Home Care and Hospice Licensure Survey Checklist

In order to assist in preparation for initial licensure survey and to ensure compliance with the North Carolina rules governing the licensure of home care agencies, you are advised to have the following items ready for review at the time of the initial survey.

Home Care and Hospice Licensure Survey Checklist (PDF, 55 KB)

  1. Administrative Policies and Procedures - to include the following at a minimum:
    1. Evidence that the applicant has previously owned or operated a home care agency or evidence that the applicant has taken a DHSR approved home care training course {10A NCAC 13J .0903(a)}
    2. Agency organization chart {10A NCAC 13J .1001(a)(8)}
    3. Evidence of the existence of premises where the agency will operate (lease agreement, ownership documents, business license, etc.) {10A NCAC 13J .0903(a-d)}
    4. Geographic service area(s) for each service (Counties where providing service) {10A NCAC 13J .1001(g)}
    5. Agency director job description (qualifications and specific responsibilities) {10A NCAC 13J .1001(b,d,e)}
    6. Service supervisor job description (qualifications and specific responsibilities) {10A NCAC 13J .1001(c,d)}
    7. Job description for each service category (qualifications and specific responsibilities) {10A NCAC 13J .1003(d)}
    8. Annual budget (projected for new agencies – expenses and revenue) {10A NCAC 13J .1002(a)}
    9. Infection control policies {10A NCAC 13J .1003(a)} (follow OSHA guidelines), include:
      1. Communicable Disease Control
      2. Bloodborne pathogen training policy and record of curriculum content, trainer, and training session dates
      3. TB and Hepatitis B policy
      4. Exposure control plan with high risk categories identified (employees with direct patient/client contact)
      5. Post-exposure follow-up procedures
    10. Annual program evaluation policy {10A NCAC 13J .1004(a-e)}
    11. Quarterly client record review policy {10A NCAC 13J .1004(d)} (for Home Care agencies only), or Interdisciplinary Care Team (ICT) meetings (for Hospice only)
    12. Order of Authority Policy {10A NCAC 13J .1001(e)}
  2. Client Care Policies and Procedures
    1. Client rights policy {10A NCAC 13J .1007(a-d)} and No Smoking Policy (GS131E-143)
    2. Client complaint policy, including state hot line number for filing complaints {10A NCAC 13J .1007(d)}
    3. Policy for reporting to the Health Care Personnel Registry (HCPR)
    4. Admissions policy {10A NCAC 13J .1101}
    5. Policy for coordination of client/patient care with other community services or other home care agencies {10A NCAC 13J .1001(a)(11) & 10A NCAC 13J .1101(a)(8)}
    6. Scope of service policy {10A NCAC 13J .1100} and applicable service policies {10A NCAC 13J .1102, 10A NCAC 13J .1103, 10A NCAC 13J .1104, 10A NCAC 13J .1105, 10A NCAC 13J .1106, 10A NCAC 13J .1107, 10A NCAC 13J .1108, 10A NCAC 13J .1109, 10A NCAC 13J .1502(a, b)}, including but not limited to:
      1. Nursing, physical therapy, occupational therapy, speech therapy, medical social work, hospice (bereavement, volunteer services), infusion, respiratory – including on-call for nursing, infusion and respiratory services
      2. In-Home Aides (IHAs), Companion/Sitters including:
        1. Documentation of training and competency verification {10A NCAC 13J .1003 (g), 10A NCAC 13J .1110(a,b), 10A NCAC 13J .1504}
        2. Supervision {10A NCAC 13J .1110(d), 10A NCAC 13J .1504}
      3. Discharge policy {10A NCAC 13J .1402 (2)(d,e)}
      4. Plan of care policy with quarterly plan of care reviews {10A NCAC 13J .1202 (a-d)}
      5. Orders policy (medication, treatment, and/or orders for in-home aide services) {10A NCAC 13J .1302}
      6. Service records policy {10A NCAC 13J .1401 & 10A NCAC 13J .1402}
        1. Storage of records
        2. Retention of records
        3. Content of records
          • Admission/intake data record
          • Client assessment data
          • Plan of care
          • Service data record
          • Supervisory visit record
          • Plan of care updates
          • Client's rights form
          • Physician's orders
          • Advance directives (if addressed in agency policy)
  3. Personnel policies and procedures - to include the following at a minimum {10A NCAC 13J .1003 & 10A NCAC 13J .1110}:
    1. Employee orientation policy
    2. Identification Badge policy (G.S. 90-640)
    3. In-service training policy and records of curriculum
    4. Employee annual performance evaluation policy
    5. Personnel records, content, access, storage and retention policy
    6. Policy defining agency's method of validating competencies
    7. Criminal background investigation policy (State Bureau of Investigation - SBI)
    8. Personnel records
      1. For initial licensure survey – bring completed personnel records for:
        1. Agency director
        2. Service supervisor
        3. Two (2) complete personnel records for each service/discipline requested on the initial application. (Hospice should include:  bereavement coordinator, patient care coordinator, medical director, volunteer coordinator, and volunteers)
      2. Each personnel record should include:
        1. Employee name
        2. Job title
        3. Application
        4. Date of hire
        5. Documentation of education and/or training
        6. License verification (nurses – NCBON verification)
        7. Nurse aide registry listing
        8. Health Care Personnel Registry check (CNAs/IHAs/Companions/Sitters)
        9. Orientation and in-service
        10. Job description (signed)
        11. Validation of skills (checklist) – signed by appropriate supervisor
        12. Bloodborne pathogen training verification
        13. Hepatitis B immunization/declination and TB status
        14. Reference checks or verification of previous employment
        15. Authorization to perform criminal background investigation by SBI
  4. Sample patient record/forms review
    • For initial licensure survey, bring sample(s) of all forms to be used for patient/client care documentation.

Home Care and Hospice Licensure Survey Checklist (PDF, 55 KB)