North Carolina Administrative Code › Title 10A - HEALTH AND HUMAN SERVICES › Chapter 06 - AGING - PROGRAMS OPERATIONS › Subchapter S - ADULT DAY HEALTH STANDARDS FOR CERTIFICATION › Section .0500 - CERTIFICATION INFORMATION › Section 06S .0501 - PROCEDURE

Current through Register Vol. 39, No. 2, July 15, 2024
(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.