What Laws Govern NC Assisted Living Facilities? A Family's Guide to DHSR Oversight

The Regulatory Landscape

Assisted living facilities in North Carolina are licensed and regulated by the NC Division of Health Service Regulation (DHSR), which is part of the NC Department of Health and Human Services. Most assisted living facilities in NC are licensed as adult care homes — a category that includes assisted living residences, family care homes, and multi-unit assisted housing.

Unlike skilled nursing facilities, most NC assisted living facilities are not Medicare- or Medicaid-certified. They are licensed by the state, but they operate on private pay. This distinction matters for what regulations apply and which agencies oversee the facility's conduct.

The Core Regulation: 10A NCAC 13F

The primary regulation governing NC adult care homes is 10A NCAC 13F — the Adult Care Home Rules. These rules are adopted by the NC Medical Care Commission and enforced by DHSR. They cover:

  • Admission criteria and assessments
  • Care plan requirements
  • Staffing ratios and qualifications
  • Physical environment standards
  • Resident rights
  • Medication management
  • Restraint and protective device rules
  • Discharge and transfer requirements

Families who want to understand what a facility is required to do — or whether a facility has violated a requirement — should consult 10A NCAC 13F. It is publicly available through the NC DHSR website.

Staffing Requirements

NC adult care home rules specify minimum staffing based on facility size and the level of care residents require. Key requirements:

  • At least one awake, on-duty staff member at all times
  • Staff-to-resident ratios that increase with the number of residents requiring substantial care
  • Administrators must meet specific training and certification requirements
  • Direct care staff must receive facility orientation and ongoing training

Understaffing is one of the most common sources of complaints to DHSR. If you observe consistent gaps in care coverage, inadequate response times, or evidence that residents are being left unsupervised, document it and file a complaint.

Resident Rights Under NC Law

Chapter 131D of the NC General Statutes establishes a Bill of Rights for residents of adult care homes. Key resident rights include:

  • The right to be treated with dignity and respect
  • The right to privacy — including in personal care, correspondence, and visits
  • The right to receive visitors of one's choice
  • The right to participate in planning one's own care
  • The right to manage personal funds (or have them managed transparently)
  • The right to file grievances without retaliation
  • The right to be informed about facility policies, fees, and any changes to care
  • The right to be free from physical or chemical restraints used for convenience or discipline
  • The right to not be discharged without proper notice and process

Facilities are required to post these rights prominently and to provide them in writing to residents and their responsible parties upon admission.

Care Plans: What Facilities Must Provide

Under 10A NCAC 13F .0801 and .0802, adult care homes must develop an individualized care plan for each resident. The care plan must:

  • Be developed within 30 days of admission
  • Be based on an assessment of the resident's needs, preferences, and capabilities
  • Address specific care activities: bathing, dressing, grooming, mobility, medication, meals
  • Identify who is responsible for each care activity
  • Be reviewed and updated at least quarterly, or when the resident's condition changes

Families have the right to participate in care plan development and review. If you are the resident's responsible party, you should be invited to care plan meetings and given a copy of the plan.

Physical Safety Equipment: Restraints and Mobility Aids

Facilities must follow specific rules about physical restraints and protective devices. Under 10A NCAC 13F, facilities may not use physical restraints (including wheelchair straps, vest restraints, or bed rails that restrict movement) without:

  • Physician order
  • Informed consent from the resident or their authorized representative
  • Documentation in the care plan of why the restraint is being used and what less restrictive alternatives were tried
  • Regular reassessment of whether the restraint continues to be necessary

A facility that applies a physical restraint without these elements is in violation of state regulations. If a family member objects to the use of a restraint, they have the right to refuse on the resident's behalf (as authorized representative) and to demand documentation of the medical justification.

Filing a Complaint With DHSR

If you believe a facility is violating state regulations, you can file a complaint with DHSR:

  • Online: ncdhhs.gov/DHSR
  • Phone: 800-624-3004 (Adult Care Licensure Section)
  • Written complaint: Submitted to the DHSR Adult Care Licensure Section

DHSR investigates complaints and can conduct unannounced inspections. Substantiated violations result in a Statement of Deficiencies, which is a public document. Serious violations can result in civil monetary penalties, directed plans of correction, or — in extreme cases — license revocation.

The Long-Term Care Ombudsman Program is a separate resource — ombudsmen advocate for residents in licensed facilities and can help resolve complaints informally or help you navigate a formal complaint. Find your regional ombudsman through NC DHHS.

What DHSR Cannot Do

DHSR enforces state licensing requirements. It cannot:

  • Represent your family in a legal dispute with the facility
  • Award damages or compensation for harm
  • Force a facility to retain a resident they want to discharge (unless the discharge process is defective)
  • Investigate matters that are purely contractual between the facility and the family

For those matters, you may need an elder law attorney or, in cases of serious harm, a personal injury attorney.

The information on this page is for educational purposes only and does not constitute legal advice. Learn more about ElderAdvocate.law.