N.C. Division of Health Service Regulation

Mental Health, Developmental Disabilities and Substance Abuse Services (MH/DD/SAS) facilities are licensed by the Division of Health Service Regulation (DHSR) in accordance with North Carolina General Statute 122C-3 and rules in Title 10, Subchapter 14V of the N.C. Administrative Code.

Special Note: The following types of beds and services do require a certificate of need and have separate procedures:

Contacts: For questions regarding any part of this process, please contact the appropriate section of the N.C. Department of Health and Human Services:

Communications and Training, Div of Mental Health, Developmental Disabilities, and Substance Abuse	(919) 733-7011
Construction Section	(919) 855-3893
Legislative Liaison, Division of Mental Health, Developmental Disabilities, and Substance Abuse Serv	(919) 733-7011
Mental Health Licensure and Certification Section	(919) 855-3795

Procedure Summary:
In order to open a facility (that does not require a certificate of need) for the care, treatment, habilitation, or rehabilitation of persons who are mentally ill, developmentally disabled, or substance abusers, an applicant must apply for and obtain a license. The facility must have the license renewed every two years.

Step	Process followed
1.0	Obtain necessary documents: Division of Mental Health, Developmental Disabilities and Substance Abuse Services
1.1	For a facility seeking its first license, the applicant may contact the Legislative Liaison in the Division of MH/DD/SAS to obtain a copy of the MH/DD/SAS edition of the North Carolina General Statutes. A fee that reflects printing, handling and postage costs, may be imposed. (For license renewal, skip to step 4.2.)
1.2	The applicant contacts the Division of MH/DD/SAS Communications and Training Branch to obtain a copy of the Administrative Rules for MH/DD/SAS Facilities and Services. A fee that reflects printing, handling and postage costs, may be imposed.
2.0	Apply for a license: Mental Health Licensure and Certification Section
2.1	Applications may be obtained by contacting the Mental Health Licensure and Certification Section. A separate license is required for each facility that is maintained on a separate site, even if the site is under the same ownership or management.
2.2	The applicant sends the completed application along with floor plans and photographs of the facility (for existing buildings) to the Mental Health Licensure and Certification Section.
3.0	Obtain Construction Approval: Construction Section
3.1	Facilities that have not been previously licensed as G.S-122C facilities require Construction Section approval before licensing is possible. Prospective facility operators are encouraged to consult with the Construction Section of DFS prior to purchasing property intended for use as a facility.
3.2	The Construction Section receives the floor plans from the Mental Health Licensure and Certification Section. New facilities that do not require Construction Section approval are therapeutic or supervised programs with three or fewer clients and day facilities with no overnight sleeping accommodations. (No Construction Section approval is required for license renewal. However, renovations, additional construction or major repairs must have Construction Section approval.)
3.3	The Construction Section reviews the floor plans and writes the applicant with requirements or review comments and instructions. The Construction Section acts as the control point for distribution of plans and specifications to the Department of Insurance. For large facilities, plans are generally reviewed in three stages: schematic, design development, and final working drawings.
3.4	Applicants and their designers work closely with local building officials and fire prevention officials as well as with the Construction Section to ensure the facility is building code- and licensure-compliant.
3.5	At least two weeks before construction is complete, the applicant sends a letter to the Construction Section requesting a final construction inspection with project information and local approvals. The facility must be ready with all systems operational and all construction completed by the final construction inspection date. The Construction Section does not do punchlist inspections; punchlist inspections are the responsibility of the designer, contractor, and owner.
3.6	The Construction Section sends a copy of the final inspection requirements, inspects the facility for licensure and for certification, and reviews the required final documentation.
3.7	If minor deficiencies are found, the applicant submits a plan of correction.
3.8	When all items are acceptable, the Construction Section sends the construction approval transmittal form (form 4086) to the Mental Health Licensure and Certification Section.
3.9	After licensing, the facility maintains documented evidence of compliance with applicable fire and sanitation codes, including an annual fire inspection.
4.0	Obtain the License: Mental Health Licensure and Certification Section
4.1	After the facility receives notification that the Construction Section has approved a new facility, the applicant contacts the Mental Health Licensure and Certification Section.
4.2	The Mental Health Licensure and Certification Section consultant for that county conducts an on-site inspection of the facility to determine compliance with all rules and statutes.
4.3	The Mental Health Licensure and Certification Section determines whether a facility is in compliance with: Building plant and physical plant requirements. Annual fire and safety and sanitation requirements. Each facility must maintain documented evidence of compliance with applicable fire, and sanitation codes including an annual fire inspection. (Facilities providing day services with no overnight sleeping accommodations or periodic service that does not handle food do not require a sanitation inspection report.) Applicable rules and statutes.
4.4	All required licensure documents are reviewed for completeness by the Mental Health Licensure and Certification. If acceptable, a license shall be issued to the specific premise for types of services indicated on the application.
4.5	A license is valid for a period not to exceed two years from the date on which the license is issued.

Step

Process followed

1.0

Obtain necessary documents: Division of Mental Health, Developmental Disabilities and Substance Abuse Services

1.1

For a facility seeking its first license, the applicant may contact the Legislative Liaison in the Division of MH/DD/SAS to obtain a copy of the MH/DD/SAS edition of the North Carolina General Statutes. A fee that reflects printing, handling and postage costs, may be imposed. (For license renewal, skip to step 4.2.)

1.2

The applicant contacts the Division of MH/DD/SAS Communications and Training Branch to obtain a copy of the Administrative Rules for MH/DD/SAS Facilities and Services. A fee that reflects printing, handling and postage costs, may be imposed.

2.0

Apply for a license: Mental Health Licensure and Certification Section

2.1

Applications may be obtained by contacting the Mental Health Licensure and Certification Section. A separate license is required for each facility that is maintained on a separate site, even if the site is under the same ownership or management.

2.2

The applicant sends the completed application along with floor plans and photographs of the facility (for existing buildings) to the Mental Health Licensure and Certification Section.

3.0

Obtain Construction Approval: Construction Section

3.1

Facilities that have not been previously licensed as G.S-122C facilities require Construction Section approval before licensing is possible. Prospective facility operators are encouraged to consult with the Construction Section of DFS prior to purchasing property intended for use as a facility.

3.2

The Construction Section receives the floor plans from the Mental Health Licensure and Certification Section. New facilities that do not require Construction Section approval are therapeutic or supervised programs with three or fewer clients and day facilities with no overnight sleeping accommodations. (No Construction Section approval is required for license renewal. However, renovations, additional construction or major repairs must have Construction Section approval.)

3.3

The Construction Section reviews the floor plans and writes the applicant with requirements or review comments and instructions. The Construction Section acts as the control point for distribution of plans and specifications to the Department of Insurance. For large facilities, plans are generally reviewed in three stages: schematic, design development, and final working drawings.

3.4

Applicants and their designers work closely with local building officials and fire prevention officials as well as with the Construction Section to ensure the facility is building code- and licensure-compliant.

3.5

At least two weeks before construction is complete, the applicant sends a letter to the Construction Section requesting a final construction inspection with project information and local approvals. The facility must be ready with all systems operational and all construction completed by the final construction inspection date. The Construction Section does not do punchlist inspections; punchlist inspections are the responsibility of the designer, contractor, and owner.

3.6

The Construction Section sends a copy of the final inspection requirements, inspects the facility for licensure and for certification, and reviews the required final documentation.

3.7

If minor deficiencies are found, the applicant submits a plan of correction.

3.8

When all items are acceptable, the Construction Section sends the construction approval transmittal form (form 4086) to the Mental Health Licensure and Certification Section.

3.9

After licensing, the facility maintains documented evidence of compliance with applicable fire and sanitation codes, including an annual fire inspection.

4.0

Obtain the License: Mental Health Licensure and Certification Section

4.1

After the facility receives notification that the Construction Section has approved a new facility, the applicant contacts the Mental Health Licensure and Certification Section.

4.2

The Mental Health Licensure and Certification Section consultant for that county conducts an on-site inspection of the facility to determine compliance with all rules and statutes.

4.3

The Mental Health Licensure and Certification Section determines whether a facility is in compliance with:

Building plant and physical plant requirements.
Annual fire and safety and sanitation requirements. Each facility must maintain documented evidence of compliance with applicable fire, and sanitation codes including an annual fire inspection. (Facilities providing day services with no overnight sleeping accommodations or periodic service that does not handle food do not require a sanitation inspection report.)
Applicable rules and statutes.

4.4

All required licensure documents are reviewed for completeness by the Mental Health Licensure and Certification. If acceptable, a license shall be issued to the specific premise for types of services indicated on the application.

4.5

A license is valid for a period not to exceed two years from the date on which the license is issued.

This page last updated on March 16, 2004

Procedure to Establish a Mental Health Facility