North Carolina Administrative Code

10A NCAC 13B .5205 SECLUSION At least one seclusion room shall be provided in all hospitals licensed to provide a psychiatric program, a substance abuse program or both. History Note: Authority G.S. 131E-79; Eff. January 1, 1996; Pursuant to G.S. 150B-21.3A, rule is necessary wit…

10A NCAC 13B .5206 COMPLIANCE WITH STATUTORY REQUIREMENTS (a) Facilities providing psychiatric or substance abuse services shall develop procedures to protect the rights of psychiatric and substance abuse patients in accordance with North Carolina statutes addressing the rights o…

10A NCAC 13B .5207 PSYCHIATRIC OR SUBSTANCE ABUSE OUTPATIENT SERVICES Partial hospitalization, outpatient and day treatment facilities shall be subject to 10A NCAC 27G .1100, 10A NCAC 27G .3500, and 10A NCAC 27G .3700 respectively, which are incorporated by reference with all sub…

SECTION .5300 - NURSING AND ADULT CARE HOME BEDS 10A NCAC 13B .5301 THE LICENSURE OF NURSING AND ADULT CARE HOME BEDS IN A HOSPITAL When a facility has nursing facility beds or adult care home beds, the beds shall be provided under the hospital's license as provided in Rule .3101…

SECTION .5400 - COMPREHENSIVE INPATIENT REHABILITATION 10A NCAC 13B .5401 DEFINITIONS The following definitions shall apply to inpatient rehabilitation facilities or units only: (1) "Case management" means the coordination of services, for a given patient, between disciplines so …

10A NCAC 13B .5402 PHYSICIAN REQUIREMENTS FOR INPATIENT REHABILITATION FACILITIES OR UNITS (a) In a rehabilitation facility or unit, a physician shall participate in the provision and management of rehabilitation services and in the provision of medical services. (b) In a rehabil…

10A NCAC 13B .5403 ADMISSION CRITERIA FOR INPATIENT REHABILITATION FACILITIES OR UNITS (a) The facility shall have written criteria for admission to the inpatient rehabilitation facility or unit. A description of programs or services for screening the suitability of a given patie…

10A NCAC 13B .5404 COMPREHENSIVE INPATIENT REHABILITATION EVALUATION (a) A comprehensive, inpatient rehabilitation evaluation is required for each patient admitted to an inpatient rehabilitation facility or unit. At a minimum this evaluation shall include the reason for referral,…

10A NCAC 13B .5405 COMPREHENSIVE INPATIENT REHABILITATION INTER-DISCIPLINARY TREAT/PLAN (a) The interdisciplinary treatment team shall develop an individual treatment plan for each patient within seven days after admission. The plan shall include evaluation findings and informati…

10A NCAC 13B .5406 DISCHARGE CRITERIA FOR INPATIENT REHABILITATION FACILITIES OR UNITS (a) Discharge planning shall be an integral part of the patient's treatment plan and shall begin upon admission to the facility. After goals of care have been reached, or a determination by the…

10A NCAC 13B .5407 COMPREHENSIVE REHABILITATION PERSONNEL ADMINISTRATION (a) The facility shall have qualified staff members, consultants and contract personnel to provide services to the patients admitted to the inpatient rehabilitation facility or unit. (b) Personnel shall be e…

10A NCAC 13B .5408 COMPREHENSIVE INPATIENT REHABILITATION PROGRAM STAFFING REQUIREMENTS (a) The staff of the inpatient rehabilitation facility or unit shall include: (1) the inpatient rehabilitation facility or unit shall be supervised by a rehabilitation nurse as defined in Rule…

10A NCAC 13B .5409 STAFF TRAINING FOR INPATIENT REHABILITATION FACILITIES OR UNIT Prior to the provision of care, all rehabilitation personnel, excluding physicians, assigned to the rehabilitation unit shall be provided training or shall provide documentation of training that inc…

10A NCAC 13B .5410 EQUIPMENT REQUIREMENTS/COMPREHENSIVE INPATIENT REHABILITATION PROGRAMS (a) The facility shall provide each discipline with the necessary equipment and treatment methods to achieve the short and long-term goals specified in the comprehensive inpatient rehabilita…

10A NCAC 13B .5411 PHYSICAL FACILITY REQUIREMENTS/INPATIENT REHABILITATION FACILITIES OR UNIT History Note: Authority G.S. 143B-165; Eff. March 1, 1996; Repealed Eff. August 1, 2023.

10A NCAC 13B .5412 ADDITIONAL REQUIREMENTS FOR TRAUMATIC BRAIN INJURY PATIENTS (a) Inpatient rehabilitation facilities providing services to patients with traumatic brain injuries shall provide staff to meet the needs of patients in accordance with the patient assessment, treatme…

10A NCAC 13B .5413 ADDITIONAL REQUIREMENTS FOR SPINAL CORD INJURY PATIENTS (a) Inpatient rehabilitation facilities providing services to patients with spinal cord injuries shall provide staff to meet the needs of patients in accordance with the patient assessment, treatment plan,…

10A NCAC 13B .5414 DEEMED STATUS FOR INPATIENT REHABILITATION FACILITIES OR UNIT (a) If an inpatient rehabilitation facility or unit with a comprehensive inpatient rehabilitation program is surveyed and accredited by The Joint Commission (TJC) or the Commission on Accreditation o…

section .5500 – supplemental rules for hospitals providing living organ donation transplant services 10A NCAC 13B .5501 applicability of rules The rules contained in this Section shall apply to hospitals providing living organ donation transplant services. History Note: Authority…

10A NCAC 13B .5502 INDEPENDENT DONOR ADVOCATE TEAM (a) The facility shall appoint an Independent Donor Advocate Team (IDAT) whose sole purpose is to represent and ensure the well-being of the potential donor, making sure he or she is aware of the risks and benefits of donation an…

10A NCAC 13B .5503 INFORMED CHOICE (a) The potential donor must be free to make an informed independent decision, which has been termed informed choice. Informed choice addresses the decision process of the potential donor as he or she determines whether or not to donate. Informe…

10A NCAC 13B .5504 EVALUATION PROTOCOL FOR LIVING ORGAN DONORS Hospitals shall complete the following evaluation protocols prior to living organ donation: (1) The facility shall confirm the potential donor's ABO blood type. (2) Only individuals 18 years of age or older shall be c…

10A NCAC 13B .5505 Perioperative Care and Facility Support (a) The donor surgical team shall have primary concern and responsibility for the donor's care and welfare throughout his or her entire hospital stay. The donor surgical team consists of the donor surgeon, his or her surg…

10A NCAC 13B .5506 DISCHARGE PLANNING (a) Pre-Donation. At the time of evaluation by the IDAT, a discussion shall be held between the IDAT social worker and the potential donor and his or her family or next of kin to address the following areas: (1) Living arrangements after disc…

SECTION .5600 - RESERVED FOR FUTURE CODIFICATION 10A NCAC 13B .5600 Reserved for future codification

SECTION .5700 - RESERVED FOR FUTURE CODIFICATION 10A NCAC 13B .5700 Reserved for future codification

SECTION .5800 - RESERVED FOR FUTURE CODIFICATION 10A NCAC 13B .5800 Reserved for future codification

SECTION .5900 - RESERVED FOR FUTURE CODIFICATION 10A NCAC 13B .5900 Reserved for future codification

10A NCAC 13B .6003 definitions In addition to the definitions set forth in G.S. 131E-76, the following definitions shall apply in Sections .6000 through .6200 of this Subchapter: (1) "Addition" means an extension or increase in floor area or height of a building. (2) "Alteration"…

SECTION .6100 – GENERAL REQUIREMENTS 10A NCAC 13B .6101 LIST OF REFERENCED CODES, RULES, REGULATIONS, AND STANDARDS For the purposes of the rules in this Subchapter, the following codes, rules, regulations, and standards are incorporated herein by reference including subsequent a…

10A NCAC 13B .6102 General (a) A new facility or any addition or alteration to an existing facility whose construction documents were approved by the Construction Section on or after April 1, 2019 shall comply with the requirements provided in the codes, regulations, rules, and s…

10A NCAC 13B .6103 equivalency AND Conflicts with REQUIREMENTS (a) The Division may grant an equivalency to allow an alternate design or functional variation from the requirements in Rule .3102 and the Rules contained in Sections .6000 through .6200 of this Subchapter. The equiva…

10A NCAC 13B .6104 ACCESS AND SAFETY History Note: Authority G.S. 131E-79; Eff. January 1, 1996; Repealed Eff. January 1, 2018.

10A NCAC 13B .6105 Incorporation by reference and application of the requirements of the FGI guidelines (a) For the purposes of Sections .6000 through .6200 of this Subchapter, the Guidelines for the Design and Construction of Hospitals and Outpatient Facilities shall be referred…

10A NCAC 13B .6207 OUTPATIENT SURGICAL FACILITIES (a) If a facility elects to share outpatient surgical facilities with inpatient surgical facilities, the outpatient operating room and support areas shall meet the requirements set forth in Sections .6000 through .6200 of this Sub…

10A NCAC 13B .6228 Neonatal Level I, II, III, and Iv Nurseries A facility that provides neonatal services as specified in Rule .4305 of this Subchapter shall meet the requirements of the FGI Guidelines as follows: (1) a Neonatal Level I nursery shall comply with the requirements …

subchapter 13C – licensing of ambulatory surgical facilities section .0100 – general 10A NCAC 13C .0101 RESERVED FOR FUTURE CODIFICATION

10A NCAC 13C .0102 reserved for future codification

10A ncac 13C .0103 DEFINITIONS In addition to the terms defined in G.S. 131E-214.13, the following terms shall apply throughout this Subchapter, unless the context clearly requires otherwise: (1) "Adequate" means, when applied to various areas of services, that the services are s…

SECTION .0200 - LICENSING PROCEDURES 10A NCAC 13C .0201 APPLICATION (a) A person shall submit an application for a license to establish or maintain an ambulatory surgical facility to the Department in writing on the form provided by the Department. Each application shall contain …

10A ncac 13C .0202 REQUIREMENTS FOR ISSUANCE OF LICENSE (a) Upon application for a license from a facility never before licensed, a representative of the Department shall make an inspection of that facility. Every building, institution, or establishment that has been issued a lic…

10A NCAC 13C .0203 SUSPENSION OR REVOCATION: AMBULATORY SURGICAL FACILITY License suspensions and revocations shall be governed by G.S. 131E-148. History Note: Authority G.S. 131E-148; 131E-149; 143B-165; Eff. October 14, 1978; Amended Eff. November 1, 1989; Pursuant to G.S. 150B…

10A NCAC 13C .0204 TYPE OF FACILITY DEEMED TO BE LICENSED An ambulatory surgical facility shall be deemed a suitable facility for the performance of abortions pursuant to G.S. 14-45.1(a). History Note: Authority G.S. 14-45.1; 131E-147; 131E-149; Eff. June 30, 1980; Amended Eff. N…

10A NCAC 13C .0205 ITEMIZED CHARGES (a) The facility shall either present an itemized list of charges to all discharged patients or include on patients' bills that are not itemized notification of the right to request an itemized bill within three years of receipt of the non-item…

10A NCAC 13C .0206 REPORTING REQUIREMENTS (a) The Department shall establish the lists of the statewide 20 most common outpatient imaging procedures and 20 most common outpatient surgical procedures performed in the ambulatory surgical facility setting to be used for reporting th…

SECTION .0300 – GOVERNING AUTHORITY MANAGEMENT 10A NCAC 13C .0301 GOVERNING AUTHORITY (a) The facility's governing authority shall adopt bylaws or other operating policies and procedures to assure that: (1) a named individual is identified who is responsible for the overall opera…

10A NCAC 13C .0302 CHIEF EXECUTIVE OFFICER OR ADMINISTRATOR (a) The governing authority shall appoint a qualified person as chief executive officer of the facility to represent the governing authority and shall define his authority and duties in writing. He shall be responsible f…

10A NCAC 13C .0303 ADMINISTRATIVE RECORDS (a) The following essential documents and references shall be on file in the administrative office of the facility: (1) appropriate documents evidencing control and ownerships, such as deeds, leases, or corporation or partnership papers; …

10A NCAC 13C .0304 SURGICAL PROCEDURES PERFORMED A current listing of all types of surgical procedures offered by the facility shall be available. History Note: Authority G.S. 131E-149; Eff. October 14, 1978; Pursuant to G.S. 150B-21.3A, rule is necessary without substantive publ…

10A NCAC 13C .0305 PERSONNEL (a) Personnel Records (1) A record of each employee shall be maintained which includes the following: (A) employee's identification; (B) resume of education and work experience; (C) verification of valid license (if required), education, training, and…