North Carolina Administrative Code

10a NCAC 26d .0510 QUALITY ASSURANCE ANNUAL REPORT (a) The Department shall make available, to the DHHS review team, a written annual report summarizing the activities and recommendations of the quality assurance committee. (b) This report shall include, at a minimum, the followi…

SECTION .0600 - FACILITIES MANAGEMENT 10a NCAC 26d .0601 SCOPE The rules in this Section apply to each service delivery site within the Department and to any other provider of services on a contractual basis. History Note: Authority G.S. 148-19(d); Eff. January 4, 1994; Pursuant …

10a NCAC 26d .0602 BUILDINGS AND GROUNDS History Note: Authority G.S. 148-19(d); Eff. January 4, 1994; Pursuant to G.S. 150B-21.3A, rule expired July 1, 2015.

10a NCAC 26d .0603 SPACE REQUIREMENTS (a) Space shall be provided to facilitate the delivery of mental health and mental retardation services. (b) Each client in an inpatient mental health unit shall be housed in a single cell. (c) Each client in a residential treatment program s…

10A NCAC 26d .0604 ADDITIONAL REQUIREMENTS FOR RESIDENTIAL/INPATIENT UNITS (a) Each residential and inpatient unit providing mental health or mental retardation services shall have indoor space for group activities and gatherings. (b) The space in which therapeutic and habilitati…

SECTION .0700 - CLIENT RECORDS 10A NCAC 26D .0701 SCOPE (a) The rules in this Section apply to each service delivery site and to any other provider of services on a contractual basis, unless otherwise specified in this Section. (b) This Section applies to the management of client…

10A NCAC 26d .0702 STANDARD CLIENT RECORD (a) The Department shall develop and maintain a standard client record for each client who receives mental health or mental retardation treatment or habilitation services. (b) The same forms and filing format shall be utilized within each…

10A NCAC 26d .0703 RECORD REQUIREMENTS (a) A written client record shall be maintained for each client, and shall contain, at a minimum, the following identifying information: (1) name; (2) record number; (3) date of birth; (4) race, sex, and marital status; (5) admission date; a…

10A NCAC 26d .0704 CONFIDENTIALITY OF CLIENT RECORD (a) All information contained in the client record shall be considered privileged and confidential, with the exception of matters of public record, as set forth in 5 NCAC 02D .0600. (b) The Department shall ensure confidentialit…

10a NCAC 26d .0705 DIAGNOSTIC CODING The Department shall code diagnoses for clients using the following diagnostic systems: (1) Mental illness or mental retardation shall be diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition - Revised (…

10a NCAC 26d .0706 CLIENT RECORD AVAILABILITY The Department shall ensure that client records are available to professional staff for a minimum of three years following the inmate's release. This shall apply to previous incarcerations. History Note: Authority G.S. 148-19(d); Eff.…

SECTION .0800 - SERVICE ELIGIBILITY 10a NCAC 26d .0801 SCOPE The rules in this Section apply to each service delivery site within the Department and to any other provider of services on a contractual basis. History Note: Authority G.S. 148-19(d); Eff. January 4, 1994; Pursuant to…

10a NCAC 26d .0802 SERVICE CRITERIA The Department shall ensure the development of service criteria for mental health and mental retardation services. These criteria shall be communicated to inmates and staff. History Note: Authority G.S. 148-19(d); Eff. January 4, 1994; Pursuant…

10a NCAC 26d .0803 SCREENING The Department shall develop a systematic means of screening each inmate referred for services to determine his need for services, and designate staff qualified to make screening determinations. History Note: Authority G.S. 148-19(d); Eff. January 4, …

10a NCAC 26d .0804 WAITING LISTS The Department shall establish criteria for prioritizing service delivery and use of waiting lists for mental health and mental retardation services. History Note: Authority G.S. 148-19(d); Eff. January 4, 1994; Pursuant to G.S. 150B-21.3A, rule i…

10A NCAC 26D .0805 INFORMATION REGARDING AVAILABILITY TO SERVICES The Department shall ensure that each inmate is informed how to access mental health and mental retardation services. History Note: Authority G.S. 148-19(d); Eff. January 4, 1994; Pursuant to G.S. 150B-21.3A, rule …

SECTION .0900 - TREATMENT AND HABILITATION 10a NCAC 26d .0901 SCOPE (a) The rules in this Section apply to each service delivery site within the Department and to any other provider of services on a contractual basis. (b) The process of treatment or habilitation shall incorporate…

10a NCAC 26d .0902 ADMISSION ASSESSMENT (a) An admission note shall be completed within 24 hours of admission which includes, but need not be limited to: (1) reason for admission; (2) present condition of the client reported in objective, behavioral terms, and when possible, a de…

10a NCAC 26d .0903 EVALUATION AND DIAGNOSIS Each service delivery site shall document, for each client, any routine diagnostic tests, assessments and evaluations, or medical examinations, as well as time frames for their completion. History Note: Authority G.S. 148-19(d); Eff. Ja…

10a NCAC 26d .0904 TREATMENT OR HABILITATION PLAN (a) Each service delivery site shall develop an individualized treatment or habilitation plan for each client based upon: (1) an evaluation of his condition, assets and needs; and (2) information gathered during the admission asse…

10a NCAC 26d .0905 PROGRESS NOTES (a) Progress notes shall be recorded at least on a weekly basis in residential and inpatient services and following each scheduled appointment in outpatient services. (b) Progress notes shall reflect the client's progress or lack of progress: (1)…

10a NCAC 26d .0906 TRANSFER OR DISCHARGE SUMMARY (a) Whenever a client is transferred to a different level of service, a written transfer note by the referring unit shall accompany the client summarizing the client's condition at the time of transfer, and any recommendations for …

10a NCAC 26d .0907 TREATMENT AND HABILITATION COORDINATION (a) Coordination shall be maintained among all staff members contributing to the evaluation, planning, and treatment and habilitation efforts for each client. (b) Each service delivery site, utilizing shifts or relief sta…

10a NCAC 26d .0908 RELEASE PLANNING IN RESIDENTIAL AND INPATIENT SERVICES (a) When release of a client can be anticipated and the need for continued treatment has been identified, each client shall have a written individualized aftercare plan. (b) The aftercare plan shall: (1) be…

SECTION .1000 - CLINICAL SERVICES 10a NCAC 26d .1001 SCOPE (a) The rules in this Section apply to each service delivery site, and to any other provider of services on a contractual basis that incorporates clinical services in their activities. (b) The provision of clinical servic…

10a NCAC 26d .1002 COUNSELING AND PSYCHOTHERAPY SERVICES Individual, group and family counseling, and psychotherapy shall be provided by, or under the direct supervision of, qualified professionals who have received training in these treatment or habilitation modalities. History …

10a NCAC 26d .1003 SPECIALIZED THERAPIES The following shall be provided by, or under the direct supervision of, staff licensed or registered to perform these activities: (1) medical care; (2) physical, occupational, or language and communication therapy; and (3) nursing care. Hi…

10a NCAC 26d .1004 TESTING SERVICES Individuals, who are privileged to utilize the particular testing instrument being administered, shall perform testing on each client, who is referred by a clinician, in the areas of: (1) psychology; (2) development; (3) education; and (4) inte…

SECTION .1100 - MEDICATION SERVICES 10a NCAC 26d .1101 SCOPE (a) The rules in this Section apply to each service delivery site and to any other provider of services on a contractual basis that provide medication services. (b) Any client who is placed on medication for problems as…

10a NCAC 26d .1102 DISPENSING OF MEDICATION (a) Medication shall be dispensed, by a pharmacist or physician, in a properly labeled container in accordance with state and federal law. (b) The medication container shall protect medication from light and moisture, and shall be in co…

10a NCAC 26d .1103 ADMINISTRATION OF MEDICATION (a) Medication shall be administered in accordance with state and federal law. (b) Prescription medication shall be administered in service delivery sites only on the order of an authorized prescriber. (c) Non-prescription medicatio…

10a NCAC 26d .1104 INVOLUNTARY ADMINISTRATION OF PSYCHOTROPIC MEDICATION (a) Psychotropic medication may be administered to any non-consenting client who has a mental illness and is receiving inpatient mental health treatment if any one or more of the following conditions exist: …

10a NCAC 26d .1105 PSYCHOTROPIC MEDICATION EDUCATION (a) To ensure the client's understanding of psychotropic medication, individual or group medication education shall be provided to each client: (1) who is to begin receiving, or is to be maintained on, psychotropic medication; …

SECTION .1200 - PROTECTIONS REGARDING CERTAIN PROCEDURES 10a NCAC 26d .1201 SCOPE The rules in this Section specify protections regarding the use of certain specified procedures, in order to promote dignity and humane care for any client receiving mental health and mental retarda…

10a NCAC 26d .1202 USE OF SECLUSION (a) Seclusion shall be used only under one of the following conditions: (1) on an emergency basis when it is necessary to prevent immediate harm to the client or to others; or (2) on a non-emergency basis if that seclusion will resolve the prec…

10a NCAC 26d .1203 USE OF RESTRAINT (a) Restraint shall be used only under the following circumstances: (1) after less restrictive measures, such as counseling and seclusion, have been attempted or if clinically determined to be inappropriate or inadequate to avoid injury to self…

10a NCAC 26d .1204 PROTECTIVE DEVICES Whenever protective devices are used for any client, the Chief of Psychiatry shall: (1) ensure that the: (a) necessity for the protective device has been assessed and approved by a mental health professional; (b) device is applied by a person…

10a NCAC 26d .1205 VOLUNTARY REFERRALS AND TRANSFERS (a) Non-emergency referrals shall be forwarded to the mental health or mental retardation professional designated to receive such referrals at the service delivery site to which the client is assigned. (b) If the mental health …

10a NCAC 26d .1206 INVOLUNTARY REFERRALS AND TRANSFERS (a) Involuntary referrals and transfers to residential or inpatient units shall occur only if the attending clinician determines that: (1) a client requires treatment services not available at his or her current service deliv…

10a NCAC 26d .1207 TRANSFER TO RESIDENTIAL OR INPATIENT UNITS All inmates who are considered for transfer to a residential or inpatient unit shall have rights which include, but need not be limited to: (1) written notice that transfer to a residential or inpatient mental health f…

SECTION .1300 - RESEARCH PRACTICES 10a NCAC 26d .1301 SCOPE (a) The rules in this Section apply to research activity or treatment involving direct contact with a client. (b) An activity or treatment procedure shall be considered research when it: (l) involves a clinical practice …

10a NCAC 26d .1302 RESEARCH REVIEW BOARD (a) Research that involves a client shall be reviewed and approved by a research review board established by the Department. (b) The research review board shall approve, require modification, or disapprove proposed research projects subjec…

10a NCAC 26d .1303 CONDITIONS OF CLIENT PARTICIPATION (a) Informed written consent shall be obtained from each client in a research project as follows: (1) documentation that the client has been informed of any potential dangers that may exist, and that he understands the conditi…

SECTION .1400 - EMERGENCY SERVICES 10a NCAC 26d .1401 SCOPE (a) The Department shall ensure that emergency mental health and mental retardation services are available to all inmates. (b) Emergency services provide: (1) immediate assessment and intervention; and (2) referral for c…

10a NCAC 26d .1402 TRAINING OF STAFF The Department shall ensure that staff who: (1) supervise inmates have been trained to access and refer to emergency services; and (2) provide emergency services are properly trained. History Note: Authority G.S. 148-19(d); Eff. January 4, 199…

SECTION .1500 - PREVENTION SERVICES 10a NCAC 26d .1501 SCOPE The Department shall develop a process to identify inmates who are: (1) at risk for developing mental disorders; and (2) provide counseling, education, instruction and protective living arrangements to enhance their abi…

SECTION .1600 - INPATIENT SERVICES FOR INMATES WHO ARE MENTALLY ILL 10a NCAC 26d .1601 SCOPE (a) Inpatient units for clients who are mentally ill shall provide close supervision by a qualified mental health professional on a 24-hour basis. (b) The inpatient unit shall be designed…