North Carolina - Assisted Living Facility — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-09-10

North Carolina licenses congregate residential care not under the generic term assisted living, but specifically as Adult Care Homes (seven or more beds) and Family Care Homes (two to six beds) through the Division of Health Service Regulation (DHSR) Adult Care Licensure Section. Medicaid reimbursement for personal care delivered in these settings is funded primarily through State Plan Personal Care Services (PCS), rather than a dedicated HCBS waiver.

New facility development requires securing a Certificate of Need (CON) from the DHSR Healthcare Planning and Certificate of Need Section before any licensure application can be submitted, dictating exactly where and when new beds may be established based on the annual State Medical Facilities Plan.

1. Service Definition and Scope

In North Carolina, assisted living services are delivered primarily in licensed Adult Care Homes and Family Care Homes. These facilities provide 24-hour scheduled and unscheduled personal care services, supervision, and medication administration to adults who do not require inpatient nursing care.

The state also recognizes Multi-Unit Assisted Housing with Services (MAHS), which is a registered setting where housing is provided but personal care must be delivered by a separately licensed home care agency.

• Adult Care Homes: Facilities licensed under 10A NCAC 13F serving seven or more residents.
• Family Care Homes: Facilities licensed under 10A NCAC 13G serving two to six residents.
• Multi-Unit Assisted Housing with Services (MAHS): Registered settings requiring a licensed home care agency for hands-on care.
• State Plan PCS: The primary Medicaid funding mechanism for personal care in these licensed settings.
• Excluded Services: Continuous skilled nursing care is not permitted unless contracted through an outside home health agency.

2. Regulatory and Oversight Agencies

The Division of Health Service Regulation (DHSR) is the primary regulatory body for facility licensure, construction approval, and bed need determination in North Carolina. Medicaid enrollment and claims are managed by the Division of Health Benefits (NC Medicaid) and its fiscal agent.

Assessments for Medicaid Personal Care Services eligibility are conducted by a contracted vendor, currently Acentra Health.

• NC DHSR Adult Care Licensure Section (ACLS): Licenses and inspects facilities (https://info.ncdhhs.gov/dhsr/acls/index.html).
• NC DHSR Healthcare Planning and Certificate of Need Section: Approves new bed development (https://info.ncdhhs.gov/dhsr/con/index.html).
• NC Medicaid Division of Health Benefits (DHB): Administers the Medicaid program (https://medicaid.ncdhhs.gov).
• NCTracks Provider Portal: Processes Medicaid enrollment and claims (https://www.nctracks.nc.gov).
• Acentra Health (NC LIFTSS): Conducts independent assessments for PCS eligibility (https://ncliftss.acentra.com).

3. Gatekeeping Prerequisites: Who Can Even Apply

North Carolina heavily regulates the supply of Adult Care Home beds. An applicant cannot simply build a facility and apply for a license; they must first navigate the state's health planning process.

The Certificate of Need (CON) process dictates that new beds can only be proposed if the state identifies a statistical need in a specific county.

• State Medical Facilities Plan (SMFP): Published annually, this document must show a designated bed need in a specific county before any application is accepted.
• Certificate of Need (CON): Required under G.S. 131E, Article 9 for all new Adult Care Home beds prior to licensure.
• DHSR Construction Section Approval: Floor plans and specifications must be reviewed and approved by the state before ACLS will accept a licensure application.
• Local Zoning and Building Approval: Must be secured prior to state construction review and final licensure.

4. Licensure and Certification Requirements

Once the CON and construction approvals are secured, the applicant submits the initial licensure application to the DHSR Adult Care Licensure Section. The facility must be ready with all systems operational by the final construction inspection date.

Licensure requires demonstrating compliance with physical plant standards, administrative policies, and administrator qualifications.

• Initial License Application: Submitted to DHSR ACLS only after the Construction Section notifies ACLS of the new project.
• Licensure Fee: Statutory base fee plus a per-bed fee as defined in G.S. 131D-2.5, payable to the Division of Health Service Regulation.
• Administrator Certification: Requires completion of a 120-hour training program and passing a state exam.
• Rule Citation: 10A NCAC 13F governs Adult Care Homes; 10A NCAC 13G governs Family Care Homes.

5. Medicaid Provider Enrollment

Providers must enroll through the NCTracks Provider Portal to bill Medicaid for Personal Care Services. The enrollment process includes credentialing, endorsement, and licensure verification by the CSRA/GDIT Enrollment Team.

Applications must be error-free and include all required supplemental information at the time of electronic submission to meet standard processing times.

• System: NCTracks Provider Portal.
• Provider Taxonomy: Must select the appropriate taxonomy code for Adult Care Home or Personal Care provider.
• Application Fee: Subject to the federally mandated CMS application fee for institutional providers.
• Credentialing: Managed by the NCTracks Enrollment Team to verify licensure and good standing.

6. Staffing, Training and Background Checks

North Carolina mandates specific training and credentialing for all staff providing direct care or administering medications in Adult Care Homes. Facilities must maintain strict personnel files documenting these requirements.

Background checks are mandatory for all staff prior to employment.

• Administrator Qualifications: Must be at least 21 years old, hold a high school diploma or equivalent, and maintain state certification.
• Personal Care Aides: Must complete an 80-hour training program or be listed on the NC Nurse Aide I registry.
• Medication Aides: Must complete a 15-hour state-approved training program and pass a written exam.
• Background Checks: Fingerprint-based criminal background checks are required for applicable staff.

7. Documentation, Policies and Records

Licensed facilities must maintain comprehensive records for both residents and facility operations. These records are subject to review during annual inspections and complaint investigations.

Clinical documentation must align with the assessments conducted by the state's vendor.

• Resident Register: Must maintain current demographic, admission, and discharge data.
• FL-2 Form: Required for documenting medical eligibility and physician orders upon admission.
• Disaster Plan: Must maintain an approved emergency preparedness plan with documented drills.
• Infection Control: Written policies and procedures required per 10A NCAC 13F .1801.

8. Billing, Rates and Claims

Medicaid reimbursement for personal care in Adult Care Homes is billed through NCTracks. Room and board costs are not covered by Medicaid and are typically funded by the resident's income or the State/County Special Assistance program.

Prior authorization is required for Medicaid PCS billing.

• State/County Special Assistance: Sets the basic rate for room and board for eligible low-income residents.
• PCS Billing: Billed based on authorized hours determined by the independent assessment.
• Prior Authorization: Managed via Acentra Health (NC LIFTSS) assessments before claims can be paid.
• MMIS: All Medicaid claims are submitted electronically via NCTracks.

9. Approval Sequence and Timeline

The timeline to open a new Adult Care Home in North Carolina is lengthy due to the sequential nature of the approvals. The CON process alone can take several months before architectural plans can even be submitted.

Medicaid enrollment is the final step and is relatively quick if the application is clean.

• CON Review: Typically takes 90 to 150 days depending on the review cycle and potential appeals.
• Construction Review: Plans are reviewed in three stages (schematic, design development, final working drawings), taking 30-60 days per stage.
• Licensure Processing: Occurs after final construction approval and submission of policies.
• Medicaid Enrollment: Averages 10 to 15 days for clean, error-free applications per NCTracks data.

10. Common Denials and Survey Findings

Facilities frequently face delays or citations due to administrative oversights or failure to adhere strictly to medication management rules. The DHSR ACLS conducts routine monitoring and complaint investigations.

Application denials often stem from skipping required prerequisite steps.

• Medication Administration Errors: A leading cause of citations during annual surveys.
• Incomplete Staff Records: Missing background checks, TB tests, or training certificates in personnel files.
• Physical Plant Deficiencies: Failure to maintain required water temperatures or HVAC systems.
• Application Rejection: Submitting a licensure application before obtaining CON or Construction Section approval.

11. Key Contacts and Resources

Prospective providers must interact with multiple state divisions and contractors. Maintaining current contact information for these entities is essential for compliance.

The DHSR website is the primary resource for rules, forms, and public notices.

• DHSR Adult Care Licensure Section: https://info.ncdhhs.gov/dhsr/acls/index.html
• DHSR Certificate of Need Section: https://info.ncdhhs.gov/dhsr/con/index.html
• NCTracks Provider Portal: https://www.nctracks.nc.gov
• Acentra Health (NC LIFTSS): https://ncliftss.acentra.com
• NC Medicaid Provider Enrollment: https://medicaid.ncdhhs.gov/providers/provider-enrollment

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