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 must apply for a certificate to the county department of social services in the county where the program is to be operated.

(b)  A designated social worker will supply necessary forms and standards for certification and will make a study of the program.

(c)  The following forms and materials make up an initial certification package and must be submitted through the county department of social services to the state Division of Aging:

(1)           The program policy statement;

(2)           Organizational diagram;

(3)           Job descriptions;

(4)           Documentation 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 DSS‑1498 (Fire Inspection Report) or the equivalent 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 DSS‑1499 (Building Inspection Report for Day Care Services for Adults) or the equivalent completed and signed by the local building inspector, or fire inspector or fire marshall 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 DSS‑2386 (Sanitation Evaluation Report) or the equivalent completed and signed by a local sanitarian, 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 if a proprietary program;

(12)         A medical statement of each proposed staff member certifying to freedom from communicable disease or condition and to good health signed by a licensed physician, physician assistant or nurse practitioner no more than 30 days prior to submission with the certification package.  When such certification cannot be made, employment may commence, continue, terminate, or be reassigned based on an assessment on whether the employee's work tasks would pose a significant risk to the health of the employee, co‑workers or the public, or whether the employee is unable to perform the normally assigned job duties; and

(13)         DSS‑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)  The following forms and materials make up a certification package for the renewal of a certification and must be submitted through the county department of social services, no more than 60 days prior to the end of the current period of certification, to the state Division of Aging:

(1)           Form DSS‑1498 (Fire Inspection Report) or the equivalent 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 DSS‑1499 (Building Inspection Report for Day Care Services for Adults) or the equivalent 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 marshall if a building inspector is not available, indicating approval of the facility, within 30 days following completion of the structural building modifications;

(3)           Form DSS‑2386 (Sanitation Evaluation Report) or the equivalent completed and signed by a local sanitarian, indicating approval of the facility, no more than 12 months prior to submission with the certification package;

(4)           A medical statement for each staff member certifying to freedom from communicable disease or condition and to good health signed by a licensed physician, physician assistant or nurse practitioner no more than 12 months prior to submission with the certification package.  When such certification cannot be made, employment may commence, continue, terminate, or be reassigned based on an assessment on whether the employee's work tasks would pose a significant risk to the health of the employee, co‑workers or the public, or whether the employee is unable to perform the normally assigned job duties;

(5)           An updated copy of the policy statement, 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)           Documentation showing planned expenditures and resources available to carry out the program of service for a 12 month period; and

(7)           DSS‑6205 (Adult Day Health Certification Report).  This form must be submitted with the certification package by the Department of Social Services to the Division of Aging 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 will so inform the applicant, indicating in writing the reasons, and give the applicant an opportunity to withdraw the application. Upon the applicant's request, the application will be completed and submitted to the Division of Aging for consideration.

(f)  Following review of the certification package, a pre‑certification visit may be made by staff of state Division of Aging.

(g)  The Division of Aging will promptly notify in writing to the applicant and the county department of social services of the action taken after a review of the certification package and visit, if made.

 

History Note:        Authority G.S. 130A‑148; 131D‑6; 143B‑153;

Eff. May 1, 1992;

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