Format for Special Care Unit Disclosure Statement

Rules require the following steps in development of special care unit (SCU) disclosure statement.

The adult care home special care unit disclosure statement must address the items in order as listed below. It is to be submitted with the Adult Care Home Initial License Application (PDF, 80 KB) or the Change Licensure Application (PDF, 185 KB). Any changes to the disclosure statement as submitted must be reported in writing to the Adult Care Licensure section and written notification must be provided to the residents.

  1. Special care units for residents with Alzheimer’s disease or related disorders
    1. The philosophy of the special care unit which includes a statement of mission and objectives regarding the specific population to be served by the unit which shall address, but not be limited to the following:
      1. Safe, secure, familiar and consistent environment that promotes mobility and minimal use of physical restraints or psychotropic medication;
      2. A structured but flexible lifestyle through a well developed program of care which includes activities appropriate for each resident’s abilities;
      3. Individualized care plans that stress the maintenance of residents’ abilities and promote the highest possible level of physical and mental functioning; and
      4. Methods of behavior management which preserve dignity through design of the physical environment, physical exercise, social activity, appropriate medication administration, proper nutrition and health maintenance
    2. The process and criteria for admission to, and discharge from, the unit;
    3. A description of the special care services offered in the unit;
    4. Resident assessment and care planning, including opportunity for family involvement in care planning, and the implementation of the care plan, including responding to changes in the resident’s condition;
    5. Safety measures addressing dementia specific dangers such as wandering, ingestion, falls and aggressive behavior or other behavior management problems;
    6. Staffing in the unit;
    7. Staff training based on the special care needs of the residents;
    8. Physical environment and design features that address the needs of the residents;
    9. Activity plans based on personal preferences and needs of the residents;
    10. Opportunity for involvement of families in resident care and the availability of family support programs and
    11. Additional costs and fees for the special care provided.
  2. Special care units for residents with mental health or developmental disabilities
    • In addition to all of the above, disclosure must address the following:
      1. Grouping of residents that takes age, interests and behaviors into account;
      2. Ensuring client rights, choice and service coordination; and
      3. Safeguarding confidential information and ensuring that such information is not further disclosed in accordance with G.S. 122C-55(f) (PDF, 23 KB).