions shall occur as applicable:

  1. When the facility requests a marked SOD report, the relevant deficiency or finding will be marked "deleted", and will be initialed and dated by the survey team leader.
  2. When the facility requests issuance of a new SOD with the relevant deficiency or finding deleted, the facility must complete and document the Plan of Correction on the new SOD and returned it to the team leader within 10 working days of receipt. A marked copy of the SOD will be entered into the facility file as the document of record if the Plan of Correction is not returned within the 10-day period.
  3. Any enforcement action imposed solely because of a deficiency or finding that has been deleted as a result of the IDR will be rescinded.

Additional Opportunities for IDR: An IDR may be requested by a facility based on the results of a follow-up visit when there is a continuation of the same deficiency, a new deficiency or a new example of a deficiency. Following a revisit, a deficiency cited with the same facts previously upheld by the IDR panel but noted under a different rule is not eligible for IDR unless the new tag constitutes a violation.

Invalid Use of IDR: The facility cannot use the IDR process to delay the formal imposition of remedies or to challenge any other aspect of the inspection process, including the following:

  1. Remedy imposed by the enforcing agency;
  2. Failure of the survey team to comply with a requirement of the survey process;
  3. Inconsistency of the survey team in citing deficiencies among facilities;
  4. Surveyor behavior; or
  5. Inadequacy or inaccuracy of the IDR process.

An incomplete IDR process will not delay the effective date of any enforcement action.