North Carolina Assisted Living
North Carolina is an attractive retirement spot with miles of coastline, picturesque mountains, and historic cities. Despite high health care costs, the Tar Heel State’s overall cost of living is low, and Social Security income isn’t taxed, which can help people stretch their budget.
The state has a wide range of senior living choices for older residents ready to look at care options. Below is information about assisted living in the state and the costs involved.
The typical resident population in North Carolina's assisted living communities is 61% female. Overall, 64% of residents are ages 75 and older, with 28% of residents ages 75 to 84 and 36% ages 85 and older.
The term assisted living residence (ALR) covers two types of residential care settings: adult care homes (ACH) and multi-unit assisted housing with services facilities. The Health Service Regulation division of North Carolina licenses ACHs based on size. Family care homes are for two to six residents, and ACHs are for seven or more residents. Both types of care facilities can only serve persons 55 years or older or an adult with Alzheimer’s disease or another form of dementia. Facilities are not required to provide respite services, but they can.
Please note that multi-unit assisted housing with services facilities are not licensed. They only must register with the Division of Health Service Regulation.
All assisted living residences are group housing facilities that provide services for two or more adults, at least one meal per day, housekeeping services, and personal care services directly or through agreements with licensed home care or hospice agencies. Nursing services may be provided but must be approved on a case-by-case basis.
Adult care homes provide their residents with 24-hour scheduled and unscheduled personal care services. Some licensed ACHs supervise residents with cognitive impairments that may jeopardize their safety or others. Medications may be administered by designated and trained staff.
A multi-unit assisted housing with services facility provides hands-on personal care services and nursing services through an individualized care plan. The resident may choose a provider for personal care and nursing services, but the facility cannot combine charges for housing and any personal care services the resident receives.
When a resident moves into an ACH, the facility must provide, in writing, the house rules, facility policies, discharge criteria, residents’ rights, grievance procedures, accommodation information, service rates, and rate change and refund policies.
An ACH that provides care for Alzheimer’s disease or another form of dementia must provide information about the special care unit (SCU) policies and procedures for caring for the residents in this unit.
ACHs with special care units must have a license indicating the number of beds they are approved for and provide a disclosure document to the state, which must approve it. The disclosure statement must include the following:
Multi-unit assisted housing with services programs must provide a disclosure statement as part of their annual rental contract. This disclosure must include the following information:
ACHs may not admit or retain any resident who meets the criteria for nursing home care or residents with any of the following conditions or treatments: mental illness, drug or alcohol abuse, maternity care, poses a threat to themself or other residents, does not need personal assistance and supervision, or whose physician certifies that placement is not necessary. ACHs must not provide care for individuals who require a ventilator, need continuous nursing care, have health needs that the ACH cannot meet, or have some medical or functional need that the ACH cannot meet.
Residents may only be discharged under certain conditions. These conditions include the facility determining it cannot meet the needs of the resident, for the resident’s welfare, if the resident no longer needs the services provided by the ACH, or if the health and safety of other residents are in jeopardy. A physician, physician’s assistant, or nurse practitioner must document any health-related discharge.
Adult care homes must provide 24-hour staff monitoring and supervision of residents and provide for both scheduled and unscheduled personal needs, transportation, and housekeeping services. Either staff or third-party relationships can provide personal and health care services. Residents have the right to obtain any service from outside agencies at their own cost.
Multi-unit assisted housing with services facilities provide personal and health care services through licensed home care agencies.
Within 72 hours of a resident moving in, the ACH must assess the resident. Within 30 days, the facility must complete a functional assessment of each resident and reassess annually. This assessment aims to determine each resident’s level of function and to measure their psychosocial well-being, cognitive status, and ability to perform all activities of daily living (ADLs). If there is a significant change in the resident's health, an assessment must be performed within 10 days.
Any staff member who performs the assessment must complete a training program established by the DHHS before performing an assessment. RNs are exempt from this training.
Within the first 30 days of admission, the facility must complete a care plan for the resident based on the assessment. The care plan is a written description of the personal care for each resident. The plan describes all care and services provided and their frequency.
Before admission to a special care unit (SCU), the facility must evaluate whether an individual should be placed. Within the first 30 days of admission to the SCU, the facility must develop a resident profile of their behavioral patterns, self-help abilities, level of daily living skills, special needs, physical abilities, disabilities, and degree of cognitive impairment. This profile must be updated quarterly.
As mentioned above, ACHs must provide one meal per day; however, the ACH must provide three meals, three snacks daily, and modified or therapeutic diets when ordered by a physician. A registered dietitian must plan or review modified or therapeutic diets. There must be sufficient staff available for residents who need assistance eating.
Each facility must have one administrator or supervisor who is directly responsible for ensuring that all required duties are carried out and that residents are never left alone. ACHs must also have a designated activity director. The facility must have a supervisor of personal care aides on the first and second shifts in facilities with 31 or more residents and on the third shift in facilities with 91 or more residents.
Each facility must ensure that an appropriately licensed professional participates in the on-site review and evaluation of residents’ health statuses, care plans, and care provided for health or health-related tasks, including bowel and bladder training and feeding techniques for residents with swallowing problems. Each ACH must have at least one staff member on the premises who have completed a CPR and choking management course, including the Heimlich maneuver, in the last 48 months.
Staff ratios vary by facility size and are specific to the shift in question. Facilities serving 20-30 residents must have 16 hours of personal care aide (PCA) time on the first and second shifts and eight hours on the third. PCA hours increase with the size of the facility, reaching 96 hours for facilities with 131-140 residents.
For facilities with SCUs, at least one staff person is required for every eight residents on each of the first two shifts, plus one hour of additional staff time for each additional resident. On the third shift, one staff member is required for every ten residents, plus 0.8 hours of staff time for each additional resident. A care coordinator must be on-duty for at least eight hours, five days per week; this is included in the total staffing requirement, except if there are more than 16 units in this facility.
ACH administrators must complete 30 hours of continuing education every two years. Administrators in charge and supervisors in charge must complete 12 hours of continuing education every year.
All staff who provide direct personal care or supervise those who do must complete an 80-hour training and competency evaluation program. Licensed health professionals and staff listed on the Nurse Aide Registry or staff who have completed a 40-45 hour or 75-80 hour training program are exempt from this training requirement. The 80-hour training program includes at least 34 hours of classroom instruction and 34 hours of supervised practical experience.
After completion of the course, a competency evaluation includes observation and documentation on basic nursing skills, including health-related tasks, personal care skills, cognitive and behavioral skills, interventions for individuals with mental disabilities, basic restorative services, and resident’s rights. Experienced staff may take the competency exam without undergoing training. The unit's personal care and supervising staff must complete 20 hours of training specific to this population.
Apartment-style units and private rooms are not required. In ACHs licensed after July 1, 2004, a bedroom may not be occupied by more than two residents. If licensed before that date, up to four residents are permitted. Bathrooms and toilet facilities are shared with at least one toilet and sink for every five residents and a tub or shower for every ten residents.
Private units are not required in SCUs. The bathroom requirements are different than in ACHs. The SCU bathroom requirements are one toilet and sink for every five residents, and a tub and shower for bathing must be in each unit.
There are several requirements that each assisted living community must provide for their residents. The facility must offer both general observations and health supervision to assist in identifying each resident's health condition and ability to function. The facility must assist residents with all ADLs and medication services and assess the need for medication attention or nursing services.
Residents are allowed to self-administer medications as long as they are competent, physically able to do so, and have a physician's order to do so. The medication label must include specific instructions for administering the medication.
ACHs are permitted to assist residents with medications. The facility must provide staff with orientation on medication policies and procedures for medicine administration before administering or supervising the administration of medications. Staff who administer medications are called medication aides, and staff who directly supervise medication administration must complete the clinical skills validation portion of the state competency evaluation before providing medication administration or supervision. Medication aides and supervising staff must score at least 90% on a written standardized exam within 90 days of course completion. All aides and supervisors must complete six hours of annual medication administration continuing education.
All medications must be reviewed by a licensed pharmacist, prescribing practitioner, or RN every quarter. The facility's medication policies and procedures are subject to quarterly review, or more frequently, based on any specific medication problems in the facility.
Multi-unit assisted housing with services facilities may provide medication self-administration by trained staff when delegated by a licensed nurse according to the home care agency’s care plan.
In North Carolina, ALFs must provide care and services in the resident’s care plan. This can include coordinating medical care and appointments. Communities may also deliver health services, with 45% of communities providing skilled nursing. Many have health care specialists and on-site services, with 56% of communities offering dental care. In addition, 58% of ALFs have hospice services.
Mental health issues are a growing consideration for communities, and services to address these concerns are becoming more common. In North Carolina, 86% of communities conduct depression screenings, and 58% offer mental health counseling. Social work programs are also found in 42% of ALFs. Social workers can provide counseling, conduct assessments, and help ensure residents can access all necessary resources.
Some assisted living residents live with various medical conditions. In North Carolina, 45% have Alzheimer's disease or another form of dementia. In addition, 41% have high blood pressure, 23% have heart disease, 23% have depression, and 23% have diabetes.
A primary service of assisted living that benefits residents is receiving help with activities of daily living (ADLs). These are fundamental tasks that a person must do regularly to sustain life and general health, including toileting, bathing or showering, dressing, transferring (getting in and out of bed or a chair), ambulating (walking), and eating. Signs that a person may benefit from living in assisted living include increased isolation, loss of mobility, noticeable weight loss or gain, and/or neglect of household chores.
Residents in North Carolina’s assisted living facilities often receive help with their ADLs. In North Carolina, 43% of residents need help eating. Other commonly used services include bed transfer (40%), toileting (54%), and walking (44%). Caregivers in ALFs help 62% of residents dress, and 76% need help bathing.
The average cost of assisted living care in North Carolina is $4,010. This cost is $490 lower than the monthly national average of $4,500 per month. The cost of living in North Carolina is less than the national average by 4.3%, with health care costs more than the national average by 9.0% and housing costs less than the national average by 11.4%.
The level of care a person requires impacts the cost of care, as does where you live. The cost of assisted living ranges from a low of $2,700 in the Goldsboro area to a high of $5,388 per month in the Raleigh area of North Carolina.
If you live close to one of North Carolina’s borders, you may find assisted living in a neighboring state is an affordable option. People in Tennessee pay around $4,105 per month, while costs in South Carolina average $3,612. Georgia’s prices are even lower, at $3,535. Of North Carolina’s neighbors, only Virginia is more expensive. Prices there average $5,250 per month.
How to Pay for Assisted Living
The North Carolina Department of Health and Human Services oversees the licensing and regulation of ACHs in the state. The Adult Care Licensure Section performs regular inspections, takes action for noncompliance with state rules, and has statewide training for providers.
The Long-Term Care Ombudsman also offers oversight to the industry. This program advocates for residents of long-term care communities, helps older adults exercise their rights and investigates and helps resolve complaints. It also raises issues of concern with policymakers to help institute broad changes in the industry.
The North Carolina Division of Health Service Regulation licenses assisted living communities in the state. The Adult Care Licensure Section is responsible for issuing and renewing licenses. It also conducts regular inspections to ensure communities are complying with the rules and regulations that govern assisted living facilities in North Carolina. The ACLS publishes the results of these inspections so people can make informed assisted living choices.
Prior to a license being approved, new communities must demonstrate the need for more assisted living beds in the area. Communities must also provide floor plans of the building and pass a construction inspection. Initial licenses are issued for a six-month period, and an inspection by the ACLS must be completed prior to obtaining a continuing license. After this, licenses are renewed annually.
Elder law is a specialized topic, and older adults who require legal assistance should seek out people with experience in the area. You or your aging family member may need assistance with creating a will or power of attorney, accessing public benefits, or managing a housing issue. Elder law also covers abuse and neglect and can help people protect their rights. In addition to services offered by private law firms, people in North Carolina can access help through the Senior Law Project. Run by Legal Aid of North Carolina, this organization provides free help to North Carolinians aged 60 and over and operates a Senior Legal Helpline.
The state has a wide range of senior living choices for older residents ready to look at care options. Below is information about assisted living in the state and the costs involved.
The typical resident population in North Carolina's assisted living communities is 61% female. Overall, 64% of residents are ages 75 and older, with 28% of residents ages 75 to 84 and 36% ages 85 and older.
Assisted Living Facility (ALF) Definitions
The term assisted living residence (ALR) covers two types of residential care settings: adult care homes (ACH) and multi-unit assisted housing with services facilities. The Health Service Regulation division of North Carolina licenses ACHs based on size. Family care homes are for two to six residents, and ACHs are for seven or more residents. Both types of care facilities can only serve persons 55 years or older or an adult with Alzheimer’s disease or another form of dementia. Facilities are not required to provide respite services, but they can.
Please note that multi-unit assisted housing with services facilities are not licensed. They only must register with the Division of Health Service Regulation.
All assisted living residences are group housing facilities that provide services for two or more adults, at least one meal per day, housekeeping services, and personal care services directly or through agreements with licensed home care or hospice agencies. Nursing services may be provided but must be approved on a case-by-case basis.
Adult care homes provide their residents with 24-hour scheduled and unscheduled personal care services. Some licensed ACHs supervise residents with cognitive impairments that may jeopardize their safety or others. Medications may be administered by designated and trained staff.
A multi-unit assisted housing with services facility provides hands-on personal care services and nursing services through an individualized care plan. The resident may choose a provider for personal care and nursing services, but the facility cannot combine charges for housing and any personal care services the resident receives.
Resident Agreements and Disclosures
When a resident moves into an ACH, the facility must provide, in writing, the house rules, facility policies, discharge criteria, residents’ rights, grievance procedures, accommodation information, service rates, and rate change and refund policies.
An ACH that provides care for Alzheimer’s disease or another form of dementia must provide information about the special care unit (SCU) policies and procedures for caring for the residents in this unit.
ACHs with special care units must have a license indicating the number of beds they are approved for and provide a disclosure document to the state, which must approve it. The disclosure statement must include the following:
- The process and criteria for admission and discharge.
- The assessment and service planning and implementation process.
- Staffing ratios.
- Dementia-specific staff training.
- The physical environment and design features for residents in the unit.
- Frequency and type of programs and activities.
- The involvement of families in the care of residents.
- Family support programs.
- Any associated costs and fees for special care.
Multi-unit assisted housing with services programs must provide a disclosure statement as part of their annual rental contract. This disclosure must include the following information:
- The emergency response system.
- Service charges.
- Service and limitations.
- Resident responsibilities.
- The financial and legal relationship between housing management, home care, or hospice care agencies.
- A listing of the area's home care, hospice agencies, and other community services.
- Procedures for initial and annual screening and referrals for services.
Assisted Living Admission and Retention
ACHs may not admit or retain any resident who meets the criteria for nursing home care or residents with any of the following conditions or treatments: mental illness, drug or alcohol abuse, maternity care, poses a threat to themself or other residents, does not need personal assistance and supervision, or whose physician certifies that placement is not necessary. ACHs must not provide care for individuals who require a ventilator, need continuous nursing care, have health needs that the ACH cannot meet, or have some medical or functional need that the ACH cannot meet.
Residents may only be discharged under certain conditions. These conditions include the facility determining it cannot meet the needs of the resident, for the resident’s welfare, if the resident no longer needs the services provided by the ACH, or if the health and safety of other residents are in jeopardy. A physician, physician’s assistant, or nurse practitioner must document any health-related discharge.
Assisted Living Services
Adult care homes must provide 24-hour staff monitoring and supervision of residents and provide for both scheduled and unscheduled personal needs, transportation, and housekeeping services. Either staff or third-party relationships can provide personal and health care services. Residents have the right to obtain any service from outside agencies at their own cost.
Multi-unit assisted housing with services facilities provide personal and health care services through licensed home care agencies.
Service Planning
Within 72 hours of a resident moving in, the ACH must assess the resident. Within 30 days, the facility must complete a functional assessment of each resident and reassess annually. This assessment aims to determine each resident’s level of function and to measure their psychosocial well-being, cognitive status, and ability to perform all activities of daily living (ADLs). If there is a significant change in the resident's health, an assessment must be performed within 10 days.
Any staff member who performs the assessment must complete a training program established by the DHHS before performing an assessment. RNs are exempt from this training.
Within the first 30 days of admission, the facility must complete a care plan for the resident based on the assessment. The care plan is a written description of the personal care for each resident. The plan describes all care and services provided and their frequency.
Before admission to a special care unit (SCU), the facility must evaluate whether an individual should be placed. Within the first 30 days of admission to the SCU, the facility must develop a resident profile of their behavioral patterns, self-help abilities, level of daily living skills, special needs, physical abilities, disabilities, and degree of cognitive impairment. This profile must be updated quarterly.
Assisted Living Food and Dietary Provisions
As mentioned above, ACHs must provide one meal per day; however, the ACH must provide three meals, three snacks daily, and modified or therapeutic diets when ordered by a physician. A registered dietitian must plan or review modified or therapeutic diets. There must be sufficient staff available for residents who need assistance eating.
Assisted Living Staffing Requirements
Each facility must have one administrator or supervisor who is directly responsible for ensuring that all required duties are carried out and that residents are never left alone. ACHs must also have a designated activity director. The facility must have a supervisor of personal care aides on the first and second shifts in facilities with 31 or more residents and on the third shift in facilities with 91 or more residents.
Each facility must ensure that an appropriately licensed professional participates in the on-site review and evaluation of residents’ health statuses, care plans, and care provided for health or health-related tasks, including bowel and bladder training and feeding techniques for residents with swallowing problems. Each ACH must have at least one staff member on the premises who have completed a CPR and choking management course, including the Heimlich maneuver, in the last 48 months.
Staff ratios vary by facility size and are specific to the shift in question. Facilities serving 20-30 residents must have 16 hours of personal care aide (PCA) time on the first and second shifts and eight hours on the third. PCA hours increase with the size of the facility, reaching 96 hours for facilities with 131-140 residents.
For facilities with SCUs, at least one staff person is required for every eight residents on each of the first two shifts, plus one hour of additional staff time for each additional resident. On the third shift, one staff member is required for every ten residents, plus 0.8 hours of staff time for each additional resident. A care coordinator must be on-duty for at least eight hours, five days per week; this is included in the total staffing requirement, except if there are more than 16 units in this facility.
Assisted Living Staff Training Requirements
ACH administrators must complete 30 hours of continuing education every two years. Administrators in charge and supervisors in charge must complete 12 hours of continuing education every year.
All staff who provide direct personal care or supervise those who do must complete an 80-hour training and competency evaluation program. Licensed health professionals and staff listed on the Nurse Aide Registry or staff who have completed a 40-45 hour or 75-80 hour training program are exempt from this training requirement. The 80-hour training program includes at least 34 hours of classroom instruction and 34 hours of supervised practical experience.
After completion of the course, a competency evaluation includes observation and documentation on basic nursing skills, including health-related tasks, personal care skills, cognitive and behavioral skills, interventions for individuals with mental disabilities, basic restorative services, and resident’s rights. Experienced staff may take the competency exam without undergoing training. The unit's personal care and supervising staff must complete 20 hours of training specific to this population.
Assisted Living Housing Requirement
Apartment-style units and private rooms are not required. In ACHs licensed after July 1, 2004, a bedroom may not be occupied by more than two residents. If licensed before that date, up to four residents are permitted. Bathrooms and toilet facilities are shared with at least one toilet and sink for every five residents and a tub or shower for every ten residents.
Private units are not required in SCUs. The bathroom requirements are different than in ACHs. The SCU bathroom requirements are one toilet and sink for every five residents, and a tub and shower for bathing must be in each unit.
What Is Included With Assisted Living Care In North Carolina?
There are several requirements that each assisted living community must provide for their residents. The facility must offer both general observations and health supervision to assist in identifying each resident's health condition and ability to function. The facility must assist residents with all ADLs and medication services and assess the need for medication attention or nursing services.
Assisted Living Medical Provisions
Residents are allowed to self-administer medications as long as they are competent, physically able to do so, and have a physician's order to do so. The medication label must include specific instructions for administering the medication.
ACHs are permitted to assist residents with medications. The facility must provide staff with orientation on medication policies and procedures for medicine administration before administering or supervising the administration of medications. Staff who administer medications are called medication aides, and staff who directly supervise medication administration must complete the clinical skills validation portion of the state competency evaluation before providing medication administration or supervision. Medication aides and supervising staff must score at least 90% on a written standardized exam within 90 days of course completion. All aides and supervisors must complete six hours of annual medication administration continuing education.
All medications must be reviewed by a licensed pharmacist, prescribing practitioner, or RN every quarter. The facility's medication policies and procedures are subject to quarterly review, or more frequently, based on any specific medication problems in the facility.
Multi-unit assisted housing with services facilities may provide medication self-administration by trained staff when delegated by a licensed nurse according to the home care agency’s care plan.
Health Care Services
In North Carolina, ALFs must provide care and services in the resident’s care plan. This can include coordinating medical care and appointments. Communities may also deliver health services, with 45% of communities providing skilled nursing. Many have health care specialists and on-site services, with 56% of communities offering dental care. In addition, 58% of ALFs have hospice services.
Mental health issues are a growing consideration for communities, and services to address these concerns are becoming more common. In North Carolina, 86% of communities conduct depression screenings, and 58% offer mental health counseling. Social work programs are also found in 42% of ALFs. Social workers can provide counseling, conduct assessments, and help ensure residents can access all necessary resources.
Some assisted living residents live with various medical conditions. In North Carolina, 45% have Alzheimer's disease or another form of dementia. In addition, 41% have high blood pressure, 23% have heart disease, 23% have depression, and 23% have diabetes.
Activities of Daily Living (ADLs) Assistance Services
A primary service of assisted living that benefits residents is receiving help with activities of daily living (ADLs). These are fundamental tasks that a person must do regularly to sustain life and general health, including toileting, bathing or showering, dressing, transferring (getting in and out of bed or a chair), ambulating (walking), and eating. Signs that a person may benefit from living in assisted living include increased isolation, loss of mobility, noticeable weight loss or gain, and/or neglect of household chores.
Residents in North Carolina’s assisted living facilities often receive help with their ADLs. In North Carolina, 43% of residents need help eating. Other commonly used services include bed transfer (40%), toileting (54%), and walking (44%). Caregivers in ALFs help 62% of residents dress, and 76% need help bathing.
Cost Of Assisted Living Care In North Carolina
The average cost of assisted living care in North Carolina is $4,010. This cost is $490 lower than the monthly national average of $4,500 per month. The cost of living in North Carolina is less than the national average by 4.3%, with health care costs more than the national average by 9.0% and housing costs less than the national average by 11.4%.
The level of care a person requires impacts the cost of care, as does where you live. The cost of assisted living ranges from a low of $2,700 in the Goldsboro area to a high of $5,388 per month in the Raleigh area of North Carolina.
How Costs Compare In Nearby States
If you live close to one of North Carolina’s borders, you may find assisted living in a neighboring state is an affordable option. People in Tennessee pay around $4,105 per month, while costs in South Carolina average $3,612. Georgia’s prices are even lower, at $3,535. Of North Carolina’s neighbors, only Virginia is more expensive. Prices there average $5,250 per month.
How to Pay for Assisted Living
North Carolina Assisted Living Oversight
The North Carolina Department of Health and Human Services oversees the licensing and regulation of ACHs in the state. The Adult Care Licensure Section performs regular inspections, takes action for noncompliance with state rules, and has statewide training for providers.
The Long-Term Care Ombudsman also offers oversight to the industry. This program advocates for residents of long-term care communities, helps older adults exercise their rights and investigates and helps resolve complaints. It also raises issues of concern with policymakers to help institute broad changes in the industry.
Quality and Safety of Assisted Living Facilities in North Carolina
The North Carolina Division of Health Service Regulation licenses assisted living communities in the state. The Adult Care Licensure Section is responsible for issuing and renewing licenses. It also conducts regular inspections to ensure communities are complying with the rules and regulations that govern assisted living facilities in North Carolina. The ACLS publishes the results of these inspections so people can make informed assisted living choices.
Prior to a license being approved, new communities must demonstrate the need for more assisted living beds in the area. Communities must also provide floor plans of the building and pass a construction inspection. Initial licenses are issued for a six-month period, and an inspection by the ACLS must be completed prior to obtaining a continuing license. After this, licenses are renewed annually.
Legal Resources
Elder law is a specialized topic, and older adults who require legal assistance should seek out people with experience in the area. You or your aging family member may need assistance with creating a will or power of attorney, accessing public benefits, or managing a housing issue. Elder law also covers abuse and neglect and can help people protect their rights. In addition to services offered by private law firms, people in North Carolina can access help through the Senior Law Project. Run by Legal Aid of North Carolina, this organization provides free help to North Carolinians aged 60 and over and operates a Senior Legal Helpline.
